Our vulnerable children: poor and overweight.

The threat of obesity to the physical and mental health of children is high and rising. Worldwide, about 1 child out of 4 is overweight or obese-nearly as many as are affected by undernourishment. (1) In the United States, 28.2% of 2 to 19 year olds were overweight or obese in 2000; by 2004, the prevalence increased to 33.6%. (2) Local data from Chesterfield County VA, reported in this issue, indicate a similar prevalence. Reports show that young children, 2 to 5 years old, are getting fatter faster than ever before. (3,4) And although the overall rates of childhood obesity are alarmingly high, they are higher still among ethnic minority and low-income communities. (5)

Nationwide, and in the Virginia county discussed in the article, low-income children are at excess risk of obesity regardless of ethnicity. Two lessons are apparent: 1) the risks of obesity affect children early and last long; 2) prevention and intervention efforts must be local as well as global and, most importantly, must target both the social and physical environments of the communities.

Why worry about overweight children? The list of health dangers--and related health care costs--is long. A short list includes:

* Twenty five percent of obese children show signs of glucose intolerance, a precursor to type 2 diabetes. (6)

* A child who is diagnosed with type 2 diabetes at age 10 may lose 17 to 26 life years to this chronic disease--a shortened life in both quantity and quality. (7)

* This generation of children could be the first to have a shorter life expectancy than their parent's generation. (8)

Hand-wringing healthcare providers recite the list often hoping to propel patients to change one or more of the usual suspected causal behaviors, mainly eating too much and moving too little. Yet, one wonders, does this bad news promote changes to improve health? Sometimes, but not often. First, the risks do not seem immediate for children. Second, parents are more concerned about unsafe neighborhoods, alcohol and illegal drug use, and sexual activity; obesity is low on the list. Parents do care about their children. But many, themselves overweight, feel an unfair judgment of their parenting from well-meaning health educators.

Why are Kids Getting Fatter? Experts say the root causes are "multifactorial," including genetics, poverty, movement-saving devices, and a "toxic" environment polluted with "junk" food. Some blame "distorted policy priorities," unregulated food marketing and media use, fueled by the gigantic food and electronics corporations that provide cheap, high-calorie, low-nutrient foods and seductive, sedentary gadgets like television and video games. Parents and families are also named (and blamed) as lacking "personal responsibility" in helping children choose foods and physical activities that support a healthy weight. Most everyone agrees that both nature (genes) and nurture (environment) are important.

Studies of twins show that predisposing genes account for 60 to 80% of obesity--when the environment allows and encourages it. The food environment in the US today is filled with excess calories--nearly 4000 for each adult and child--twice the calories needed for health. Excess energy consumption early in an infant's life, even 20 calories daily above energy requirement, coupled with being born to obese parents may set the stage for future childhood obesity. A pattern of rapid weight gain during early infancy is associated with increasing obesity through adolescence. (9) A vicious cycle begins: eating high calorie foods and sitting 2 to 4 hours a day with TV and video games makes moving uncomfortable and painful. Teasing leads to isolation and less activity. And worse, fat discrimination toward overweight children by their peers (10) and families often lasts for life.

When a health crisis affects children, we would expect parents and politicians to be especially alarmed by the early signals. Because excessive weight gain is often imperceptible but steady, and because it is overshadowed by more immediate challenges confronting families and society today, prevention is way behind schedule. Add to this, reluctance of nearly everyone to talk about it. Our nation, the fattest in the world, is touchy about its weight problem.

What to do? A crucial starting point in stalling this rapid rise in obesity is with the vulnerable, the economically disadvantaged and minority children who are most affected by environmental factors. A new report from the Robert Wood Johnson Foundation shows that, compared with advantaged children, low-income kids have more commercial advertising exposure per hour of TV (mainly high-calorie food products), more fast food restaurants and fewer vendors of healthful foods nearby, more unsafe streets, and more dilapidated parks and school playgrounds. (5) Intervention from both business and government--local and federal--is required. Schools can, with local support and leadership, make a big difference. But the majority of resources are narrowly fixed on test scores. Nine year old boys and girls can not sit still through school days without recess, gym, and healthy food and drink. All too often, however, these activities are sacrificed to cram in more hours for test preparation, or due to lack of teachers and facilities.

Suggestions for families, schools and communities are abundant and worth trying (11):

* Families should eat together at least twice a week. If parents eat moderately, the children will copy.

* Families should talk, walk, and play together instead of sharing "screen" time.

* Families should get enough sleep, as this is related to a healthy weight (children need 9 hours per night).

* Schools should phase out soda and high-fat/sugar snacks, and should offer tasty meals and snacks.

* Schools need to promote physical activity throughout the day.

* Communities should reclaim their streets for play and community activities.

* Communities can promote affordable nutritious food in low-income neighborhoods.

* Health providers should intervene early with sensitive, ongoing support for families.

Helping overweight children calls for large doses of prevention and moderation. The challenge is bigger than any one of us. It requires immediate attention from all.

References

1. Lobstein T, Baur L, Uauy R, IASO International Obesity TaskForce. Obesity in children and young people: a crisis in public health. Obesity Reviews 2004;5 (Suppl 1):4-85.

2. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006;295:1549-1555.

3. Sherry B, Mei Z, Scanlon KS, et al. Trends in state-specific prevalence of overweight and underweight in 2- through 4-year-old children from low-income families from 1989 through 2000. Arch Pediatr Adolesc Med 2004;158:1116-1124.

4. Stettler N. High prevalence of overweight among pediatric users of community health centers. Pediatrics 2005;116:e381-388.

5. Kumanyika S, Grier S. Targeting interventions for ethnic minority and low-income populations. Future Child 2006;16:187-207.

6. Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med 2002;346:802-810.

7. Narayan KM, Boyle JP, Thompson TJ, et al. Lifetime risk for diabetes mellitus in the United States. JAMA 2003;290:1884-1890.

8. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med 2005;352:1138-1145.

9. Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ 2005;330:1357.

10. Latner JD, Stunkard AJ. Getting worse: the stigmatization of obese children. Obes Res 2003;11:452-456.

11. Dalton S. Our Overweight Children: What Parents, Schools, and Communities Can Do to Control the Fatness Epidemic. Berkeley, University California Press, 2004.

Unbeing dead isn't being alive.
--e.e. cummings

Sharron Dalton, PhD, RD

Sharron Dalton, PhD, RD, Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York 10012. Email: [e-mail]

Reprint requests to Sharron Dalton, PhD, RD, Department of Nutrition, Food Studies, and Public Health, New York University, New York, NY 10012. Email: [e-mail]

Accepted August 2, 2006.