Future of Children

The Future of Children
Volume 16, Number 1, Spring 2006
Childhood Obesity

CONTENTS

    Anderson, Patricia M., 1963-
    Butcher, Kristin F. (Kristin Frances)
  • Childhood Obesity: Trends and Potential Causes
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    Subject Headings:
    • Obesity in children -- United States.
    Abstract:
      The increase in childhood obesity over the past several decades, together with the associated health problems and costs, is raising grave concern among health care professionals, policy experts, children's advocates, and parents. Patricia Anderson and Kristin Butcher document trends in children's obesity and examine the possible underlying causes of the obesity epidemic.

      They begin by reviewing research on energy intake, energy expenditure, and "energy balance," noting that children who eat more "empty calories" and expend fewer calories through physical activity are more likely to be obese than other children. Next they ask what has changed in children's environment over the past three decades to upset this energy balance equation. In particular, they examine changes in the food market, in the built environment, in schools and child care settings, and in the role of parents—paying attention to the timing of these changes.

      Among the changes that affect children's energy intake are the increasing availability of energy-dense, high-calorie foods and drinks through schools. Changes in the family, particularly an increase in dual-career or single-parent working families, may also have increased demand for food away from home or pre-prepared foods. A host of factors have also contributed to reductions in energy expenditure. In particular, children today seem less likely to walk to school and to be traveling more in cars than they were during the early 1970s, perhaps because of changes in the built environment. Finally, children spend more time viewing television and using computers.

      Anderson and Butcher find no one factor that has led to increases in children's obesity. Rather, many complementary changes have simultaneously increased children's energy intake and decreased their energy expenditure. The challenge in formulating policies to address children's obesity is to learn how best to change the environment that affects children's energy balance.

    Daniels, Stephen R.
  • The Consequences of Childhood Overweight and Obesity
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    Subject Headings:
    • Obesity in children -- Complications -- United States.
    • Obesity in adolescence -- Complications -- United States.
    Abstract:
      Researchers are only gradually becoming aware of the gravity of the risk that overweight and obesity pose for children's health. In this article Stephen Daniels documents the heavy toll that the obesity epidemic is taking on the health of the nation's children. He discusses both the immediate risks associated with childhood obesity and the longer-term risk that obese children and adolescents will become obese adults and suffer other health problems as a result.

      Daniels notes that many obesity-related health conditions once thought applicable only to adults are now being seen in children and with increasing frequency. Examples include high blood pressure, early symptoms of hardening of the arteries, type 2 diabetes, nonalcoholic fatty liver disease, polycystic ovary disorder, and disordered breathing during sleep.

      He systematically surveys the body's systems, showing how obesity in adulthood can damage each and how childhood obesity exacerbates the damage. He explains that obesity can harm the cardiovascular system and that being overweight during childhood can accelerate the development of heart disease. The processes that lead to a heart attack or stroke start in childhood and often take decades to progress to the point of overt disease. Obesity in childhood, adolescence, and young adulthood may accelerate these processes. Daniels shows how much the same generalization applies to other obesity-related disorders—metabolic, digestive, respiratory, skeletal, and psychosocial—that are appearing in children either for the first time or with greater severity or prevalence.

      Daniels notes that the possibility has even been raised that the increasing prevalence and severity of childhood obesity may reverse the modern era's steady increase in life expectancy, with today's youth on average living less healthy and ultimately shorter lives than their parents—the first such reversal in lifespan in modern history. Such a possibility, he concludes, makes obesity in children an issue of utmost public health concern.

    Cawley, John H. (John Horan)
  • Markets and Childhood Obesity
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    Subject Headings:
    • Obesity in children -- Economic aspects -- United States.
    • Medical policy -- United States.
    Abstract:
      In examining the childhood obesity epidemic from the perspective of economics, John Cawley looks at both possible causes and possible policy solutions that work through markets. The operation of markets, says Cawley, has contributed to the recent increase in childhood overweight in three main ways. First, the real price of food fell. In particular, energy-dense foods, such as those containing fats and sugars, became relatively cheaper than less energy-dense foods, such as fresh fruits and vegetables. Second, rising wages increased the "opportunity costs" of food preparation for college graduates, encouraging them to spend less time preparing meals. Third, technological changes created incentives to use prepackaged food rather than to prepare foods.

      Several economic rationales justify government intervention in markets to address these problems. First, because free markets generally under-provide information, the government may intervene to provide consumers with nutrition information they need. Second, because society bears the soaring costs of obesity, the government may intervene to lower the costs to taxpayers. Third, because children are not what economists call "rational consumers"—they cannot evaluate information critically and weigh the future consequences of their actions—the government may step in to help them make better choices.

      The government can easily disseminate information to consumers directly, but formulating policies to address the other two rationales is more difficult. In the absence of ideal policies to combat obesity, the government must turn to "second-best" policies. For example, it could protect children from advertisements for "junk food." It could implement taxes and subsidies that discourage the consumption of unhealthful foods or encourage physical activity. It could require schools to remove vending machines for soda and candy.

      From the economic perspective, policymakers should evaluate these options on the basis of cost-effectiveness studies. Researchers, however, have as yet undertaken few such studies of obesity-related policy options. Such analyses, once available, will help policymakers achieve the greatest benefit from a fixed budget.

    Sallis, James F.
    Glanz, Karen.
  • The Role of Built Environments in Physical Activity, Eating, and Obesity in Childhood
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    Subject Headings:
    • Obesity in children -- United States.
    • Exercise for children -- United States.
    • Children -- United States -- Nutrition.
    Abstract:
      Over the past forty years various changes in the U.S. "built environment" have promoted sedentary lifestyles and less healthful diets. James Sallis and Karen Glanz investigate whether these changes have had a direct effect on childhood obesity and whether improvements to encourage more physical activity and more healthful diets are likely to lower rates of childhood obesity.

      Researchers, say Sallis and Glanz, have found many links between the built environment and children's physical activity, but they have yet to find conclusive evidence that aspects of the built environment promote obesity. For example, certain development patterns, such as a lack of sidewalks, long distances to schools, and the need to cross busy streets, discourage walking and biking to school. Eliminating such barriers can increase rates of active commuting. But researchers cannot yet prove that more active commuting would reduce rates of obesity.

      Sallis and Glanz note that recent changes in the nutrition environment, including greater reliance on convenience foods and fast foods, a lack of access to fruits and vegetables, and expanding portion sizes, are also widely believed to contribute to the epidemic of childhood obesity. But again, conclusive evidence that changes in the nutrition environment will reduce rates of obesity does not yet exist.

      Research into the link between the built environment and childhood obesity is still in its infancy. Analysts do not know whether changes in the built environment have increased rates of obesity or whether improvements to the built environment will decrease them. Nevertheless, say Sallis and Glanz, the policy implications are clear. People who have access to safe places to be active, neighborhoods that are walkable, and local markets that offer healthful food are likely to be more active and to eat more healthful food—two types of behavior that can lead to good health and may help avoid obesity.

    Story, Mary, Ph. D.
    Kaphingst, Karen M.
    French, Simone.
  • The Role of Schools in Obesity Prevention
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    Subject Headings:
    • Obesity in children -- United States -- Prevention.
    • Exercise for children -- United States.
    • Children -- United States -- Nutrition.
    Abstract:
      Mary Story, Karen Kaphingst, and Simone French argue that U.S. schools offer many opportunities for developing obesity-prevention strategies by providing more nutritious food, offering greater opportunities for physical activity, and providing obesity-related health services.

      Meals at school are available both through the U.S. Department of Agriculture's school breakfast and lunch programs and through "competitive foods" sold à la carte in cafeterias, vending machines, and snack bars. School breakfasts and school lunches must meet federal nutrition standards, but competitive foods are exempt from such requirements. And budget pressures force schools to sell the popular but nutritionally poor foods à la carte. Public discomfort with the school food environment is growing. But can schools provide more healthful food options without losing money? Limited evidence shows that they can.

      Although federal nutrition regulations are inadequate, they permit state and local authorities to impose additional restrictions. And many are doing so. Some states limit sales of nonnutritious foods, and many large school districts restrict competitive foods.

      Several interventions have changed school food environments, for example, by reducing fat content of food in vending machines and making more fruits and vegetables available. Interventions are just beginning to target the availability of competitive foods.

      Other pressures can also compromise schools' efforts to encourage physical activity. As states use standardized tests to hold schools and students academically accountable, physical education and recess have become a lower priority. But some states are now mandating and promoting more physical activity in schools. School health services can also help address obesity by providing screening, health information, and referrals to students, especially low-income students, who are at high risk of obesity, tend to be underinsured, and may not receive health services elsewhere.

    Story, Mary, Ph. D.
    Kaphingst, Karen M.
    French, Simone.
  • The Role of Child Care Settings in Obesity Prevention
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    Subject Headings:
    • Obesity in children -- United States -- Prevention.
    • Exercise for children -- United States.
    • Children -- United States -- Nutrition.
    • Day care centers -- Health aspects -- United States.
    Abstract:
      Mary Story, Karen Kaphingst, and Simone French argue that researchers and policymakers focused on childhood obesity have paid insufficient attention to child care. Although child care settings can be a major force in shaping children's dietary intake, physical activity, and energy balance—and thus in combating the childhood obesity epidemic—researchers know relatively little about either the nutrition or the physical activity environment in the nation's child care facilities. What research exists suggests that the nutritional quality of meals and snacks may be poor and activity levels may be inadequate.

      Few uniform standards apply to nutrition or physical activity offerings in the nation's child care centers. With the exception of the federal Head Start program, child care facilities are regulated by states, and state rules vary widely. The authors argue that weak state standards governing physical activity and nutrition represent a missed opportunity to combat obesity. A relatively simple measure, such as specifying how much time children in day care should spend being physically active, could help promote healthful habits among young children.

      The authors note that several federal programs provide for the needs of low-income children in child care. The Child and Adult Care Food Program, administered by the Department of Agriculture, provides funds for meals and snacks for almost 3 million children in child care each day. Providers who receive funds must serve meals and snacks that meet certain minimal standards, but the authors argue for toughening those regulations so that meals and snacks meet specific nutrient-based standards. The authors cite Head Start, a federal preschool program serving some 900,000 low-income infants and children up to age five, as a model for other child care programs as it has federal performance standards for nutrition.

      Although many child care settings fall short in their nutritional and physical activity offerings, they offer untapped opportunities for developing and evaluating effective obesity-prevention strategies to reach both children and their parents.

    Lindsay, Ana C.
    Sussner, Katarina M.
    Kim, Juhee.
    Gortmaker, Steven Lawrence, 1949-
  • The Role of Parents in Preventing Childhood Obesity
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    Subject Headings:
    • Obesity in children -- United States -- Prevention.
    • Exercise for children -- United States.
    • Children -- United States -- Nutrition.
    • Parenting -- United States.
    Abstract:
      As researchers continue to analyze the role of parenting both in the development of childhood overweight and in obesity prevention, studies of child nutrition and growth are detailing the ways in which parents affect their children's development of food- and activity-related behaviors. Ana Lindsay, Katarina Sussner, Juhee Kim, and Steven Gortmaker argue that interventions aimed at preventing childhood overweight and obesity should involve parents as important forces for change in their children's behaviors.

      The authors begin by reviewing evidence on how parents can help their children develop and maintain healthful eating and physical activity habits, thereby ultimately helping prevent childhood overweight and obesity. They show how important it is for parents to understand how their roles in preventing obesity change as their children move through critical developmental periods, from before birth and through adolescence. They point out that researchers, policymakers, and practitioners should also make use of such information to develop more effective interventions and educational programs that address childhood obesity right where it starts—at home.

      The authors review research evaluating school-based obesity-prevention interventions that include components targeted at parents. Although much research has been done on how parents shape their children's eating and physical activity habits, surprisingly few high-quality data exist on the effectiveness of such programs. The authors call for more programs and cost-effectiveness studies aimed at improving parents' ability to shape healthful eating and physical activity behaviors in their children.

      The authors conclude that preventing and controlling childhood obesity will require multifaceted and community-wide programs and policies, with parents having a critical role to play. Successful intervention efforts, they argue, must involve and work directly with parents from the earliest stages of child development to support healthful practices both in and outside of the home.

    Kumanyika, Shiriki Kinika, 1945-
    Grier, Sonya.
  • Targeting Interventions for Ethnic Minority and Low-Income Populations
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    Subject Headings:
    • Obesity in children -- United States -- Prevention.
    • Children of minorities -- Health and hygiene -- United States.
    • Poor children -- Health and hygiene -- United States.
    Abstract:
      Although rates of childhood obesity among the general population are alarmingly high, they are higher still in ethnic minority and low-income communities. The disparities pose a major challenge for policymakers and practitioners planning strategies for obesity prevention. In this article Shiriki Kumanyika and Sonya Grier summarize differences in childhood obesity prevalence by race and ethnicity and by socioeconomic status. They show how various environmental factors can have larger effects on disadvantaged and minority children than on their advantaged white peers—and thus contribute to disparities in obesity rates.

      The authors show, for example, that low-income and minority children watch more television than white, non-poor children and are potentially exposed to more commercials advertising high-calorie, low-nutrient food during an average hour of TV programming. They note that neighborhoods where low-income and minority children live typically have more fast-food restaurants and fewer vendors of healthful foods than do wealthier or predominantly white neighborhoods. They cite such obstacles to physical activity as unsafe streets, dilapidated parks, and lack of facilities. In the schools that low-income and minority children attend, however, they see opportunities to lead the way to effective obesity prevention. Finally, the authors examine several aspects of the home environment—breast-feeding, television viewing, and parental behaviors—that may contribute to childhood obesity but be amenable to change through targeted intervention.

      Kumanyika and Grier point out that policymakers aiming to prevent obesity can use many existing policy levers to reach ethnic minority and low-income children and families: Medicaid, the State Child Health Insurance Program, and federal nutrition "safety net" programs. Ultimately, winning the fight against childhood obesity in minority and low-income communities will depend on the nation's will to change the social and physical environments in which these communities exist.

    Caprio, Sonia.
  • Treating Child Obesity and Associated Medical Conditions
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    Subject Headings:
    • Obesity in children -- Treatment -- United States.
    Abstract:
      With American children on course to grow into the most obese generation of adults in history, Sonia Caprio argues that it is critical to develop more effective strategies for preventing childhood obesity and treating serious obesity-related health complications. She notes that although pediatricians are concerned about the obesity problem, most are ineffective in addressing it.

      Treatment should begin, Caprio explains, with a thorough medical exam, an assessment of nutrition and physical activity, an appraisal of the degree of obesity and associated health complications, a family history, and full information about current medications. Caprio also summarizes the current use of medications and surgery in treating child obesity and argues that for severe forms of obesity, the future lies in developing new and more effective drugs.

      Caprio explains that today's most effective obesity treatment programs have been carried out in academic centers through an approach that combines a dietary component, behavioral modification, physical activity, and parental involvement. Such programs, however, have yet to be translated to primary pediatric care centers. Successfully treating obesity, she argues, will require a major shift in pediatric care that builds on the findings of these academic centers regarding structured intervention programs.

      To ensure that pediatricians are well trained in implementing such programs, the American Medical Association is working with federal agencies, medical specialty societies, and public health organizations to teach doctors how to prevent and manage obesity in both children and adults. Such training should be a part of undergraduate and graduate medical education and of continuing medical education programs.

      Caprio also addresses the problem of reimbursement for obesity treatment. Despite the health risks of obesity, patients get little support from health insurers, thus putting long-term weight-management programs beyond the reach of most. Caprio argues that obesity should be recognized as a disease and receive coverage for its treatment just as other diseases do.




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