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The incidence of diabetes linked to obesity has jumped significantly in U.S. children in the past few decades, according to new findings presented last week at a U.S. Department of Agriculture meeting on the causes and prevention of obesity in kids.
Obesity in children has emerged as a major health problem, particularly among African American girls, and Hispanic American and Native American children. One of the more worrisome trends is the sharp rise in the type of diabetes normally found only in adults.
"Childhood obesity is at epidemic levels in the United States," said U.S. Surgeon General David Satcher. "We have been remiss in shedding light on this problem, which leads to so many other health problems, particularly when we consider the threats this disease imposes on our children. Today, we see a nation of young people seriously at risk of starting out obese and dooming themselves to the difficult task of overcoming a tough illness."
The percentage of overweight children, aged 6 to 17 years, has doubled in the United States since 1968. The most recent National Health and Nutrition Examination Survey conducted by the National Center for Health Statistics from 1988 to 1994 found that one in five children in the United States was overweight.
Studies show that 70 percent of overweight kids aged 10 to 13 years will be overweight and obese as adults, Goran said. There is also psychological and emotional fallout from being overweight in childhood, as youngsters struggle with self-esteem and often become the brunt of teasing from peers.
Findings released at last week's meeting add to this troubling picture of the effects of obesity in childhood. In particular, researchers cited findings from a study of 1,000 schoolchildren in Cincinnati that showed an increasing incidence of type II, or adult onset, diabetes, the form of the disease that is closely linked to weight. In 1982, about 4 percent of children in the study had type II diabetes. By 1994, the rate had risen to 16 percent. Most children developed it between the ages of 10 and 14, researchers said, and the onset of the disease was directly linked to obesity. Other studies have found similar trends in other cities.
"It's a very dramatic problem," Michael Goran, an obesity researcher at the University of Alabama at Birmingham, told the meeting last week. "And it's not just occurring in Cincinnati, it's occurring nationally."
Obesity also puts overweight children at risk of other diseases. The Bogalusa (La.) Heart Study, an ongoing project funded by the National Heart, Lung and Blood Institute, found, for example, that overweight children tend to have readings in the highest levels of the normal ranges for their blood sugar, blood pressure and blood fats. Each of these factors places them at increased risk of health problems.
Why excess weight sets in motion a cascade of adverse health effects is not completely understood. But the latest evidence points to visceral fat, the type that hides deep within the recesses of the body, close to organs.
Visceral fat is more metabolically active, meaning that its cells churn out more byproducts, than other types of fat cells, researchers said. Included among these substances are free fatty acids that are dumped directly from the visceral fat into vessels leading to the liver. "The point is," Goran explained, "that when visceral fat releases its breakdown products, it has harmful effects on the surrounding organs."
What researchers still don't understand, however, is the relationship between visceral fat and total body fat. CT scans of the body show that not all heavy children have the same amount of visceral fat.
"What we are seeing is that obese children definitely have more visceral fat," Goran said. "But as with adults, you don't have to be obese to have a lot of visceral fat."
Nor can anyone explain why obesity has emerged as such a significant health problem worldwide during this century. During the past 15 years, the percentage of fat in the American diet has dropped from at least 40 percent to about 30 percent of total calories. There's been a proliferation of fat-free and low-fat foods.
"Despite that, the prevalence of obesity in adults and kids has increased substantially," said William H. Dietz, director of the Centers for Disease Control and Prevention's Division of Nutrition and Physical Activity.
Cultural changes in food preparation and family meals likely play a role in the problem, he said. In 1934, all food was prepared from scratch and was largely consumed based on seasonal harvests. The advent of frozen food in 1954 opened up a wider array of food choices, and the introduction of the microwave oven in 1974 meant that children could take a far more active role in choosing and preparing foods without parental guidance, Dietz said.
Adding to the problem is the recent trend of eating food that has been prepared outside the home. National food surveys show that about 30 percent of family meals nationwide are fixed outside the home, regardless of family income. Such meals often are higher in calories and fat and contain larger portions than those prepared at home, Dietz said. (See related story on Page 20.)
Lack of physical activity contributes to the problem. Fewer than half of U.S. schoolchildren participate in daily physical education. Television, video games and computers also add to the problems of sedentary living. Studies by Dietz showed that childhood obesity is related to the amount of time spent watching television.
"But television viewing is not a single behavior," Dietz said. "It represents a marker for inactivity and altered patterns of food consumption. The more television a child watches, the more likely they are to consume foods advertised on television and the more likely it is that those foods are high in calories."
There are signs, however, that some of these trends can be reversed. At Johns Hopkins Bayview Medical Center in Baltimore, Kerry Stewart, head of cardiac rehabilitation, has developed a prevention program targeted at children. "We find that we can increase the knowledge of children and improve their eating habits so that they report consuming lower percentages of fat, salt and sugars in their diet," Stewart said.
At Stanford University, Thomas Robinson and his colleagues have studied the effect of reducing children's use of television, videotapes and computer games. Using body mass index--a measurement that takes into account height and weight--the team found that they could cut BMI by half a unit in children who watched between a quarter to a third less television and videotapes and played fewer computer games.
An effective but simple change may be removing television sets from children's bedrooms. The Stanford team found that half of elementary schoolchildren they studied had a television set in their bedrooms.
"If there's any one thing that parents could do, it's that," Robinson
said. "There's no reason for a child to have a television in the bedroom."
AHA Scientific Position
The American Heart Association recommends these dietary guidelines for all healthy children and adolescents over the age of about 2 years:
Adequate nutrition should be achieved by eating a wide variety of foods.
Energy (calories) should be adequate to support growth and development and
to reach or maintain desirable body weight.
The following pattern of nutrient intake is recommended:
Saturated fat -- 7-10 percent of total calories
Total fat -- an average of no more than 30 percent of total calories
Dietary cholesterol -- less than 300 milligrams per day
Each of these numbers refers to an average of nutrient intake over several
days.
The American Heart Association recommends this eating pattern for families:
Eat foods low in saturated fat, cholesterol and total fat.
Choose a variety of foods to get enough carbohydrates, protein and other nutrients.
Eat only enough calories to maintain a healthy weight for your height and
build.
This eating pattern supports a child's normal growth and development. It provides
enough total energy and meets or exceeds the recommended daily allowances
for all nutrients for children and adolescents, including iron and calcium.
The guidelines aren't intended for infants from birth to 2 years of age. Their fast growth requires a higher percentage of calories from fat. Toddlers 2 and 3 years of age may safely be moved to the recommended eating pattern as they begin to eat with the family.
Childhood obesity: Parenting advice
Obese children are often shunned both by peers and adults, so it's extremely
important for you to treat your obese child as an equal to other children.
You play a crucial role in helping your child feel normal, control weight
and develop healthy habits to stay fit for life.
Take advantage of every opportunity to help your child build a positive self-image.
Heavy children are at increased risk of low self-image because of the social
emphasis on appearance and being slim.
Here are some other tips to help your obese child — and yourself:
Be a positive role model. "Parents play a vital role in the development
of their children," says Philip Fischer, M.D., a pediatrician at Mayo
Clinic, Rochester, Minn. "Take notice of lifestyle habits that can contribute
to overeating and inactivity in your children — then set a good example."
You can make subtle lifestyle changes to help your kids eat healthier. Limit
portion sizes. Make an effort to cook with less fat — for example, bake
foods instead of frying them. Don't order french fries if you don't want your
kids ordering french fries. Don't buy Oreos if you don't want your kids sneaking
a few of them from the cookie jar. Likewise, your child will be more willing
to snack on fruits and vegetables after seeing you doing the same.
Get active. Try to plan activities that get the whole family moving, such
as skating, hiking or biking. Make an after-dinner walk a regular part of
your family's evening. Remember that exercise doesn't have to be hard work.
Gardening, running through the sprinkler, shoveling snow and cleaning the
garage are all good options.
Make eating an activity in itself. "Eating is a significant event, and
it should be enjoyable," says Dr. Fischer. "Kids, especially overweight
kids, shouldn't eat while watching TV, riding in a car or walking through
the kitchen. They should sit down just to eat, enjoy the meal and then get
up and do something else fun."
A good way to accomplish this goal: reinvigorate the family dinner. Setting
aside time to eat together at the table will help you monitor your child's
food intake and will give you some quality time together. Get the kids involved
in the menu choices, meal preparations and clean up, too.
Try not to love with food. Instead of rewarding your children with snacks,
teach them to use food for energy. Rather than treating your child to an ice-cream
cone for a good grade, choose an alternative way of celebrating. Spend some
quality time with your child — take a walk, go to the bowling alley,
play a game of cards or go on a long bike ride together.
Watch what your kids drink, too. Drinks with calories provide lots of sugar
with little health benefit. Limit fruit juice to 4 to 6 ounces daily for children
ages 1 through 6, and less than 12 ounces every day for older children. Although
juice is "natural" and considered healthy, too much juice —
including sweet fruit drinks that are fortified with vitamins and minerals
— can be a major source of excess calories in children's diets.
Be wary of diet soda, as well. Diet soda doesn't have calories or sugar, but
it also doesn't have any nutritional value. It's important to remember that
juices and sodas may take the place of other nourishing beverages like milk,
which is a major source of calcium needed for growing bones.
Don't be too restrictive. Sweets and fast foods don't have to be completely
eliminated. They should just make up a very small part of your child's overall
diet. Also, don't put your child on a diet unless recommended by your child's
doctor — too few calories can interfere with proper growth.
Limit television, video and computer time. "There's a clear link between
television time — especially when combined with eating — and obesity,"
says Dr. Fischer. "Children should not have televisions in their bedrooms,
and all kids should limit television, video or computer game time to no more
than an hour or two a day."
Focus on positive goals. "Overweight children should focus on achieving
goals they want to achieve," says Dr. Fischer. "They may set their
sights on running laps with, instead of behind, the class, or being able to
bike for more than 20 minutes without getting tired. It's much better to choose
these kinds of positive goals than to focus on more negative-sounding goals,
like losing weight."
Take small steps as a family. Make sure changes are subtle and involve the
whole family. It's better to substitute fruit in place of dessert than to
omit dessert altogether. That way your child won't feel like there has been
a revolution. Other examples of subtle changes you can make include parking
your car a little farther away, not picking up fast food as often and taking
a family walk in the evenings.
Children's snacks: Don't ban them, plan them
My child eats only junk: Tips for introducing new foods to children
Careful, crucial communication
Most overweight kids are fully aware of their weight. They have likely faced taunts and name-calling at school long before you thought to intervene. So don't be afraid to bring up the topic of health and fitness, but do be sensitive that your child may interpret your concern as an insult.
"Talk to your kids directly, openly and without judgment," says Dr. Fischer. "See what they think. Help them set positive goals and work with them to meet those goals."
By modeling healthy-living habits, staying positive and — above all — letting your children know that they're loved no matter what, you'll find it's much easier to help your child lose weight without damaging his or her self-esteem.
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