Childhood Obesity: Beyond Baby Fat

One Family's Struggle

Until the blood test, Stacey Parisi, of Howard Beach, New York, had never worried about her son, Phillip's, weight. Sure, he was a chubby baby, often charting above the 90th percentile for weight and only 50 to 60 for height. But Parisi was confident that the baby fat would simply burn off as Phillip got older. So you can imagine her shock when the doctor called earlier this year with bad news about 4-year-old Phillip's cholesterol. At 254, it wasn't merely high -- it was actually higher than Phillip Sr.'s 246, and way beyond 170, the American Heart Association's target level for children. "I've always been worried about cholesterol with my husband," Parisi says, "and now I have a 4-year-old I have to worry about."

At 47 pounds, Phillip's body mass index (BMI), a calculation that, for children, uses height, weight, age, and gender to determine total body fat, is above the 95th percentile. That puts him in the obese category, according to the American Academy of Pediatrics (AAP). Doctors, including a lipid disorder specialist, have said they're not overly concerned now because he is young enough to make the changes necessary to avoid disease. They warn, however, that Phillip's weight could become a problem in the future, especially if he were to trade in his sneakers for a video game controller. That, combined with a family history of overweight and heart disease, was enough to convince Parisi to revamp household habits.

Small Changes Toward Better Health

She started by reading food labels. One of the first things to go was the boxed macaroni and cheese. Now she makes her own and controls the amount of cheddar and butter. Instead of the instant pancake mix, she buys the basic variety and adds her own egg whites and skim milk. Cheese, yogurt, and milk are all low-fat or fat-free. And Phillip Sr., never a fan of vegetables, is now filling his plate with them. Being a role model matters when it comes to diet. "It's hard to change habits, but slowly we're working on them," says Parisi. These changes have helped Phillip's cholesterol come down 25 points so far. And his weight gain has been steady -- another good sign.

The Parisis are one of a growing number of families worried about their children's waistlines and the diseases that could come along with obesity. Sandra Hassink, MD, director of the Pediatric Weight Management Clinic at Alfred I. duPont Hospital for Children, in Wilmington, Delaware, says that about two-thirds of the kids treated for obesity in her weight management program have high cholesterol. And nationwide, 9 percent of children ages 2 to 5 are above the 95th percentile, according to research from the Woodrow Wilson School of Public and International Affairs at Princeton University, in New Jersey, and The Brookings Institution, in Washington, D.C. Thirty years ago, that number was 6.5 percent. Plus, one out of every five 4-year-olds who is obese will continue to carry extra weight in adulthood, says Dr. Hassink, who is also the editor in chief of the AAP's new book, A Parent's Guide to Childhood Obesity: A Road Map to Health (IPG).

Weight-Related Health Issues

There is no "magic number" indicating when a child's weight goes from an afterthought to a serious concern, says Henry Anhalt, MD, director of pediatric endocrinology at St. Barnabas Medical Center, in Livingston, New Jersey. The number on the scale is just one part of the equation. A family history of obesity or diabetes, especially at an early age, is something your doctor should know about.

Diabetes & Other Conditions

Diabetes is one of the direst complications of excessive weight. Overweight children are at increased risk of developing type 2 diabetes. Before 1994, less than 5 percent of childhood diabetes diagnoses were type 2; more recently, with rising obesity rates, 30 to 50 percent of new pediatric cases of diabetes are type 2. Dr. Anhalt has seen a child as young as 6 years with type 2. It's a diagnosis he hates to make. "Type 2 diabetes represents the end of the road," says Dr. Anhalt. Once type 2 diabetes sets in, unfortunately, "you can't just say lose weight and it will go away," he says.

The road to obesity is littered with diseases no child should have to confront. The snores of an overweight toddler could someday develop into obstructive sleep apnea, a collapse or narrowing of the airway that can inhibit breathing, and overweight children are more likely to develop asthma. Atherosclerosis (arterial plaque), which can result from high cholesterol, a risk factor for heart disease, has been seen in children as young as 3 years old. Liver disease, gallstones, pancreatitis, and severe headaches are also seen in these children. "I went into pediatrics to take care of healthy, bouncing babies," says Dr. Anhalt. "Instead, I'm putting kids on multiple drugs to get their triglycerides under control."

Hormonal Issues

Fat excretes hormones, and the more fat, the more hormones. In girls this may lead to menstrual irregularities, such as polycystic ovarian syndrome, a leading cause of infertility. In boys, the concern is gynecomastia, or breast enlargement. Extreme weight can lead to infections in skin folds and pain in the knees, thighs, back, and hips. And then there are the psychological repercussions: The low self-esteem these kids feel can erode confidence and sabotage educational success.

How Does Fat Happen?

Just as eye color is inherited, so is a propensity toward a husky build. If one parent is obese, your child's risk triples, says Dr. Hassink. If you both are, he is at 10 times the risk.

Big Babies, Small Babies

Plus, there's also a prenatal connection. Gaining too little weight when pregnant can result in a baby who is small for his gestational age. While the mechanics are still being studied, these babies born too small are at greater risk than those of average size of becoming overweight adults, says Emily Oken, MD, a prenatal nutrition expert at Brigham and Women's Hospital, in Boston. In general, small babies have less muscle but more fat than the average baby. It's possible that this body composition can continue through adulthood, adds Dr. Oken.

On the other side of the spectrum are those big babies, especially those born with weights in the double-digit range. If Mom gained too much weight during pregnancy or developed gestational diabetes, she can have a big baby who was exposed to more glucose and fats in utero. These babies are born larger than average and are more likely to become obese by adolescence, says Dr. Oken.

Does Ethnicity Matter?

Families from low-income and some minority ethnic groups are also at greater risk for obesity. African- and Mexican-Americans have higher rates of obesity than Caucasians, according to the National Center for Health Statistics. Minority children watch more TV on average than Caucasian kids, which exposes them to more junk food advertising, says consumer psychologist Sonya A. Grier, PhD, of the University of Pennsylvania, in Philadelphia. And minority neighborhoods tend to have more fast-food restaurants and fewer grocery stores than white neighborhoods, she adds.

But a kid from any socioeconomic background who doesn't eat properly or get enough activity is at risk. According to a new University of Michigan Health System study, 3-year-olds who watch more than two hours of TV daily are three times more likely to become overweight than kids who are instead playing outdoors. Past research has also found that preschoolers are influenced by what their parents eat and are more likely to consume a diet high in saturated fat if their parents do.

Juice & Bottle Battles

What are some other poor habits parents may encourage? Marilyn Tanner, RD, a pediatric dietitian at St. Louis Children's Hospital, sees many children who consume more than the recommended 4 ounces of juice per day. "I see parents giving kids juice like it's water and not offering milk as an option," Tanner says.

But sugary drinks are just part of the problem. LeAnn Kridelbaugh, MD, medical director of the Dean Foods Lean Families Program at Children's Medical Center of Dallas, says that the longer a baby uses a bottle, the greater his risk of excess pounds. That's because, she says, sucking on a ba-ba is comforting as well as nourishing, and tots may take in too many calories between eating solids and drinking too much milk (35 to 40 oz. a day compared to the 16 oz. to 20 oz. 1- to 2-year-olds need). If your child is filling up on milk and eating fewer solid foods, he could also be at risk for iron deficiency.

Weaning should begin at 1 year, says Dr. Kridelbaugh, and the bottle should be packed away by 18 months. By that age, children need to learn other ways to self-soothe, especially during the night. "Another problem is those kids who can't sleep without having a bottle of something in bed with them and who consume calories all night long," says Dr. Kridelbaugh. "Your child doesn't need this any more than you need to get up and make bacon and eggs at midnight."

Make a Difference

When it comes to obesity, no one factor is to blame, but you can be singularly instrumental in stopping this condition from hitting home. Here's expert advice to guide you.

Try to breastfeed for as long as you can. Several studies have pointed to a possible association between breastfeeding and decreased risk of obesity. More research is needed, says Dr. Hassink, but so far it seems that obesity rates are higher in children who were never breastfed or were breastfed for less than a year. One report in the American Journal of Epidemiology reviewed 17 studies on the nursing-obesity link and found that for every month that a mom breastfeeds her baby, the risk of obesity falls 4 percent.

Use food for nourishment, not comfort. "Not every cry has to be addressed with food," says Dr. Kridelbaugh. Starting in the newborn phase, learn to distinguish the "I'm bored" cry from the "I'm hungry" cry. As kids get older, resist using food as a bargaining chip, reward, or punishment. A child who is given cookies every time she cries could grow up to be an adult who uses sweets to cope with stress.

Be a role model. Starting from the first time you open that jar of pureed squash, your baby will be looking at your reaction to know whether she should trust what you are trying to get into her mouth. "You have to show them with facial expressions that this is the best stuff on earth," says Tanner. So if you're curious about how those mashed green beans taste, try the baby food when you're alone.

When your baby is ready to move on to table foods, make sure that the peas on her plate are on yours as well. And when your toddler refuses to drink milk, see what's in your glass. Children strive to be like their parents, and there's a good chance if you start wearing a milk mustache, your kid will too.

And if you're a couch potato, consider how much tube time your child is getting with you. "It's surprising how many people put their little baby in the car seat in front of the TV set," says Dr. Hassink. Infants need tummy time just as much as preschoolers need to run around the park, she says. Tummy time is real exercise, helping babies to learn how to hold their head up while developing arm strength.

Don't panic. Once your toddler starts walking, it may seem as if she is living on air considering how little interest she has in mealtime. The baby who used to spend half the day eating now fights you when you want to put her in the high chair.

But parents shouldn't be overly concerned. Once a child turns a year old, you'll notice that she doesn't eat as much as she did as a baby "because it doesn't take as many calories to grow in the second year of life," says Dr. Kridelbaugh. "Parents get confused and worried that something is wrong and start pushing kids to eat. Toddlers are good at self-regulating and knowing when they are full." When you force a child to eat when she's not hungry, you're teaching her to ignore satiety cues. That can lead to a pattern that sets the stage for weight gain, says Dr. Kridelbaugh.

So how much food should you offer your child? Familiarize yourself with kid-size portions, says Tanner. One serving is about the size of the child's fist. Place only that much on the plate. Kids should be encouraged to eat as many vegetables (as in whole produce, not french fries) as they want. They fill you up while providing important nutrients, such as fiber and vitamins. Tanner recommends a combined five servings of fruits and vegetables per day.

Make healthy culinary choices. Don't ask your child, "what would you like for a snack?" advises Tanner, because the answer will likely be "cookies." Instead, offer halved grapes or orange wedges. Holly Williams Leppo of York Springs, Pennsylvania, makes an extra effort to keep her 2-year-old son Samuel at a healthy weight. She adds ground vegetables to her meatballs and makes her own "ice cream" out of frozen bananas. "I think it's my responsibility to offer him the best choices for him," Leppo says. "I hope that by providing a variety of healthy foods now, while he is little, he will learn to like them and will choose wisely when he's older."

Ask questions. Only a doctor can tell you whether weight is a problem and determine the healthiest way to combat it. BMI isn't perfect. It doesn't distinguish weight from muscle, for instance. "A kid who is muscular and big-boned might appear to be overweight, but his body composition would indicate that the child is normal," Dr. Anhalt says.

Discuss diet with your pediatrician as well. Is your child a picky eater? Ask for suggestions on introducing new foods. "If you're a family of big people with a history of diabetes, you should be talking to your pediatrician as early as you can," advises Dr. Anhalt. Developing a plan early on can help prevent a lot of problems, he says. The good habits you establish now will keep your child healthy far into the future.

Weight Gain by the Numbers

Here's a look at how much your baby should grow during his first 5 years of life.

• 1 to 4 months
  Weight gain: 1.5 to 2 lbs. per month
  Growth: 1 to 1.5 inches per month
• 4 to 7 months
  Weight gain: 1 to 1.5 lbs. per month
  Growth: 0.5 to 1 inch per month
• 8 to 12 months
  Weight gain: 1 lb. per month
  Growth: 0.5 to 1 inch per month
• 1 to 2 years
  Weight gain: 3 to 5 lbs. per year
  Growth: 3 inches
• 2 to 3 years
  Weight gain: 4 lbs. per year
  Growth: 2.5 inches
• 3 to 5 years
  Weight gain: 4.5 to 5 lbs. per year
  Growth: 2.5 to 3.5 inches per year

Source: American Academy of Pediatrics and the Centers for Disease Control and Prevention

Fitting Car Seats

At 3 years old and 42 pounds, Grace Schleter, of Dublin, Ohio, is bigger than most kids her age, who average about 32 pounds. Her doctors aren't overly concerned about her weight yet, but her safety is another issue. Her car seat, like most on the market, has a 40-pound weight limit. Most children hit that mark at age 4, but for Grace, and thousands of children like her, a bigger seat is the only way to ensure safety in case of an accident.

Grace is one of many toddlers who are too big for their car seats, says Lara Trifiletti, PhD, of the Columbus Children's Research Institute, in Ohio. Nearly 300,000 kids ages 1 to 6 may be in this category, including 5 percent of all 3-year-olds, according to a new study for which Trifiletti was the lead author. "We can't wait until kids lose weight for them to be safe in the car," she says.

A booster seat is not an option for children as young as Grace, because she still needs the five-point harness seatbelt. So her parents were left with only one other choice: getting a new car seat. There are a few units that accommodate larger children. Britax and Cosco make models that fit children up to 65 pounds, and they retail from $100 to $300. But considering that car seats reduce the risk of fatal injury by 54 percent for toddlers, according to Trifiletti, these car seats for larger children are an investment more parents may want to make. And as a bonus, Grace is much more comfortable, says her mom, Angie Schleter.

If you aren't sure whether your child needs a new seat or just want to make sure yours is installed correctly, call 866-SEAT-CHECK to find the car-seat inspection service nearest you.

Don't Overreact

If your baby or child is hitting the high percentiles on his growth chart, it's very important not to panic. Babies need a high-fat diet until age 2, and even after that you never want to restrict a child's calories without your pediatrician's guidance.

Marilyn Tanner, RD, pediatric dietitian at St. Louis Children's Hospital, has seen the ill effects of parents who were too aggressive in controlling their children's weight. "I would see well-educated moms whose babies were failing to thrive," Tanner says. "But during the first two years, kids need 40 percent of calories from fat." Healthy fat sources include whole milk, cheese, and eggs, says pediatric obesity expert Sandra Hassink, MD. Ice cream and french fries are also high in fat but come bundled with extras your child doesn't need, such as trans fats and too much sugar.

Switching from whole to nonfat milk at age 2, combined with your toddler's love of running and climbing, will often be enough to melt away that baby fat. As your child ages, try not to make weight an issue -- and don't draw lines between food that's good and bad. As Rosemary Nagy, RD, in St. Louis, tells her kids: There are everyday foods, such as apples, and once-a-week fare, such as ice cream.

Cynthia Ramnarace, a freelance writer, lives in Brooklyn, New York.

The information on this Web site is designed for educational purposes only. It is not intended to be a substitute for informed medical advice or care. You should not use this information to diagnose or treat any health problems or illnesses without consulting your pediatrician or family doctor. Please consult a doctor with any questions or concerns you might have regarding your or your child's condition.

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