No child left on their behind.

At breakfast the other day, my son asked if he could have a banana in his lunch, I paused a moment in my hectic morning music to think fondly that I was raising him right, that he valued the relentless education he has received about healthy foods, and that at school he would be eating foods that were mother-approved.

"Sorry, honey, we're out of bananas," I said. "How about I slice up an apple?"

My health-conscious little darling said, "Nah, that's no good. I can't trade for anything good with an apple."

At least someone's child will be eating that banana. I am certainly not the only parent concerned about what my child eats at school. Across the country, schools are struggling with what students eat, how much they exercise, and whether or not healthy habits can be mandated by the state. Obesity rates have more than doubled in the past 30 years, with more than 15 percent of children aged 6 to 19 defined as obese. That number was a paltry 6 percent in the 1970s.

Obesity is, by definition, an excess of body weight (fat, muscle, bone and water) in proportion to a person's height. Detailed charts are provided for physicians and the public outlining norms for children and adults. If a person's body mass index (BMI, measured as weight divided by height squared [kg/m2]) falls above the 85th percentile, he or she is "overweight;" above the 95th percentile is "obese."

With obesity comes an array of medical complications, according to the American Obesity Association, including asthma, type 2 diabetes, hypertension, orthopedic complications, psychosocial effects and stigma, and sleep apnea. Worse, obese children often become obese adults, which carries its own set of medical problems, including heart disease, high blood pressure, stroke, and even some forms of cancer:

Perhaps the most alarming aspect of the rise in obesity among children is the concurrent sharp rise in diagnoses of type 2 diabetes. The average age of onset of this disease used to be 40. Now, according to the American Diabetes Association, "The population of children with type 2 diabetes is growing perhaps to epidemic proportions." Healthcare professionals as well as medical researchers are scrambling to catch up.

So far, a combination of factors are known to contribute to obesity and diabetes: Lack of physical activity, general sedentary behavior, low socioeconomic status, poor eating habits, and over-exposure to advertising of foods that are high in calories are all implicated. And don't rule out genetics. "Our ability to store fat is how we survived as a species," says Dr. Francine Kaufman, Head of the Center for Diabetes and Endocrinology at Children's Hospital in Los Angeles and the author of the up-coming book Diabesity. Apparently, our bodies are adapted to store fat through lean winter months, insuring survival till spring and summer when there is a greater abundance of food. That adaptation doesn't just go away when there is a year-round supply of goods: we still store it.

Schools' Role is Key

Just because our bodies are good at storing fat doesn't mean we are doomed to obesity. Far from it. Health experts agree that a combination of diet mad exercise can prevent both obesity and its associative diabetes. What that means for schools, though, isn't as clear, nor is it as simple as laying down health guidelines.

Schools need to take a three-pronged approach, says Dr. Howard Taras, a professor at University of California at San Diego, a specialist in school health, and a member of the American Academy of Pediatrics Task Force on Obesity. Physical education, health education and the availability of nutritious foods all need to be addressed. The idea is to promote healthy habits for the entire school, not to single out children who are identified as "at risk" by reason of their weight.

"A kid can be at risk without being overweight," Dr. Taras argues. "Children can be poorly nourished and not be obese, which still puts them at risk for heart disease." By bringing the whole community into the nutritional picture, schools can avoid the stigmatization that can happen around obese children. "Singling out these children can be psychologically damaging, and may do more harm than good." Plus, says Dr. Taras, "You're not wasting your time teaching health and nutrition to the entire school population." You're giving them the habits of a lifetime.

Legislating Activity and Diet

In Connecticut, the state legislature is trying to pass a bill that will mandate the amount of time that students must spend in some form of physical education. California already has such a mandate-100 minutes per week--but in Connecticut or California there is no reliable way to ensure that the activity the children are engaged in is within the state mandate. Standing in line waiting to kick a ball or standing in right field waiting for a power hitter with pull to knock one your way are both examples of physical activity that masquerades as aerobic exercise.

Creating legislation around the food in schools is also being tried, with better measurable success. A big part of the trick involves replacing vending machines full of sugary sodas, empty-calorie candy and high-fat snacks with ones packed with juices, granola bars and fruit. The "soda ban" at Venice High School in Los Angeles created a bit of an uproar two years ago, but, says Dr. Kaufman, the results are in and it is a success. Instead of the drop in revenue that some predicted (and indeed used as a reason to leave the vending machines selling sodas and candy), vending revenue is higher than ever. With only healthy snacks and healthy drinks available, the kids are eating and drinking healthier While the student population's overall health is difficult to measure in the short run, Kaufman is confident that the long-term effects will be healthier eating habits.

Even if your school doesn't have candy available in vending machines, the selling of candy and other snacks could be weighing down your student population. School bands are notorious for their year-round, never-ending candy sales; classrooms hold bake sales where donuts, cookies and cake sell best; class parties are all about pizza and soda; afterschool sporting events sell sugary drinks and supersize candy bars. The USDA recommendations for healthy eating require that any food on sale at school be within the "healthy foods" guidelines. It takes creative thinking to ditch a fund-raising "sure thing," but the health of the student population should come first. And booster groups that sell alternative goods like trail mix or protein bars report that they can make just as much money with them as they can with candy.

Eric M. Bost, the Food Nutrition and Consumer Services Undersecretary of the USDA, emphasizes that the USDA is taking seriously the rise in childhood obesity. The Childhood Nutrition Program has been up for reauthorization in Congress for the past year and a half. In that bill, the USDA has outlined new guidelines for higher levels of nutrition specifically regarding obesity. Those recommendations include such things as daily physical activity requirements and discouraging the use of withholding recess as a punishment. "This can't wait," says Bost. "Obesity is still increasing, and we can't sit on our hands while our children are at risk."

Another culprit in the less-than healthy food in schools is National School Lunch Program itself. It hasn't been revised since the end of World War II and as a guideline for nutrition in the 21st century it is sadly lacking. "The calorie allowances are too high," says Kaufman. As it stands now, "If the student gets a fruit cup, a salad, and a burrito, the nutritional analysis balances out. But if they're just eating the burrito, that's no good. I think each element should be healthy and meet the guidelines in itself and not have to be combined with other foods in order to make the grade." The menus in general offer too much meat and not enough whole-grain options to keep our children healthy.

The government has long been involved in what our children eat at school and how much they exercise. The President's Council on Physical Fitness was founded in 1956 to encourage students' participation in sports. Now the President's Council on Physical Fitness and Sports, in the great tradition of "If you can't beat 'em, join 'em," has branched out beyond its basic incentive program by running MTV-style ads that attempt to ridicule teens into exercising. With taglines like "Whatever you do with your butt, get off it," the PCPFS hopes to motivate kids into getting into shape. Another ad shows a group of preteens pigging out on snack cakes and then lying around in a room-wide junk food coma.

Since kids are consuming so much TV, maybe the TV approach will work to raise the awareness of the obesity problem. At the same time, children need to be educated about the media they are exposed to on a daily basis, not just how to take an ad aimed at educating them. Media consumption is blamed for over-consumption of heavily advertised and nutritionally empty products like fast food and sodas. With media education, students can be taught to be conscious of commercial images and make better choices not based on what advertising is telling them to want. "If they're not going to get this in the schools," Dr. Taras asks, "where are they going to get it?"

It Takes a Village

Schools do not stand alone on the front lines of the obesity battle. Bringing in the support of the families and the community is key to sustaining a successful health and nutrition program. The message needs to be consistent: healthy foods and physical activity are important components of a healthy life. "Healthy kids involves a concerted effort," says Bost, "on the part of the schools, families, communities, and educators, to encourage what kids eat, how much they eat, and how much physical activity they engage in. It involves everyone." DA

Online Resources

No need to develop your own program to promote healthy eating and physical activity in your school. Nutrition professionals and medical researchers have taken some of the work off your hands with ready-to-go, off-the-shelf programs that encourage life-long healthy habits.

SPARK PE www.sparkpe.org SPARK's program teaches teachers how to include physical activity in their daily instruction as well as how to measure whether that physical activity has results in terms of fitness, activity and even academic performance.

CATCH

(Coordinated Approach to Child Health) www.sph/uth.tmc.edu/catch/index.htm Used in several states, CATCH takes a four-pronged approach to student health: vigorous PE activity, eating guidelines that reduce fats and salts, classroom materials that emphasize why eating right and taking care of your health is important, and take-home materials that draw the parents and family into the process of eating right and getting active.

Nutrikids www.nutrikids.com LunchByte Systems, the makers of Nutrikids software, sells a nutrition analysis software package that allows food services quickly and easily to create nutritious balanced meals for their school's lunch program. All the nutritional analysis of the ingredients, recipes, and menus is done for you.

PE Links www.pelinks4u.org This clearinghouse of school physical education information offers links to a wide variety of other sites, plus original content just for education professionals. Get your very own "No Child Left On Their Behind" button free on the site and show your support for physical education in schools.

3 Low-cost Plans of Action

Dr. Howard Taras of the American Academy of Pediatrics Task Force on Obesity suggests these low-cost ways to kick-start your school's physical and nutritional health:

* Re-price available foods so the healthy options are more affordable and the unhealthier options are more expensive. You can generate the same revenue and make healthy alternatives more attractive.

* Design more aerobic activity into PE. Less standing-and-waiting and more jumping and running,

* Create an environment that encourages walking and biking to school. Provide bike racks, make school grounds open after school, publicly praise the kids who bike or walk, and offer crossing guards.

* If you're buying a product or method, make sure it is research-based, with proven methodology, just as you would with any academic program.

* Publish and circulate information, like the American Academy of Pediatrics recommendations for preventing and mitigating obesity.

www.aap.org

Elizabeth Crane is a freelance writer based in San Francisco.