Your Questions on Kids and Obesity

Ask a kid to read a nutrition label, and you're asking for trouble. Saturated fats, potassium, sodium — intriguing to adults, perhaps. But as exciting as cleaning their closet to kids. Yet there's little doubt, America's children weigh more than those growing up even in the 1970s. So how to capture a kid's interest in a healthy lifestyle? At the Packard Hospital's Pediatric Weight Control Program, specialists have divided foods according to an easy to remember traffic-light system. Take-out pizza? A big red light. Broccoli? Green of course! Spaghetti gets a cautious yellow. Here, program specialists answer your questions on how to make eating fun and healthful.

Also, evidence suggests that even our babies are weighing more with each generation. Pediatrician Matthew Gillman, director of Harvard Medical School/Harvard Pilgrim Health Care's Obesity Prevention Program, answers your questions on how to figure out whether your baby is too fat.

Can a Baby Be Too Fat?, Answered by Dr. Gillman:

What's the relationship between breastfeeding and obesity? — April Creager, Clovis, Calif.

This is a hot area of research right now. No studies suggest that breastfeeding causes obesity, but the question is how much it might protect a child from obesity. Estimates run anywhere from not at all to a lot! The sticking point in the research is that families who breastfeed have lean kids for other reasons. Kids who have been breastfed may get more physical activity just because they live in more health-conscious households. It is hard to tease out those factors. Bottom line: Breastfeeding probably does lower the risk for childhood obesity to some extent, and it's good for so many other reasons, that it's wise to promote. The American Academy of Pediatrics recommends exclusive breastfeeding for four to six months, then any amount of breastfeeding until at least one year.

My 27-month-old son is about 35 inches and 36 pounds. What is frustrating is that I feel I was doing everything right (fruits and veggies, whole wheat bread, skim milk, no juice, no TV), but Rowan just loves to eat and is not very active. We try to encourage daily walks/outdoor play, and he's in soccer. Any advice? — Ann McCurdy, Seattle, Wash.

If you go to the Centers for Disease Control and Prevention Web site and plug in your son's age, height and weight, you'll find that his body mass index (BMI) is in the 99th percentile for his age. That means he's heavier than 99 percent of the reference population, which derives from decades ago when our children were thinner. OK, those are the facts. Now what do you do with them? Without knowing more about your family history and pregnancy, and your son's early history, I would be off base giving you individual recommendations. Except, try not to freak out. For most families, the best things to do are the kinds of things you are doing. Talk to your pediatrician for specific advice, and ask whether you would benefit from consultation with a nutrition professional who is an expert in toddler/preschool eating habits. And remember: no weight loss diets for young kids. Kids are growing, and they need to gain weight as they gain height.

Is high birth weight a reason for concern? Our daughter was nearly 10 pounds at birth. She is now 5 years old and still has her baby fat, but does seem to be stretching out just a little. I'm wondering if I should be concerned about her obesity potential? — Doug Crosby, Las Vegas, Nev.

Birth weight is just a proxy for thousands of different things. Yes, the higher the birth weight, the higher the BMI later in life, but that's an observation based on the average person. Remember, some big babies have a lot of muscle relative to their overall size, and some small babies have a lot of fat. Now, if you had diabetes during pregnancy and that's why your daughter was 10 pounds, you may want to keep an eye on her a bit more closely. But if you and your family just tend to have big babies and they thin out over time, then you have less to worry about.

If a baby is breastfed or fed with bottled breast milk, how do you know how many ounces is enough? How do you know if he is getting enough milk? Or too much? — Sevgi Gencer, Reading, Pa.

The key here is growth. The way we tell whether breastfed babies are fed adequately is by looking at how fast they are growing in length and weight. It's amazing that unless there is a particular problem with mom or baby, infants have a highly evolved sense of how much they need to eat. Often, the best thing is just to pay attention to when your baby appears to be full. No need to force more breast milk, top a feeding off with other foods, etc. The World Health Organization just came out with new infant-growth charts for breastfed infants. These charts are not yet in use in the U.S., but in the future, they may become the standard for growth for breastfed, and maybe even bottle-fed, infants.

At 9 weeks old, our boy was consuming up to 36 ounces of formula (Enfamil Lipil) in just under 24 hours. I was concerned after noticing that he seemed to be putting on weight — more so than seemed appropriate for a baby his age. We looked online for a feeding chart and became alarmed that he was eating almost twice the recommended feeding. We have since dropped the amount (gradually) to no more than 5 ounces a feeding. He calls for food roughly every four hours with a long sleep time at night of up to six hours. Are we on the right track? Have we done irreparable damage? What do you recommend a 3-month-old eat at each feeding? — Mary Ann Nelson, Fort Leavenworth, Kan.

The answer for bottle feeders, believe it or not, is not much different from breastfeeders (see above answer). The best thing is to pay attention to the baby's cues about fullness, such as the baby stops sucking or appears pleased. Don't overfeed, either at one feeding episode or because you think your baby has to feed on a particular schedule — maybe he doesn't. Sounds like you are on the right track. And don't forget, we parents do all sorts of not-so-great things to our kids, with no irreparable damage! Kids are so resilient.

What about children who have the opposite problem — they are superthin. What can I do if my 1 1/2-year-old is in the 10th percentile for weight? — Zhanna Yermakov, Chicago, Ill.

One of our sons also was way down on the growth charts as an infant and toddler — and is still in about the 10th percentile for weight and BMI, at age 15! Some kids just grow on a different curve from others. The time to seek medical attention is if he or she "crosses percentiles." That means, if they go way down or up over time relative to other children. If your son or daughter has always been at the 10th percentile, but is growing right along that line, you generally can be quite calm, especially if you and your partner are "10th percentilers" yourselves.

Sorting Foods into Reds, Yellows and Greens

Pediatrician Thomas Robinson, director of the Center for Healthy Weight at Lucile Packard Children's Hospital in Stanford, Calif., and Cindy Zedeck, director of the Packard Pediatric Weight Control Program, answer your questions on obesity in older children:

Many listeners want to know how to find a good weight-loss program for their kids. What's your advice?

First, ask your pediatrician or family physician for suggestions. Many of them will be aware of what programs and resources are available in your area. Next, try to find a program that keeps track of its results and can tell you its success rate. Not just how much weight kids lose — different programs aim for different rates of weight loss — but what proportion of kids or families complete the program. You also want to know what their attendance rate is like. For instance, do a lot of kids or families skip sessions?

Finally, find a program that fits your life and family. Some programs are just for parents, some just for kids, and some for both parents and kids, like ours. Not all families are ready to make the changes necessary to succeed. Is your entire family motivated enough to stick with it? Is the time and place convenient? Does the program make weight loss fun and challenging enough to make your family want to keep coming back?

Where can we learn more about which foods best fit which category? I began to talk to my 5-year-old about red-light, yellow-light and green-light foods yesterday, and this morning he wanted me to categorize his breakfast! — Lida Cope, Winterville, N.C.

Many programs use a form of the traffic-light food classifications. Our categories are based on the amount of calories per gram. You can calculate that information from the food labels on all your foods. You divide the calories per serving by the number of grams per serving. The higher calories per gram are red, the middle are yellow and the lowest are green.

But you can use this tool without doing the calculations. Almost any parent can say what junk foods they want their child, and often themselves, to eat less of. Those foods can be assigned as red. Foods that you want to limit portions of, like bread and pasta, make those yellow. Green is for foods you feel comfortable not worrying about the portions.

One thing to remember is that the diet doesn't stand alone, it's part of a full behavior-change program that includes goals for increasing exercise and reducing sedentary behaviors, like watching TV and computer use.

How do you begin to change the diet of a 6 ½-year-old girl and 9-year-old boy? Going cold turkey on all sweets and carb snacks would be extreme, but figuring out how to "moderate" is even harder. — Suzanne Peretz, Croton on Hudson, N.Y.

We don't suggest going cold turkey on all sweets and other high-carb foods. Try to reduce them gradually. Select the foods that you don't want your kids to eat and make goals about not buying them. If the food isn't in the house, they won't eat it. You also want to reduce the number of red-light foods eaten outside the house.

We recommend that you track consumption for one week, and add up how many red-lights your kids are eating. Take that total and reduce it by two to five red-light servings. See how that goes, and then the next week, reduce that number again by another two to five servings, and so on. Or set a goal to reduce the number of red-lights eaten daily, if that's easier.

Your children are old enough to participate in the process, especially if the 6 ½ year old likes to copy her 9-year-old brother. Make it fun. Encourage them to come up with solutions for cutting back. They might have ideas that you would have never thought of. Even if their ideas are the same as yours, if they think they came up with them, your kids are more likely to be successful.

My son is 28 months old and attends a Montessori school five days per week while I work. I strive to provide him with healthy foods, including a healthy lunch at school. But many parents send things like potato chips, sugary fruit punch and cookies in their toddlers' lunch boxes. My son often ends up eating his classmates' unhealthy foods, and the teacher hasn't been helpful. Do you have any suggestions? — Michele May, Fort Worth, Texas

You are not alone. We hear this frequently. It is great if the teacher can help, but you may want to start with the other parents first. We have yet to meet a parent who doesn't want his or her young child to be healthy and get good nutrition. Talk to your fellow parents about their ideas for healthy lunches and snacks. Other parents may come up with a lot of great ideas. They may even want to share the responsibility, like having fresh fruit delivered to the school or having water and milk on hand at school instead of requiring parents to pack it every day.

Also, if you make other parents or the teacher feel like they are doing something wrong, they may be less likely to want to change than if you enlist their participation and give them a chance to do something right for their kids. It is a lot easier to be a cheerleader for change than to be a food cop.

We know we should watch what our kids eat by not letting certain foods in the house and controlling portions. But how do we talk to our older kids about food choices without creating other issues? How do we walk that balance between giving our pre-teens independence and control and preventing health problems down the road? — Nancy Whittaker, Kirkland Wash.

Helping children to learn to behave healthfully on their own is difficult for all parents. When kids get to be pre-teens, they still need parents to set limits and guide them. They want and need your guidance. At the same time, older kids need to feel they are getting a chance to make their own decisions. We see a lot of parents trying to police their kids' eating, and often everything else, pointing out every "poor choice" and trying to "make" them change. We work very hard with parents so they'll become helpers instead of police. We try to put the primary responsibility for eating and exercise back on the kids and teach them to ask for help when they need it. We teach parents to back off a little. Instead of criticizing kids for everything they do wrong, keep an eye out for what they do right and praise them for it.

A parent can also ask a child, "What can I do to help you meet your goal? Do you want me to not buy foods you would rather not be tempted by? Are there any sports you'd like to try?" Of course, as parents you still need to provide a healthful environment in the home, so it makes it easy for your children to learn to make healthful choices.

My son was diagnosed with OCD in fourth grade. He started to gain weight a few months before his diagnosis, and then he was put on Prozac. It dramatically improved his OCD symptoms, but he has now gained about 50 pounds. Our psychiatrist recently changed his medication, but insisted that Prozac was supposed to be "weight-gain neutral" with kids. Our son doesn't get enough exercise, but his appetite skyrocketed in the last two years. Will exercise and proper nutrition help our son in spite of these drugs for OCD? — Roger Lewis, St. Louis, Mo.

Some drugs can make it harder to maintain a healthy weight, and medications do affect different kids in different ways. No matter what the contributing causes, though, it still boils down to energy balance: calories taken in versus calories expended. So even if a drug is making it harder, your son still needs to eat less or exercise more, or both, to bring those calories back into balance. That may mean moving toward foods that are lower in calories, like switching from sugar-sweetened soft drinks and juice to calorie-free drinks and water. You could also cut out TV on school days or limit it to seven hours or less per week, and consider an after-school sports program. Also, if your son's psychiatrist is already treating his OCD, he might also be able to help your son change his eating and activity behaviors.

Our granddaughter, who is 8, has gained a lot of weight in the past two years. Up until then, she was normal — you would almost say thin. In the past two years, her parents were having marital problems, which ended in divorce. Do you find that weight gain in children is associated with divorce? — Gloria Mahood, Albany, N.Y.

We often hear from parents going through a divorce that they're concerned their child has put on weight. A stressful life event can definitely affect a child's eating and exercise habits, just as it does with adults. The reasons may be going out to eat more often, getting "treats" twice as often or just starting to eat more and exercise less because of stress. Counseling can support a child through this transition; you may want to ask your doctor for a recommendation. In our program, we highly recommend that both parents attend so they can be on the same page about the foods they will be offering. It is difficult for a child who has one parent with a red-light free household to go visit the other household full of red-light options.

In some cases, only one parent is willing to attend the group and the other refuses to make recommended changes. In this situation, we work with the child to come up with a strategy that feels comfortable. The child may want to save up all of the red-lights for visiting one parent's home, or bring healthy yellow-light options when going to visit. Parents also need to support the child in the effort to say no to red-lights. Over time (this can take several months), the less supportive parent often sees how committed the child is to reducing red lights and how well the program is working. The parent often becomes inspired to reduce red lights in the home and sometimes even in his or her own diet.

We were wondering if there is a flaw in the growth charts used by pediatricians. We have heard they were designed from averages of children in the 1940s living in the Midwest. Is there a chart we can use that might more accurately reflect what our children's weight should be? — Herb Weltig, Sleepy Hollow, N.Y.

Pediatricians and family physicians should use growth charts developed in 2000 by the Centers for Disease Control and Prevention. These are made up of measures from several national samples of children from the 1960s through the 1990s. There is even a body mass index growth chart for children age 2 years and older. Body mass index is a way to look at both weight and height and how they fit together. Weights for children in the most recent samples were not included in creating the charts because the CDC was already seeing rapid increases in obesity in the population. There are also different growth charts for boys and girls, who grow and develop differently. Your doctor can "plot" your child's height, weight and body mass index on the charts and tell you where they are in comparison to these national samples of kids of the same gender and age.

That doesn't mean the growth charts are perfect, because growth may also differ a little by race and ethnicity, and because of past nutrition and health and other factors. So the growth percentile as a single number is not always helpful on its own. Your doctor will interpret the growth percentile in the context of all those other things. It is especially helpful to plot the measures over time, so you can look at trends in your child's growth. Finally, unlike many other things in life, such as test scores, you do not necessarily want you child to be above the 95th percentile for body mass index. In this case, being average can be a good thing.

If you want to learn more about how the growth charts were developed and how they are used, you can go to the CDC Web site.

We try to promote eating different "colors" of food for my three grandchildren, who go through phases of what they like to eat. Will they ever really like vegetables like I do? — Patti Hair, Indianapolis, Ind.

Kids usually go through periods of likes and dislikes for different foods. Some like all vegetables from the start. Others never really like them. But most fall somewhere in the middle and change their tastes over time. Unfortunately, the most popular vegetable eaten is French fries, which isn't really much of a vegetable. Kids can learn to like vegetables, however. Studies done in preschoolers have shown that the more children are exposed to a food and the more positive the context, the more they will learn to like it. So keep serving! Don't give up if children say they don't like a food at first. It may take 10 tastings or more before they start to get used to a new taste.

For snacks, have precut vegetables ready to eat so they're as easy to eat as other snacks. Make eating vegetables fun: See how many colors you can get in one meal or other challenges. And if you like eating vegetables and make eating them a positive thing instead of something everyone "has to" do, your kids will learn to like them more. If you show distaste for vegetables, kids often will, as well. It sounds as if your grandchildren may be beyond this stage, but both the foods that a mother eats while breastfeeding and the vegetables you introduce early in life can improve the likelihood that the children will enjoy those same tastes as they grow.