Weighing in on the issue of childhood obesity: an overweight child often becomes the target of discrimination and ridicule on the playground. Clearly, the problems that overweight children encounter go beyond the physical.

Kyle is outside on the school playground with the other 4-year-olds. He is standing to the side and watching longingly as other children climb the wooden ladder, crawl through the tunnels, hang from the monkey bars, and glide down the slide. Finally, with encouragement from a teacher, Kyle tries to join in. But he has difficulty keeping up with the other children. When he repeatedly tries unsuccessfully to climb the wooden ladder, some of the children laugh. One child yells out, "'My brother says you're fat." Humiliated, Kyle stops trying and moves to the sandbox to play alone.

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Kyle is one of a growing number of children who are overweight. As educators, the above scenario is cause for concern because it is not unique; an overweight child often becomes the target of discrimination and ridicule on the playground. Clearly, the problems that overweight children encounter go beyond the physical. They are also emotional and social. These preventable problems will result in untold future costs in terms of both related medical expenses and unrealized potential of our most valuable natural resource--our children.

This article focuses on overweight children and the role that educators (and schools) might play in supporting and reinforcing this unhealthful lifestyle. Included are strategies for promoting more healthful eating and activity habits. The article concludes with a list of resources offering additional help in addressing this growing threat.

WHY ALL THE Fuss ABOUT OVERWEIGHT CHILDREN?

The prevalence of overweight children in the United States and many other areas of the world has increased dramatically over the past several decades. This increase has been found among all ethnic, gender, racial, and age groups (Ogden, Flegal, Carroll, & Johnson, 2002; Smith, 1999). Currently in the United States, about 10 percent of children ages 2 to 6 and 15 percent of children ages 6 to 19 are considered overweight (Ogden et al., 2002).

This growing problem of obesity presents a number of challenges for educators and schools alike. Overweight children face higher than normal odds of suffering from both immediate and long-term physical, psychosocial, and emotional consequences (Dietz, 1998; Smith, 1999). They are at greatly increased risk for lifelong health problems, including high blood pressure and high cholesterol levels, Type II diabetes mellitus, and orthopedic complications (e.g., increased stress on weight-bearing joints). Furthermore, overweight children are at a greater risk of becoming overweight adults. The relative risk of becoming overweight as an adult increases with the age of an obese child and with the presence of obesity in at least one parent (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997).

Although greatly increased risks for health-related problems often accompany obesity, perhaps the most devastating consequences of children being overweight are psychosocial. Children develop negative attitudes about overweight peers at early ages. Unchecked, such attitudes often lead to intentional weight-related teasing.

From an early age, research suggests that many cultures stigmatize overweight children as lazy, stupid, slow, and self-indulgent (Dietz, 1998). One study, for example, found that children as young as age 6 associated being overweight with an assortment of negative characteristics, including laziness and sloppiness (Dietz, 1998). Moreover, overweight children are perceived as being less likable. As a result, they often are excluded from social development opportunities such as play. Richardson, Goodman, Hastorf, and Dornbusch (1961) and Latner and Stunkard (2003) found that 10- and 11-year-old boys and girls ranked drawings of children with a wide variety of handicaps as more likeable than children who were overweight. As a result of the negative perceptions of being overweight, obese children are likely to experience depression and low self-esteem and to become socially withdrawn (Smith, 1999). A recent study of children as young as age 5, for instance, found that overweight girls reported lower self-concept and lower perceived cognitive ability than girls of lower weight (Davison & Birch, 2001).

Obesity, then, is a complex problem with multiple consequences that are likely to affect the growth and development of increasing numbers of children. Awareness of the causes of obesity in children and its potential consequences can help educators respond more appropriately to the special needs of these children, as well as work to decrease the incidence of obesity among children.

WHY DO CHILDREN BECOME OVERWEIGHT?

In general, obesity results from an imbalance between energy intake (calories obtained from food) and energy output (calories expended in the basal metabolic rate and physical activity) (Epstein, 1993). The factors that appear to contribute to this imbalance among children, however, are complex, including economic, social, cultural, behavioral, nutritional, psychological, and genetic factors. The extent to which each of these factors contributes to obesity has not been established yet and is likely to differ among children (Smith, 1999). Smith (1999) perhaps best described this relationship in saying, "Experts believe that obesity most probably results from the interaction of an individual's genetic makeup with the environment in which the person lives" (p. 82). Regardless of the relative contribution of these variables, however, eating and activity patterns have been shown to be consistently related to obesity (Epstein, 1993)--and educators can influence these two factors.

Eating Patterns

Diets in which a high proportion of caloric intake comes from fats have been linked to childhood obesity (Parizkova & Hills, 2001; Smith, 1999). The majority of today's children consume excessive amounts of foods high in fat. A recent survey (Troiano, Briefel, Carroll, & Bialostosky, 2000) of children in the United States, for example, found that only 1 in 4 children and adolescents met U.S. Department of Agriculture (USDA) recommendations for fat intake. As a result, "inadequate amounts of fresh fruits, vegetables, and complex carbohydrates, but excessive amounts of fats, are consumed" (Smith, 1999, p. 84). A review of current food consumption practices in school settings suggests that many schools promote unhealthful eating habits. Such detrimental practices include: school meals high in fat, food-centered celebrations and activities, increased availability of a la carte food and beverage options and vending machines, rewarding children with food, and teaching staff modeling unhealthy dietary habits (e.g., drinking soda, eating candy or potato chips).

School Meals. School meals represent a major source of food eaten away from home for school-age children. Meals provided by the National School Lunch Program (NSLP) are required to be balanced and nutritious. While school lunches in 1998-1999 had fewer calories from total fat and saturated fat than in previous years, they still, on average, were found to exceed the levels for total fat and saturated fat that are considered healthful (USDA, 2001a). Children who participate in these meal programs have been found to consume higher amounts of fat and saturated fat in a 24-hour period than children who did not participate in the program (USDA, 2001b). In addition to the school meals they consume, many children have access to foods sold in a la carte sections of school cafeterias, school stores, or vending machines (Kramer-Atwood et al., 2002). Unlike the meals offered by the NSLP, however, these foods do not have to meet nutritional guidelines and are likely to be high in calories, total fat, saturated fat, added sugars, cholesterol, and/or sodium. Ninety percent of schools in the United States offer foods or beverages a la carte for lunch (USDA, 2001a). In addition, 9 percent of elementary schools have school stores or snack bars, while 15 percent have vending machines (USDA, 2001a). Such statistics suggest it is easy for children to choose unhealthful foods, which are readily available.

Food-centered Celebrations and Activities. Many schools regularly plan events for students and their families where food that is high in calories, fats, and added sugars often becomes the focal point. Examples of such events include: multicultural food festivals, ice cream socials, bake sales, and school carnivals featuring caramel popcorn, pizza, candy, soft drinks, and cotton candy. Birch, Johnson, and Fisher (1995) suggest that "the ready availability of high-fat foods, their association with positive social contexts, and children's predisposition to learn to like high-fat and other high-energy foods contributes to the increased incidence of childhood obesity" (p. 75).

Likewise, teachers often use foods to promote children's learning. Graphing children's favorite brand of chocolate chip cookies, adding and subtracting with M&M's, counting marshmallows, or making homemade ice cream are just a few common ways that teachers use foods to engage children in the learning process. Children's desire for and consumption of foods high in sugar and fat may be enhanced by environments where such foods are common (Birch & Fisher, 1998). Teachers also promote unhealthful food use by using it to reward desired classroom behavior. Teachers may, for example, have a candy jar or a candy drawer filled with different sweets that children can choose from as a special reward. When educators repeatedly reward a child with goodies that are high in sugar and/or fat, they are placing undue emphasis on these foods and sending a message that these foods are better than other, more healthful foods. This practice leads children to attach great value to such treats (Birch, Johnson, & Fisher, 1995). More important, when foods are given to children as rewards, children's preference for these foods intensifies (Birch, Johnson, & Fisher, 1995).

Teachers As Role Models. Many schools send mixed messages regarding healthful eating practices to their students. On the one hand, schools provide nutrition education that encourages healthful eating behaviors. On the other hand, teachers often endorse high fat and/or high sugar foods in their classroom activities and celebrations and use nutritionally suspect foods as rewards. This kind of environment makes it difficult for students to develop a disposition for making better eating choices. Perhaps even more important, a teacher's own unhealthful eating behaviors or negative eating attitudes provide poor models of dietary health. Educators who consume soft drinks while sitting at their desks, snack on hard candy or gum while teaching, or buy high-calorie foods from school vending machines are not setting good examples for children. Teachers serve as role models for children, and their attitudes and behaviors are extremely influential in shaping the development of children's food preferences and eating behaviors (Birch & Fisher, 1998). Children learn through observation, and demonstrating poor eating habits in front of children increases the likelihood that these behaviors will be imitated at the expense of children's health.

Activity Patterns

Many American children lead inactive lives (Harrell, Gansky, Bradley, & McMurray, 1997). Increasingly, their leisure time activities are more sedentary, with television watching, video games, and personal computing among the most popular pastimes. In several cross-sectional studies (Anderson, Crespo, Bartlett, Cheskin, & Pratt, 1998; Dietz & Gortmaker, 1985), television watching has been found to be significantly correlated with child obesity. Parizkova and Hills (2001) contend that physical activity often "decreases with increasing age, most commonly after entering primary school. This decrease in activity is related not only to time spent in school but also leisure time and weekends and during and after puberty" (p. 106). A number of activities in elementary schools currently discourage healthful patterns of activity. Such practices are especially evident in increasing numbers of physical education and school recess programs.

Physical Education Programs. Most states require students to participate in some type of physical education program (Burgeson, Wechsler, Brener, Young, & Spain, 2003). The percentage of required classes in physical education, however, declines with each subsequent grade. About one third (39.7 percent) of elementary schools require physical education in kindergarten, one half (50 percent) of elementary schools require physical education in grades 1 through 5, one fourth (25 percent) in grade 8, and only 5 percent in grade 12 (Burgeson et al., 2003).

The American Academy of Pediatrics (2000) recommends that K-12 students have daily opportunities for physical education. According to the National Association of State Boards of Education (NASBE) guidelines, elementary school students should have at least 150 minutes per week of physical education and at least 225 minutes per week when they reach middle/ junior and senior high school (Burgeson et al., 2003). The School Health Policies and Programs Study (SHPPS), conducted in 2000, found that only 8 percent of elementary schools, 6.4 percent of middle/junior high schools, and 5.8 percent of senior high schools provide daily physical education for the entire school year for all grades (Burgeson et al., 2003).

School Recess. School recess, ideally, provides children with opportunities for socialization with peers as well as physical activity. However, not all schools are required to provide students with regularly scheduled recess time. The above-mentioned School Health Policies and Programs Study (Burgeson et al., 2003) found that only a few states in the U.S. require (4.1 percent) or recommend (22.4 percent) that elementary schools provide students with regularly scheduled recess. In those school districts that have a specified time required for recess, the most common scheduled time was 20 to 29 minutes per day (35.5 percent of districts), 30 or more minutes per day (35.2 percent of districts), and 10 to 19 minutes per day (27.7 percent of districts). At the same time that children are given scant opportunities for recess, they are given increasing opportunities to entertain themselves during free time with such sedentary activities as videos or computer games, instead of engaging in even minimal physical play. Such sedentary activities promote further inactivity and greatly reduce the time children spend being physically active.

Finally, in response to pressures from No Child Left Behind legislation to boost test scores, increasing numbers of schools are cutting back on even the most minimal of recess time to devote every possible second to academic pursuits (Castle & Ethridge, 2004). In light of the rapid emergence of obesity and the resulting near certainty of associated health risks, such practices are shortsighted, at best, and likely hazardous to our children's health.

WHAT CAN TEACHERS DO?

Schools are ideal institutions for addressing childhood obesity issues. Most schools provide children with at least one meal a day, most provide opportunities for physical activity, they have the potential of integrating healthful lifestyle programs into existing curricula, and they have the potential for working with cafeteria staff, families, and community in supporting and reinforcing healthful lifestyle behaviors (Baranowski et al., 1997). Below are some specific strategies that can be used in schools to combat childhood obesity:

Provide Nutritious Foods That Meet Dietary Guidelines 

Teachers can demand that their schools provide appealing, low-fat, low-sugar foods for school meals. In this regard, Baranowski et al. (1997) suggest:

Healthy and appealing foods should be available in meals, a la carte items in cafeterias, snack bars and vending machines, as classroom snacks, and at special events, athletic competitions, staff meetings, and parents' association meetings. In addition, schools should discourage the sale of foods high in fat, sodium, and added sugars such as candy, fried chips, and soda on school grounds and as part of fundraising activities. (p. 10)

Children need access to healthful foods. When healthful foods are the only available sources of food, they may enhance a child's liking for and promote the consumption of those foods (Birch & Fisher, 1998). In one study, for example, 4th-grade students who had access to the NSLP meals (which are required to provide at least one serving of fruits or vegetables) consumed more fruits and vegetables than 5th-grade students who had access to foods from a snack bar foods (Cullen, hagen, Baranowski, Owens, & de Moor, 2000).

Consider Food Use in Programs

Teachers can refrain from using unhealthful foods as rewards, as materials for curricular activities, or as the focus of celebrations. Instead, teachers can provide nonfood rewards, such as privileges or activities, to reinforce desired behaviors. Providing a child with special time to do a favorite classroom activity is one way to motivate a child without using food. Teachers also can use nonfood materials when teaching about different concepts in the classroom. Graphing the eye color of classmates, adding and subtracting with counters or plastic chips, or making play dough are some ways that educators can engage children in the learning process without using food. In addition, educators can plan classroom celebrations where food is substituted with different activities that involve physical movement as the focal point. For example, having children engage in participatory games that emphasize cooperation rather than competition is one way to encourage physical activity. Finally, teachers can serve as role models for their students. As such, teachers must be sensitive to the messages they convey through their own dietary behaviors. Teaching a class on nutrition while drinking a can of soda clearly sends the wrong message.

Provide Opportunities for Children To Be Active

Teachers can provide environments that encourage children to be physically active. Physical exercise needs to be built into the daily routine of all schoolchildren. If your school does not provide daily physical education classes, you can still try to find time to take children outside or to the gym. Even short periods of physical activity can recharge the students' energy and provide necessary exercise time. Moreover, physical education teachers can ensure that they are not using teaching practices that overemphasize winning or competition, or that discourage the participation of children who are not good at physical activity. Instead, physical education classes should encourage cooperation and emphasize the physical development of all children (Smith, 1999). Finally, teachers should realize that physical education classes and recess are important for children's growth and development. Taking children outside at recess time and providing equipment that promotes physical activity, such as balls, jump ropes, and Frisbees, encourages children to be active. Teachers who periodically participate in different physical activities with their students promote lifelong dispositions for physical activity.

CONCLUSION

Children who are overweight face a combination of risk factors that can directly or indirectly affect classrooms. Teachers should be aware of the causes of the rapidly emerging obesity epidemic and they should understand the role they can play in stemming this major threat to the health of children. Some of the measures discussed herein might be considered important first steps to take in dealing with this complex problem. While school environments can play a powerful role in influencing children's behaviors, families and the community are equally significant, and schools should find ways to work with the families and communities to promote healthful eating and activity patterns.

References

American Academy of Pediatrics. (2000). Physical fitness and activity in schools. Pediatrics, 105(5), 1156-1157.

Anderson, R. E., Crespo, C. J., Bartlett, S. J., Cheskin, L. J., & Pratt, M. (1998). Relationship of physical activity and television watching with body weight and level of fatness among children: Results from the third National Health and Nutrition Examination Survey. JAMA, 279(12), 938-942.

Baranowski, T., Contento, I., Crockett, S. J., Evans, S., Frank, G. C., Lytle, L. A., & Manning, A.D. et al. (1997). Guidelines for school health programs to promote lifelong healthy eating. The Journal of School Health, 67, 9-26.

Birch, L. L., & Fisher, J. O. (1998). Development of eating behaviors among children and adolescents. (The causes and health consequences of obesity in children and adolescents). Pediatrics, 101(3), 539-550.

Birch, L. L., Johnson, S. L., & Fisher, J. A. (1995). Children's eating: The development of food-acceptance patterns. Young Children, 50(2), 71-78.

Burgeson, C. R., Wechsler, H., Brener, N. D., Young, J. C., & Spain, C. G. (2003). Physical education and activity: Results from the school health policies and programs study 2000. The Journal of Physical Education, Recreation & Dance, 74, 19-37.

Castle, K., & Ethridge, E. A. (2003). Urgently needed: Autonomous and effective early childhood teacher educators. Journal of Early Childhood Teacher Education, 24(2), 111-118.

Cullen, K. W., Eagan, J., Baranowski, T., Owens, E., & de Moor, C. (2000). Effect of a la carte and snack bar foods on children's lunchtime intake of fruits and vegetables. Journal of American Dietetic Association, 100(12), 1482-1486.

Davison, K. K., & Birch, L.L. (2001). Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics, 107(1), 46-53.

Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. (The causes and health consequences of obesity in children and adolescents.) Pediatrics, 101(3), 518-525.

Dietz, W. H., & Gortmaker, S. L. (1985). Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics, 75(5), 807-812.

Epstein, L. H. (1993). New developments in childhood obesity. In A. J. Stunkard & T. A. Wadden (Eds.), Obesity: Theory and therapy (pp. 301-312). New York: Raven Press.

Harrell, J. S., Gansky, S. A., Bradley, C. B., & McMurray, R. G. (1997). Leisure time activities of elementary school children. Nursing Research, 46(5), 246-253.

Kramer-Atwood, J. L., Dwyer, J., Hoelscher, D. W., Nicklas, T. A., Johnson, R. K., & Schulz, G. K. (2002). Fostering healthy food consumption in schools: Focusing on the challenge of competitive foods. Journal of the American Dietetic Association, 102(9), 1228-1233.

Latner, J. D., & Stunkard, A.J. (2003). Getting worse: The stigmatization of obese children. Obesity Research, 11,452-456.

Ogden, C. L., Flegal, K. M., Carroll, M. D., & Johnson, C. L. (2002). Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA, 288(14), 1728-1732.

Parizkova, J., & Hills, A. (2001). Childhood obesity: Prevention and treatment. Washington, DC: CRC Press.

Richardson, S. A., Goodman, N., Hastorf, H. A., & Dornbusch, S.M. (1961). Cultural uniformity in reaction to physical disabilities. American Sociological Review, 26(2), 241-247.

Smith, J. C. (1999). Understanding childhood obesity. Jackson, MS: University Press of Mississippi.

Troiano, R. P., Briefel, R. R., Carroll, M. D., & Bialostosky, K. (2000). Energy and fat intakes of children and adolescents in the United States: Data from the National Health and Nutrition Examination Surveys. American Journal of Clinical Nutrition, 72, 1343S-1353S.

U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation. (2001a). School nutrition dietary assessment study-II: Summary of findings. Retrieved April 29, 2003, from www.fns.usda.gov / oane / MENU / Published / CNP / CNP.HTM 

U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation. (2001b). Children's diets in the mid-1990s: Dietary intake and its relationship with school meal participation. CN-O1-CDI. Retrieved April 29, 2003, from www.fns.usda.gov/OANE/ MENU / published / CNP / CNP.HTM

Whitaker, R. C., Wright, J. A., Pepe, M. S., Seidel, K. D., & Dietz, W. H. (1997). Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine, 337(13), 869-873.

Additional Resources

American Obesity Association www.obesity.org / subs / childhood / healthrisks.shtml This Web site provides information on research, prevention, and treatment of obesity.

Food and Nutrition Information Center www.nal.usda.gov / fnic / etext / 000023.html This Web site provides information on Food Guide Pyramids for different cultures.

Center for Nutrition, Policy and Promotion (CNPP) www.usda.gov/cnpp This Web site provides nutrition information on projects, publications, and reports, such as the Food Guide Pyramid for young children or Dietary Guidelines for Americans.

International Association for the Study of Obesity (IASO) www.iotf.org This Web site provides information as well as links from an international perspective of the problem of obesity.

Cynthia Lynn-Garbe is a doctoral student in early childhood education. James L. Hoot is Professor, Early Childhood Education, and Director, Early Childhood Research Center, Department of Learning and Instruction, State University of New York at Buffalo.