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By Dr. Peter Nieman
The question “Is my child too fat?” often comes up in the paediatrician’s office. This is an important issue because obesity is a common problem. The incidence of obesity among Canadian children is close to 20 % and still increasing every year. Yet, it is also one of the most easily preventable conditions. Prevention is indeed better than cure when it comes to childhood obesity.
Think of the causes of obesity as a three-legged stool: genetic causes, overeating and not enough exercise. It is important for parents to understand the cause of obesity is often a combination of these three factors. Very rarely, perhaps as often as 1 %, is obesity due to a so-called “glandular” problem – a hormonal cause.
What about the question “Do fat children become fat adults?” A 1998 study in the New England Medical Journal showed if the parents’ weights are normal, slightly overweight children between the ages of 1 and 3 do not have an increased risk for obesity later in life. However, overweight children between 1 and 3, whose parents or brothers and sisters are overweight, have a higher risk of becoming overweight themselves.
We cannot change our genes – although there are studies being conducted where researchers are looking into this possibility, something that is still many years away into the future – but we can definitely eat better and exercise more. Parents have a big responsibility when it comes to preventing obesity in their children, as with so many other issues. Children’s perceptions are influenced by the views of their parents and peers, and good parents lead by being good examples.
Paediatricians evaluate children’s growth and build by means of standardized growth charts and body mass index (BMI). Children with weight far above the 95th percentile are examined with special concern. Body mass index is a calculation of your child’s weight relative to height. A BMI over the 85th percentile indicates overweight and above the 95th percentile, severely overweight. Some doctors also use skin fold callipers to determine if a child is carrying too much fat. This is an instrument that looks like a pair of spring-loaded tongs. It gently pinches the flesh on the trunk and the back of the upper arm. The results, based on the resistance to the pressure exerted by the callipers, indicate how much fat lies directly under the skin.
Most paediatricians enjoy their work because so much of children’s health has to do with prevention. Yet, when it comes to helping overweight children lose weight, a team approach works best. The paediatrician, dietician and other healthcare professionals are only part of the team. The parents are perhaps the most important members of the team and should know the importance of doing it together as a family, rather than singling out the overweight child.
Regarding food choices: As a parent, you determine what food is offered, so ensure you offer healthy choices. Create an atmosphere for lifelong healthy eating and be consistent. When allowing treats for parties or other special occasions, make it clear that these are exceptions. Make changes permanent – a healthy approach to eating and physical activity should become your lifestyle, rather than a patch for a weight problem. For children older than 2 years of age, use low-fat milk such as 2% rather than homogenized. Fat should not be restricted from the diets of children under age 2 because it is needed for proper brain growth and development.
Switch from full-fat mayonnaise and dressings to reduced-fat or fat-free varieties. Make sandwiches with reduced-fat spreads. Keep unsalted pretzels on hand for snacks. Serve low -fat popcorn instead of cookies for after-school snacks. Serve frozen juice and fruit bars without fat or added sugar, instead of ice cream. Frozen yoghurt, even if promoted as low-fat or fat-free dessert, may be high in sugar and therefore in calories. Let your child choose between an apple and air-popped popcorn for a snack, rather than an apple or chocolate-covered cookie.
Do not offer food as a reward, instead offer activities such as going to the zoo. If you find making these food choices are getting too complicated, ask your paediatrician to refer you to a dietician. Alternatively, research healthy food choices together as a family at the library, Canada’s food guide or the Internet. The Internet should be used with caution, as there is less control over the quality of advice given. Be careful of so-called “fad diets.”
Becoming more active is not always easy; especially in the busy world we live in these days. In a future column, I will talk more about how to get your child to be more active. One of the main reasons for an increase in obesity among children is inactivity. There is television and more recently, the frequent use of the Internet to compete with. The Canadian Paediatric Society suggests children should watch no more than one to two hours of television per day. Children who watch more than five hours of TV per day are four-and-a-half times more likely to become overweight than those who watch two hours or less. With watching TV comes the problem of unhealthy snacks and exposure to advertisements promoting unhealthy foods.
When looking for a good weight loss program, make sure it is designed with children and adolescents in mind. Some commercial programs do not specifically address the problem from a paediatric perspective. The ideal situation is to attend an university-based medical centre, especially if your child’s obesity is severe enough to threaten his or her health. Some questions to ask when evaluating a program are: Is it staffed with a variety of health professionals? Does the program focus on behavioural changes? Does it include a medical evaluation? Does it involve the whole family and not only the overweight child? Is the program appropriate for your child’s age and capabilities? Does the program include a maintenance program? What about weight control camps? There are many camps to choose from and one advantage is that all campers are overweight, making the fear of being teased or stigmatized less. Yet, there is little follow-up and thus the relapse rate is high.
Should your child be screened for cholesterol? Both the American Academy of Pediatrics and the Canadian Paediatric Society recommend cholesterol and fat screening only in those children with a strong family history of high cholesterol, or in cases where there is a family history of early heart attacks or strokes. If you have such a child, make sure to alert your family doctor or paediatrician about this history.
When a child is already overweight, the problem becomes hard to solve. A study published last year in the Canadian Medical Journal revealed that in 1997, the cost of obesity amounted to $1.8 billion. The price is paid through a higher incidence of high blood pressure, more diabetes and also poor self-esteem or depression. Not only is it a health issue; overweight children are often teased and ostracized. Because the relapse rate is so high, some doctors and health professionals become sceptical when caring for obese children. Given the above, it is never too early to talk about preventing obesity. It should be done with care and in a balanced way so as to avoid extreme approaches to this very important and preventable health concern.
About Dr. Peter Nieman
Dr. Peter Nieman has been practicing as a specialist with children for more than twenty years and has been a pediatrician in Alberta since 1987. In addition to his medical experience, he is also a parent who recognizes the challenges of raising healthy children.
Dr. Peter Nieman obtained his undergraduate degree at Tygerberg Hospital in Capetown, South Africa in 1979. He moved to Calgary in 1983 and completed his residency at Alberta Children's Hospital. In 1987, Dr. Nieman became a Fellow of the Royal College of Physicians and Surgeons of Canada (Pediatrics).
Dr. Peter Nieman is a pediatrician at Alberta Children’s Hospital and Rockyview General Hospital, as well as a member of the Alberta Pediatric Association, the Canadian Pediatric Society and the American Academy of Pediatrics. He currently serves on the National Advisory Committee on Physical Activity and Healthy Active Living for Children and Youth and the Canadian Pediatric Society's Psychosocial Committee. He has been part of the Obesity Management and Prevention Committee of the Alberta Medical Association and sat on the Academic Advisory Board of the National Foundation for Family Research and Education. Dr. Nieman teaches as a Clinical Assistant Professor in the Department of Pediatrics at the University of Calgary and is a regular medical contributor to newspapers and radio and television broadcasts.
Dr. Peter Nieman has completed 38 marathons, including two Boston Marathons. Dr. Nieman is also Husband and father of four young children.
Dr. Nieman runs HealthyKids.ca, an online service dedicated to helping concerned parents raise healthy children. DLTK visitors are entitled to a complimentary one-year subscription to HealthyKids.ca by using the coupon code: DLTK.