by Caroline J. Cederquist, M.D.
Diplomate of the American Board of Bariatric Medicine

Ten-year-old Joe is too heavy. He hates to exercise. Like his parents, who were never particularly gifted in sports, he prefers to read, watch TV or play Nintendo rather than run and romp outdoors. During the rare gym class at school, when he is forced to play softball, Joe spends a little time trying to catch the ball and throw it to another player, but his skill level falls far below his classmates’. Joe is nearly the last one picked to be on a team, reinforcing his dislike of sports and exercise. After school, he feels depressed, unwanted. While watching TV, he polishes off a bag of potato chips and a Coke.

Joe represents a sad scenario that has been repeated far too often in recent times. Over the past 20 years, the rates of obesity have taken a dramatic upswing. Today, 27 percent of children are classified as obese [carrying an excess accumulation of body fat], representing a 54 percent increase in the last two decades. Similarly, adolescents show a prevalence of obesity at the 21 percent mark, which reflects a 39 percent increase over that same time period.

What has caused such an alarming jump in childhood obesity? And, more important, can this trend be reversed?

Is it a medical condition? Or genetics?

Many components influence the development of childhood obesity. I have found that parents often worry that their child’s obesity is caused by a medical condition. Studies indicate this is rare, occurring in only one to 10 percent of cases of childhood obesity. The majority of those children who are obese because of an underlying hormonal or defined genetic defect also experience a deficiency in height. An annual checkup with a family physician or pediatrician can monitor overall growth patterns to rule out a medical cause of obesity.

A child with evidence of obesity needs a blood analysis to determine thyroid and liver function, and to evaluate cholesterol and glucose levels, as well as fasting serum insulin levels. Just as in adults, obesity-- excess fat-- is responsible for the metabolic changes that can bring on elevated cholesterol and blood pressure, diabetes and a predisposition to early heart disease.

Several other medical conditions are related to obesity. Bone and soft tissue problems often result from the excess fat’s additional weight on the body structure. Sleep apnea and other sleep disturbances that are more common in obese children than in their leaner peers may indirectly affect school performance.

From genetic studies, we know that various factors, such as basal metabolic rate-- the level at which energy is expended while the person is at rest-- are passed from parent to child. Also inherited is the rate at which food intake increases metabolism. Other genetically determined elements include appetite control, what it takes to feel satisfied, and the metabolism and storage of fat.

While it is important to recognize the genetic factors in the development of obesity as a way to dispel some of the guilt, and consequent depression and low self-esteem which often accompany it, we must focus our attention on lifestyle issues. Human genetic makeup has not changed in the past 20 years, so we can’t point to that as the primary cause of the epidemic of childhood obesity. Rather, it is a lifestyle that combines an increasing tendency toward sedentary activity with a diet laden with fat and calories.

Too much television, too little exercise

In the United States, people spend more time watching television than any other activity except working and sleeping. Over the course of the year children and adolescents spend more time watching TV than time in school. Surveys show children ages 6-11 spent 3.5 hours a day watching television and adolescents aged 12 -17 spend three hours a day at this “activity.”

The National Health Examination Survey data showed that television watching was the most important indicator of obesity in adolescence. Obviously, time spent in this sedentary activity detracts from time spent doing activity which could result in a greater calorie expenditure, such as playing vigorously outdoors. In addition, TV viewing is often accompanied by snacking, predominantly with food high in calories. An article in the Journal of the American Dietetic Association revealed that during prime time TV watching the average person eats eight times more compared to other times of the day! Commercials which depict mouthwatering foods-- often being eaten by beautiful, thin people-- no doubt play a substantial role here.

During children's programming advertisements are loud, bright and tout the taste appeal of cereal that looks like cookies or candy. This cereal is said to be “part of this complete breakfast” when combined with juice, toast, butter, jam and milk. When I do the nutritional analysis of that meal, I find it extremely high in processed flour, sugar and fat and sorely lacking fiber and protein. As a parent of two children ages six and four, I know how persuasive food advertisements are. My daughters have given up asking me to purchase these cereals at the grocery store, but every once and a while a box of classic “kid’s” cereal will enter the house, usually via a visiting grandma. It is interesting to see how quickly the box of cereal disappears, with my daughters requesting a second and third serving at breakfast and another bowl as an after-school snack. From years of treating patients with obesity, I know that highly sugared foods stimulate more eating during the day.

Recent study results analyzed what happens to body metabolism while a kid watches TV. Researchers found that children's basal metabolic rates lapsed into a deeply relaxed, semiconscious state as they watched a 25-minute show. Children of normal weight had a decline in their metabolic rate of 12 percent, and obese children's metabolism declined by 16 percent. This decline in the metabolic rate accompanied with increased snacking and decreased physical activity place television viewing as one of the most important lifestyle changes parents must consider to decrease the incidence of obesity.

We must also place video-game playing and Internet and computer use in a category similar to television watching. Participation in these activities is on the rise, especially among adolescents-- an obvious factor in the increasing prevalence of obesity.

Changing dietary and family habits

Dietary habits have changed considerably over the past 20 years and directly contribute to the rise in obesity. Currently three-quarters of all meals are eaten outside the home, with the majority being eaten at restaurants. In 1994, fast food business comprised 47 percent of all restaurant sales.

The increasing reliance on restaurant and fast foods increases obesity in several ways. First, in order to make the foods taste better, restaurant chefs add notoriously high amounts of sodium and fat. Second, portion sizes are considerably larger at a restaurant-- often to help justify the cost of the meal. We are aware of the great bargain of “supersizing” our soda and French fries for a mere 39 cents. Most people by nature are “completers”: if we are given a larger portion we will finish it. After all, it is right there in front of us and paid for. Finally, after spending considerable time at restaurants, families increase their portion sizes when eating at home to make those servings more consistent with the restaurant meals.

Family dynamics have also changed, with many families having both parents working. Less time is available for preparing homemade foods, increasing the reliance on restaurant and pre-prepared foods. Pre-prepared meals can be found that pay attention to nutrient content, but the majority tend to be higher in fat and lower in fiber than recommended. Fewer families eat together these days, and busy schedules, especially in the adolescent years, can force family members to “fend for themselves.” When adults and teens grab something quick and convenient, it is rarely a healthful choice. Instead, we go for processed foods higher in sugar and fat.

Lack of physical activity also contributes to childhood obesity. Budgetary constraints have caused many schools to reduce or eliminate physical education for the student body.

Average grade schoolers these days receive only thirty minutes of physical education per week. Since the schools place little importance on physical activity, more and more young “Joes” are being created.

The decrease in physical activity is not entirely due to a lack of formal exercise like sports. We also experience less physical exertion in our daily living. I routinely question the audience at a lecture on obesity as to who remembers walking to school as a child. The majority of hands will go up. When I ask who has a child or grandchild who walks to school, I often have no or only one positive response. There are many reasons our children don't walk to school, including safety and changes in community development so that schools are not within walking distance. The bottom line is that children-- and adults-- have to make efforts to be more physically active because it is not happening in the day-to-day experience of our modern lives.

Strategies to treat or prevent obesity

Busy parents need practical advice on how to decrease the likelihood of obesity in their children while living our modern lives. The first recommendation I would make is to limit television watching. Parents can accomplish better relaxation habits by selecting videos for their children to watch, rather than TV shows, while Mom and Dad are busy preparing dinner. The videos are a specified length in time and usually do not contain commercial advertisement for high fat foods. By choosing videos, parents can also monitor the content, selecting those that support values the family considers important. I recommend that parents provide children with a television allowance of a certain number of minutes per day or per week so children plan their viewing as an event and not as a substitute for physical play or reading.

The second recommendation is to add more physical activity as a family. With our busy lives, this will take time and effort to implement, but children are really desperate to spend more fun time with their parents. Suggestions include bicycle riding, playing Frisbee or catch in the yard, hide and seek and tag with a lot of running. You might even try vigorous dancing to loud and fun music as a family. If it is impossible for the parents to participate in these activities, they might engage a teenage baby-sitter or playmate whose responsibility would be playing actively with their kids several days a week. What a healthy investment this would be! Activities like washing the family car and house-cleaning can be creatively developed to accomplish needed tasks and provide exercise at the same time. If the parents are able to afford the time and money for lessons of interest to the child, such as swimming or tennis, these sports will also set the foundation for a more active lifestyle into their adult years. Participating in team sports at a younger age can instill confidence and an enjoyment of physical activity. Remember: it may take several trials of different activities to see what a particular child will enjoy or excel at, so don’t give up!

Families often acknowledge achievement in school or other arenas with food and celebration. A novel twist would be to plan a family camping trip or bike ride as praise and celebration of an excellent report card.

Nutritional interventions are very important in the prevention and treatment of obesity. Of utmost importance is a commitment to involve the entire family in better nutritional habits. It is not fair to have tempting foods in the house and then blame the overweight child for wanting to eat them. The family does not have to always be on a diet, but a conscious effort to eliminate empty calories from the family's diet is important.

I recommend changing the type of liquids the family consumes daily. Surveys reveal that children drink much more soda-- which possesses no nutritive value, only empty calories-- than either milk or water. Soda should not be a staple of the diet but allowed only on limited occasions. I advise parents to stop drinking it themselves and replace it with water as the beverage of the household. Changing this habit is a fairly painless way to avoid extra calories.

With regards to milk, the family should drink skim milk. Children below the age of two need to drink whole milk for important brain development. However, after the age of two the only benefit of whole over skim milk is excess fat, which most children do not need. Many parents are confused by food labels and feel 2% milk is a low fat product. At five grams of fat per cup, it is not. Skim-- fat free-- milk has no grams of fat but contains all the protein, carbohydrate and calcium of whole milk. Children raised on skim milk are used to the taste of it, whereas children raised on whole or 2% milk may find it watery if they are introduced to it later in life.

I recommend that parents limit the amounts of juices and fruit-flavored drinks served in the family. These drinks often bear the label “contains 100% of the day’s requirement of vitamin C,” making them appear to be healthful. However, these drinks often contain added sugar. It is easy to drink large quantities and thus consume too many calories.

Pure juice products are better nutritionally because they contain more nutrients, but the volume of juice still needs to be limited. When fruits are taken in as juice, they lack the fiber contained in the whole fruit, which is important in digestion and the satisfaction of hunger. Juices are metabolized quickly and leave one hungry again quickly, whereas fruit promotes a feeling of fullness or satiety.

I recommend that parents take advantage of their children's natural appetites. Most children are ravenously hungry at three to four PM, after school. This is an excellent opportunity for children to eat fruits and vegetables. At this time, they will readily eat grapes, apple or pear segments or cut-up carrots, peppers or celery along with a low fat dip. The same vegetables presented with dinner may be given little attention by the child who prefers the other-- higher calorie-- foods served with the meal. I advise parents to buy precleaned baby carrots for their ease of preparation-- none-- and cut up the fruit snacks the evening before.

As a modern convenience, parents should take advantage of frozen vegetables. With busy schedules, fresh vegetables are often bought but not used while their nutrient content is best. A frozen vegetable medley or broccoli bits have as many nutrients and almost as much taste as the fresh variety. Their quick addition to a fast meal like chicken breast-- or even pizza-- improves nutritional values without piling on the calories.

Serving foods “family style” may encourage more eating of favorite foods. I suggest that the plates be filled from the stove instead of from bowls on the table that may encourage “seconds.” This is specially important with desserts, which should never be accessible on the table.

Candy and treats do not have to be banished forever, but the two- to three-pound bags of M&Ms sold at food clubs should be. I once commented to my six-year-old that she took quite a few handfuls of a snack food. She advised me there was a lot left plus we had another bag. The mere availability of more snack food influenced the speed of her eating, as if she was trying to get as much as possible before it was taken away. I have since found that single-serving size treats and candies are savored and enjoyed more slowly because there is an awareness that once they are gone there will be no more.

Finally, parents need to expose their children to a variety of different foods.

Studies show that most obese adults have a limited selection of what they are willing to eat. This certainly makes substituting healthier choices more difficult. It is a paradox that overweight individuals-- because they eat the wrong things-- can be undernourished. Yes, some children are picky and eat only kid fare of burgers, fries and chicken nuggets. They are less likely to turn up their nose at a new food, however, if it is presented in a small quantity along with some favorite foods. Try it and see!

For both adults and children, the treatment of obesity presents many challenges. Although it takes effort, prevention is far easier. So initiate appropriate lifestyle changes, replace sedentary activities with robust exercise and practice better eating habits. The healthier results are worth the effort!

Caroline J. Cederquist, M.D. is a board certified Bariatric Physicians, the medical specialty of weight management, and a board certified Family Physician. She specializes in lifetime weight management at the Cederquist Medical Wellness Center, her Naples, FL private practice.

Dr. Cederquist is a contributing medical editor for NBC-2 News, a trustee of the American Society Of Bariatric Physicians and the author of " Helping Your Overweight Child - A Family Guide", www.Amazon.Com or by Calling Toll-Free 1-800-431-1579.

If you are interested in a delicious, doctor-designed, foolproof plan for fast and healthy weight loss please visit Dr. Cederquist's Diet-To-Your-Door program by clicking here.

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