How can parents help their young children maintain a healthy weight? What does research tell us? What’s the appropriate role of a pediatrician or family doctor? How can community agencies and governments help? Let’s get started.

Janet, Raleigh, NC: Are you aware of any successful community-wide collaborations that have addressed the “talking to parents about their children’s weight” issue?

Marlene: I don't think it is useful to focus on solely on weight when talking with parents. One reason is that the stigma of obesity is so strong in our culture, that parents often feel blamed and guilty when a health professional speaks with them. Second, the implication in talking with parents is that there is a solution out there that they are just not using. That isn't true -- we really don't have any highly successful weight loss programs to offer. It's no easier to treat childhood obesity than it is to treat adult obesity, and we aren't very good at doing that.

My guess is that a better approach is to focus on eating and activity of all children... Even normal weight or thin children will benefit from getting their calories from nutritious sources, and spending less time watching TV and more time in physical play.

It is also important acknowledge that parents are fighting an uphill battle. The food industry spends billions of dollars a year to convince children to eat poor foods. Schools have given in to the financial incentives of selling poor foods to make ends meet and sustain their food service program. Kids are surrounded by cheap, convenient, high fat and high sugar foods. Parents need to figure out a way to protect their children from this environment without worrying that they are going to extremes and creating a bigger problem by being too restrictive. Acknowledging these difficulties may lead to a more productive discussion of strategies that will work for their family.

Heidi Ham, Education and Development Specialist: What is the single most important thing that we could do as a provider of Early Childhood Programs to positively impact childhood obesity?

Marlene: In my opinion, the most important thing you can do is provide as healthy an environment as possible. Only serve foods that are nutritious, and consider making your program a "junk food free zone." People are nervous about doing this because they feel it is too restrictive and they feel kids need to learn moderation. My answer to that concern is that we do not have a cupcake deficiency problem in this country, so there is no reason to increase the opportunities for kids to eat cupcakes. Second, kids will learn moderation better if their parents are the ones who decide when and where to have those "treat" foods. I think every school in the country could ban cupcakes, and every household in America could stop buying cupcakes at the grocery store to have around, and kids will still get plenty of cupcakes at birthday parties and other outside events. Our research in Connecticut found that kids are eating 3 times the number of servings of high-fat, high-sugar foods recommended per day - we are going to have to make a lot of changes to get that number down. The goal isn't for them to have zero servings per day -- it's to have one serving per day -- and that is going to take a big change in the environment.

Robert Capriccioso, Reporter, Connect for Kids: Hi Marlene, I know you're joining TalkTime Live! from the North American Association for the Study of Obesity in Las Vegas -- is childhood obesity a main topic of discussion out there? What's on the agenda and what "new stuff" should the audience be aware of?

Marlene: Childhood obesity is a big topic out here. There is research on the impact of making changes in schools that is very encouraging about the potential positive benefits of changing what we serve and the portion sizes. There are also studies of clinical trials that suggest that it's important to include the parents whenever you want to help kids make changes.

Roberta Miksch, WIC Coordinator, Nebraska: I work with a WIC clinic (Special Supplemental Nutrition Program for Women, Infants and Children) in Nebraska and we are seeing an increase in the number of children that are in the 85th-95th percentile on the weight-for-age growth chart and in the number of children that are at the 95th percentile and above. We do counsel the parents on the health aspect of their child’s weight, but I am wondering what specific information you would recommend to give to parents that you’ve found to be particularly helpful. The population on the WIC program varies greatly not only in nationalities but in education levels.

Marlene: I think the most important thing is to focus on healthy behaviors, and not get into a struggle with the parents about whether or not their child is “really” overweight. Different ethnic groups vary on how they view body size and shape, and sometimes the parents don't agree that their child is actually overweight, so do not listen to any advice. I recommend focusing instead on the child's behaviors, and there are four behaviors I'd address first:

1. How many servings per day is the child getting of fruits and vegetables? The goal is five per day.

2. How many servings of candy, chips, cookies, fried foods, etc.? The goal is only one per day.

3. How many hours watching TV and playing video games? The goal is only one hour per day.

4. How many hours playing and being physically active outside or inside? The goal is as much as possible.

One easy way to talk about different types of foods is to divide foods into Green, Yellow, and Red foods. Green foods are those foods that we want children to be eating more of (e.g., fruits and vegetables, whole grains, low fat dairy). Yellow foods are foods that are a bit more calorie dense, but still part of a good diet (e.g., pasta, higher fat cheeses, tomato sauce, etc.) Red foods are those you need to stop and think about before eating (e.g., candy, cake, cookies, chips, fried foods, etc.).

On the activity side, encourage parents to limit TV and computer time to 1 hour a day. Try to work with the family to find safe and fun activities for the kids to do. Ideally, see if you can help the family engage in some activities together.

Jenna Lundy, RurAL Cap Head Start Health Coordinator : Who can diagnose obesity? As a health coordinator without any specific medical training, am I qualified qualified to diagnose for Head Start children? Who should recommend treatment?

Irene: There are diagnostic criteria for obesity. Children with a BMI over the 85th percentile is considered overweight, and over the 95th percentile is obese. If you know how to measure and weigh children in order to determine BMI, you can identify children who are overweight or obese. They should be seen by their pediatrician who can then refer the child for treatment.

Susan Stewart, Dumas, Arkansas: Hi. I am sure you've read about Arkansas adopted a Body Mass Index requirement for schools. In fact, they are being done this week in our schools. Parents receive a confidential report in the mail stating the child's BMI as well as where they are on a "health chart", for lack of a better term. Parents may sign a request that their children not be measured. The parents I know that have opted for this are ones that are aware their children are perhaps a little on the "heavy side" and don't need another opinion on it. In my personal case, my kids (boys 14 & 17) are both thin. Last year, they almost had both of them on the malnourished end of the chart. That is nothing short of ridiculous. My kids are very rarely ill and eat like 2 horses!! They eat good foods and are just thin. I don't know how they come up with the "malnourished" or "obese" parts on the chart & would be interested to find out.

Richard S. Garcia, pediatrician comments: It seems to me, a pediatrician, that parents give liquid or solids every time a baby cries. Sometimes even when they're crying because their stomachs are already too full! This idea is always met with great resistance: Withholding food from a baby seems inhumane, right? It certainly goes against any cultural beliefs about feeding infants and toddlers. This doesn't even get into WHAT the babies are getting fed. That is yet another topic. But ALL parents know that cookies and cream are fattening. So, telling them that there are healthy alternatives won't change their behaviors. It hasn't so far.

Irene: Unfortunately, there is a belief that “food means love,” and this belief is very strong in certain cultures, particularly in the Mexican culture, as you have experienced, but it is quite pervasive in the general American culture as well. Consequently, parents offer food as an expression of their affection, as a reward, and for comfort if the baby or child is distressed. In the process, parents teach their children that food can stand in for love and affection, that when the children feel lonely or rejected, food will comfort them. In the process the children do not learn to deal with their emotions in a healthy way, and they confuse hunger with their emotional needs.

Parents need to be convinced that if they truly love their children that they should not offer food for comfort, as a reward, or for fun, because otherwise they set up their children for overeating and for poor coping with their emotions. I explain to parents that using food this way is the easy way, and I challenge them to show their love for their children by doing the hard thing by looking at food only as nutrition, and by helping their children deal with their emotions without relying on food.

Erica, librarian: I recently read an article about movement/music storytimes such as "Gymboree on the Go" and "Tiny Tot Tunes." I would very much like to do a movement storytime this year with 3-5 year olds (but would welcome suggestions as to the most appropriate age for this type of activity). I'm really walking in the dark on this one, so I would welcome any ideas for activities (I have some vague ideas already), books that I might consult, or even your ideas on how many weeks I should offer the program.

Susan: Any ideas from the audience on this one?

Richard, Rootstown, OH: Are you aware of any medical school partnerships with public schools that have studied the relationship between childhood obesity and academic performance?

Marlene: I think this is an extremely interesting and important question. I don't know of any studies that have documented a clear relationship between childhood obesity and academic performance. I believe there was a recent study that showed poorer academic performance among obese children, but that relationship did not hold up once socioeconomic status was taken into account. In other words, children who come from disadvantaged backgrounds are more likely to be obese and more likely to do poorly in school, but it's unclear what is causing what.

Rosemary Szot, Connecticut: I have a comment regarding obesity in children. I am a member of the Farmington Health, Wellness and Nutrition Pilot, and I have a five-year-old son with life-threatening food allergies to peanuts and treenuts, who attends kindergarten. If we could implement some changes to counteract obesity, it would greatly improve the quality of life at schools for children with life- threatening food allergies as well, such as non-food birthday and holiday celebrations and non-food rewards. I truly hope that the health, wellness and nutrition pilots, as well as the CT department of education can make some of these changes down at the district and school levels, and I ask that you keep in mind how many food related school events these children are unable to participate in, because of their disability.

Irene: I fully agree with you that schools participate in the general cultural attitude that food is good for everything: to celebrate, to reward children, to entertain and to keep children busy. As you point out, this is especially difficult for children who cannot participate in these food "events" because of food allergies, but I think that this cultural attitude is detrimental to all children because we teach children to confuse eating to meet their emotional needs with eating out of hunger. Consequently, children learn to eat to deal with their emotional "hunger", and they overeat. The school would be a good place to change this use of food!

Susan adds: Thanks, Rosemary, for pointing out how the issue of food allergies can be powerful part of an overall argument in favor of celebrations and rewards that don’t involve food. While parents can be reluctant to embrace the idea of birthdays without cupcakes on the basis of nutrition, the allergy issue is compelling: there is an immediate short-term threat to a child’s health, and there is a sense of simple schoolyard fairness. We all remember being left out of some fun event as a child, and most parents are likely to be empathetic to the plight of an allergic kindergartner sitting on the sidelines during a classroom party.

I’m not sure, though, if these are arguments that can be successfully made at the district level, it seems more likely that a school-by-school approach would have more success, though of course the effect is more limited. Does anyone with experience in trying to get school celebrations off their sugar high have suggestions?

Keshia, Washington DC: I work with an organization that helps municiple leaders take action on behalf of children. Have either of you seen any ways that cities or city leaders have taken steps to work with city offices such as the Department of Family Services or family and children organizations in general?

Susan: I do know that city leaders in Detroit have taken to heart the city's designation this year as the nation's fattest -- city schools have received a federal grant through No Child Left Behind to improve school nutrition, and grantmakers in Detroit have held meetings to discuss funding obesity-related projects. Anyone else have information on this?

Willie E. Breeze, Coordinator School Health Services: Do you have any sample letters that might be used to send to families of obese students? Some parents see this as an invasion of privacy. Can you comment on that?

Marlene: Actually, I am opposed to the practice of sending letters to families of obese children notifying the parents that their child is obese. The reason is that I think that assumes that all parents need to know is that their child has a problem. What I think would be more useful would be for the school to do a valid nutritional assessment and physical fitness assessment, and send that information home to all parents, letting them know what concrete steps they can take to help improve their child's nutrition and fitness.

Further, I'd like to see the schools do their own self-evaluation of the food served and given out in school and see what they can do to improve the number of opportunities kids have to eat healthy foods and decrase the number of opportunities to eat poor foods.

Susan: Yes, a previous comment/question from Arkansas relating to the state's new practice of sending home reports on students' Body Mass Index made it clear that this is an approach which isn't useful for everyone. Parents do need information, but it's probably more welcome if it comes in a supportive context.

Katie, Washington, DC: What role do you see the government playing in addressing obesity prevention in the 0-5 population? Also, are their any curriculums that you have seen that have had positive outcomes in terms of nutrition and physical activity in child care and after school programs?

Irene: I like to say that we have a "societal eating disorder" because we use food for many purposes, such as entertaining, comfort, boredom and fun that have nothing to do with hunger. I think the government should fund research into treating toddlers and pre-school children with obesity and how to prevent it in this age group.

Unfortunately, I am not aware of any initiatives for this young age group.

Saioa Aranceta comments: I am a social worker at a non-profit agency that services 90% Latino families located in Chicago. I primarily work with children ages 3-5 that come from very poor families and I run into the problem of obesity frequently. One of the misconceptions that I find within the Latino community is that the more weight their children have the “healthier” they become. The parents feel that at a young age the children are suppose to be “chubby” because it is healthy for them and eventually they will grow out of it. Especially working with low-income families, they feel the skinnier their children it reflects the lack of funds to purchase food for them. It seems convenient to some of these families that McDonalds is inexpensive and also cause the children to gain weight.

Lou de la Cruz, Ontario, Canada: I would like to find out what programs you have evaluated that have been deemed effective.

Marlene: We are in the middle of evaluating a program in Connecticut in collaboration with the State Department of Education. The program involves working with the food service directors at schools and giving them specific nutritional guidelines for what foods can be sold or given out at school. We are assessing this change for both its economic and nutritional impact. We should have the results by next fall, so stay tuned!

Edward S. Trainer, Maine: I am the youth and schools person for the Maine Cardiovascular Health Program. Our Bureau of Health based program is working with the Department of Education and several other organizations and groups in a state wide, comprehensive population-based program designed to encourage increased physical activity, decreased tobacco use and better eating by the young people of Maine. We recognize obesity as a major risk factor for cardiovascular and other chronic diseases.

We are now considering to also more directly attacking the cardiovascular health problem through teaching signs and symptoms of heart attack and stroke and emergency responses (e.g. utilizing 911) in the schools and other venues where youth can be reached. To come up with a statewide plan for this, we need to know of any experience with Cardiovascular Disease education programs in the schools and research on their benefit-cost and effectiveness.

Susan: Chatters? Any experience with this topic?

Thomas Cruz, California: How might breastfeeding reduce the risk of childhood obesity? Is it psychological (being held close to the mother at an early age)?

Susan: Thanks for your question, Thomas. This is an interesting area for research right now. One working theory is that breastfeeding is harder work for infants, so they tend to stop feeding sooner. A related idea is that a parent might encourage an infant to finish up a bottle with only a little bit left in it, inadvertently teaching the infant to ignore the signs of feeling full, and that as a result the infant grows into a toddler with a reduced ability to regulate his or her food intake. And some new research suggests that mothers who breastfeed for an extended period are closely tuned in to their child’s states of hunger or satiety, and are less likely to feed them too much. The psychological and emotional component is interesting; I’d love to know more about that.

Marlene adds: I don't know of any evidence of the psychological factor you propose -- my guess is that bottle fed babies can also be held close while fed, so I'd be surprised if that had a big impact.

Laura, New York, NY: How do you define "serving?" How does one communicate what the appropriate size of a serving is? Thank you.

Irene: I don't think you can apply "one-size-fits-all" when it comes to food servings/portions. Children need to learn to regulate their food intake internally by being taught to listen to their stomach when they are hungry and when they are full. I have not known a single individual who regulated their food intake this way who was obese.

Elizabeth: What are the best exercises for young chidren who are overweight?

Irene: For young children, the best advice is to take children to the playground and encourage physical play. When children didn't have all the distractions of television and computers, they played outside much more and we need to encourage that with our children today.

Brian, Birmingham, AL: As a health educator, I agree the problems of childhood obesity is multi-faceted. I am encouraged that our state public health and education agencies have launched task forces to study the extent of the problem and potential solutions. This is a first! Committee members are considering recommending that schools calculate BMI scores for students and that public health clinics promote breastfeeding.

I am greatly concerned that our best efforts will be restricted due to limited funding. As a rural poor state, we cannot fund basic health services for those in need. There are too few affordable service/treatment programs for obese families in our rural state. It seems better not to identify overweight and obese children unless we can offer education and treatment of the condition. Your thoughts?

Marlene: I absolutely agree that simply identifying overweight and obese children is not the way to go. Obesity is a stigmatized condition and my guess is that there are very few obese children who don't already know they are obese and feel "identified" as obese by peers and teachers. Sending home those letters runs the risk of contributing to the stigma of obesity.

Marcel Horowitz: I would like to know your opinion on educational and or active television. The recommendations I have seen say less than 1 hour of television for children over 2, and none for those under 2. What do you think about TV that gets toddlers moving- such as the Wiggles.

Then of course there is educational television. Very sedentary, but I think helpful to the development of toddlers language, math, reading, and reasoning skills. My thinking is also that if children are expected to sit still for 6 hours of the day when they are 6, doesn't some training prove helpful. In other words, if they learn to sit still for television, then wont they do better at sitting still when they are older, assuming the shows aren't too stimulating, but still educational.

I am just a bit conflicted in my views on this and would like another’s opinion on these two points. Thanks very much.

Susan: This is one for the experts, but I do want to say this: Any pre-K or Kindergarten program that involves children sitting still for 6 hours of the day should be avoided at all costs! This is a time for active learning – overemphasis on seatwork is the scariest recent development in early childhood education. It flies in the face of everything we know about how kids grow, learn, and thrive. And no, I don’t think there is any need to use TV to train kids to sit still. I think kids are better able to sit quietly for short periods if they are physically active the rest of the time.

Kelly, Gettysburg, PA: Do you have an easy-to-implement/practical suggestions for getting preschoolers interested/engaged in exercise/"getting moving" in the preschool setting? Ideally, these suggestions could be carried over into the home setting as well.

Susan: This is a great question, I wish I had more information on this topic. A study of preschools in South Carolina found that most children weren't getting even half the recommended amount of physical activity during the day.

Anyone else?

Keshia, Washington DC: In regards to the comment about food allergies, I worked in a preschool that seemed to manage the problem. At the beginning of the year, parents agreed on healthy foods that were safe for all children to be served at snack time. During the "snack time" birthdays or events were celebrated, without other food being brought in. It seemed to illiminate any problems that would come up.

Susan: Thanks, Keshia. The nice thing about that solution is that all of the parents were involved in coming up with the answer to the problem. I know that sometimes teachers will unilaterally make a rule about birthday party treats, for instance, and parents will feel quite put out about it.

Christopher R. Peterson, Holmen Middle School: I was wondering if you could give some resources and/or information that support health and PE as it relates to improving test scores. I've been told that I need to have research to support that these curricula can help improve standardized test scores in the core classes. I've been cut down to 7-week classes.

Marlene: A review of the research on the impact of time spent in PE on academic performance was written by Roy J. Shephard. The paper called "Curricular Physical Activity and Academic Performance" and it was published in the journal, Pediatric Exercise Science, 1997, volume 9, pages 113-126. He states in the abstract that "when a substantial proportion of curricular time (14-26%) is allocated to physical activity, learning seems to proceed more rapidly per unit of classroom time, so that academic performance matches, and may even exceed, that of control students."

Katie, Washington DC: Do you have any ideas regarding curricula and outreach efforts in terms of mitigating social stigma around obesity? I am concerned about any unintentional effects on children and self-image.

Ocala, Florida: Teens are going to eat what they want - when and where they want it. Middle schoolers are, perhaps, amenable to listening to food and nutrition advice, but the real "capturable" audience is the elementary kids. Perhaps we need to look at the success of "Blue" "Barney" and the Wiggles" and come up with a strategy similar to that to target these youngsters that will sit up, dance around and make eating healthy fun. Would that work?

Irene: Why does eating have to be fun? Children should learn to eat to satisfy their feelings of hunger. Unfortunately, eating has become so much fun in our culture that people cannot stop eating.

Susan adds: I’m always a little wary of using television to promote kid’s fitness, especially very young children. The TV habit is such a big contributor to the problem to begin with.

Kelli Grissom: I think the two biggest questions I hear from parents are 1) at what point do you need to be concerned about your under age 6 child's weight (like what's baby fat vs. fat) you should be concerned about, and 2) how to make sure picky eaters get proper nutrition (like the kids who won't touch a green vegetable - but LOVE mac and cheese!). I'd love to hear some breakfast/lunch and dinner suggestions for the picky eater. Like are those "fruit and cereal" bars healthy - or not?

Susan: I’ll take on the picky eater part of this question, at least from a parent’s perspective. We really struggled with this at my house.

I had to get over my fear of wasting food and come to terms with the fact that a young child needs to encounter a new food over and over again before making peace with it. Put it out there, eat some yourself, and then throw it away if they don’t touch it. Repeat. Repeat. Repeat.

Also, buried within that little food conservative is a fearless adventurer, and I sometimes would bring home weird new fruits and vegetables. Pomegranate, which is a vitamin and anti-oxidant powerhouse, was a huge hit. Too bad it costs a fortune and the juice stains whatever it touches!

Let them help cook. They are much more inclined to eat what they make.

Sometimes of course there’s nothing left but to sneak the vegetables into a main dish. Spaghetti sauce, lasagna, tacos, chili, and soup are all good for that. Never seems to work with mac-n-cheese though.

I was grateful when my pediatrician reminded me to keep my focus on what the kids were eating over several days or weeks, rather than stressing about a single day or meal.

But the most important thing she told me was to never, ever make food a focus of family power struggles. Unless your child has special feeding problems, medical issues, or allergies, the long-term value of putting him or her in charge is enormous. If you worry about too many cookies, then don’t buy cookies. The same goes for soda. If you are comfortable with all the foods in your cupboards and fridge, you don’t have to worry so much.

And I think those fruit-cereal bars are OK sometimes. Do our experts agree?

Marlene adds: I have 4-year-old twins who are very picky and here are some things I have tried. First, I don't ask if they want an orange, for example, I just peel the orange and put it in front of them. My observation is that they will eat is because it is there, which is consistent with the research on why we all eat the foods we do -- sometimes it's just because it is there! Second, I don't keep junk food in the house. That way, when they are hungry, I tell them what their choices are, and that's all there is. I know they would go for the junk food if it was there, so keeping it out of the house increases the likelihood that they will settle for some fruit or cheese if they are truly hungry. Third, I remind myself of the research that it takes up to 10 times for a child to be exposed to a new food to develop a preference for it. If your child rejects a food the first few times, don't give up. Keep putting it on the table in front of him and eventually he may eat it. Fourth, the research also shows kids are most likely to try new foods if they see a peer eating them (more so than if they see a parent or teacher eating them). So, invite over all of those non-picky eaters and let your child observe.

In terms of actual foods, my experience has been that the simpler the food, the better. My kids favorites are fresh or canned fruit, various yogurts (in my house we have "drinking yogurt," "pop-up yogurt" - the tube yogurts you can freeze and then eat like a popsicle, and regular yogurt), cottage cheese, turkey sandwiches, and low-sugar cereals. Personally, I don't like the fruit and cereal bars because they are so processed and usually contain added sweetners. I'd rather give my kids real fruit and real cereal. I realize it's not as convenient to carry around, but I feel better about them eating it.

One last piece of advice - kids will eat what they are used to. If you only buy skim milk or whole wheat bread, they will get used to it and eat it, even if they eat other types of bread or milk outside the house.

Irene adds:

Up to 2 years of age, children tend to regulate their weight, and some chubby babies slim down, and some less chubby babies become chubby. So if a child, by 2, looks more than chubby, that should be of concern. A parent of any child older than 2 who appears overweight or obese should talk to their pediatrician and seek help develop healthy eating habits. Between 2-3 is an ideal age to help children regulate their eating and stay slim.

Many people do not understand that there are different types of picky eating. First, young children like to control their parents and if the parent allows it, they will use food choices as a way to control their parents. These children usually eat one type of food one day, then refuse it the next day. They are inconsistent in their refusal to eat certain foods.

Another type of picky eating is demonstrated by children who have sensory food aversions. These are children who appear to be very sensitive to the taste, texture or smell of certain foods. From adult studies, we know that individuals who are very taste or texture sensitive have more tastebuds on their tongue than others who are less sensitive. Adult studies have also indicated that this is an inherited condition that travels in families. So children with sensory food aversions usually grimace, spit out food or gag or vomit when exposed to foods that they are sensitive to. Consequently they refuse to eat these foods and often generalize to other foods that look or smell similarly.

For the first type of picky eaters, parents need to be consistent and not allow the child to ask for different foods than what has been offered. For the second type, parents should only offer foods that the child is comfortable with and allow the child to ask for new foods. If the child is put under pressure to eat foods he/she is afraid of, the child becomes more and more limited in his/her food selections.

Jacqui Cassar: My husband and I are foster carers for siblings in Malta. We are very concerned about providing the right balance for both children. The ages are 1year 3 months (boy) and 3 years 9months (girl). How can I make snack time interesting rather than being the same menu?

Irene: I would not worry about that because you want to teach children to learn to eat to satisfy their hunger and find other things interesting.

Jessica, Anniston, Alabama: How can communiities educate parents before their children reach school age? What types of motivation can take people from knowing what is and isn't healthy to actually changing theirs and their children's habits?

Susan: It seems to me that a great time to reach parents is before a child is born. If a woman is having regular prenatal visits with her doctor, that seems like a great opportunity to start the discussion -- not just about infant feeding, but toddler years and beyond.

Another missed opportunity, it seems to me, is at the playground. When my children were toddlers, the hours I spent at the playground with them, and with other parents of small children, were usually spent watching the kids, and talking about them -- their new skills and quirks, etc. We educated each other, but it was informal and perhaps all the information wasn't as good as it should have been.

Parent education could also happen during library story hours for young kids. It could be a good opportunity to pass out flyers and other information.

Kelly, Gettysburg, PA: The idea of playground activity is ideal -- but what about ideas for activity within the confines of the preschool classroom?

Keshia, Washington DC: I have recently heard a bit about the correlation between hunger issues and childhood obesity. Do either of you know more about this?

Marlene: One important question when trying to treat obesity is understanding how both hunger and satiety impact consumption. Some people may have trouble identifying when they are hungry; other people may have trouble identifying when they are full. I am aware of some clinical programs for children that really focus on this, teaching children to pay close attention to their stomachs and evaluate how full they feel at the beginning, middle, and end of a meal. When we treat obesity at our clinic, we encourge people to rate how hungry they feel at different points during the day to increase their awareness of this. Many clients say at first that they can't even tell when they are hungry or not, so this is something we work on in treatment.

Penny Lofton, Marion County Children's Alliance: In a time when walking to school, walking at school and walking home from school is a memory, what can we (as children's advocates) do to begin reaching children at a much younger age of the importance of eating right and exercising regularly?

Of course, sometimes kids just can’t walk to school. Fortunately, most young kids want to keep moving, so encouraging physical activity isn’t hard. What worked for my kids and their friends in the very early years was just a lot of time outdoors on the playground with other kids, walks in the park, and walking to do errands like going to the bank. Gymboree and similar programs for young kids are popular, but cost money – many community recreation centers, however, open up their gyms for toddler playtime during cold weather, and that can be a lot of fun – especially if someone can donate balls of all sizes, hula hoops, and other good stuff.

Faye Beach, Nutrition Consultant comments: I am currently a consultant working with food service departments in school districts who need to improve their programs to meet national guidelines for nutrition in school meals. I have been a school nutrition director and have taught nutrition in college. In all of my research, I have learned that nutrition education is effective only if it is comprehensive and begins at a very early age. We need to encourage states to include nutrition and healthy food choices, and physical activity in their required curriculum standards. It will take several years to begin to see a difference, but it takes years before a student can write effectively, do advanced math skills, etc. Uneducated parents cannot teach healthy eating and lifestyle habits to their children, therefore, we need to educate students who will become educated parents, and then I believe we will start to see a major difference in the obesity and poor eating choices in our population.

Paul: As a parent, I am particularly concerned with my children's health. I have been concerned with the cafeteria at my son's school especially. The children are able to purchase processed snacks with high sugar and hydrogenated oil content in addition to chocolate milk, sweetened drinks and fried foods. I am dismayed at getting lunch menus sent home with no vegetables except potatoes and things like Bacon Cheese Burgers, Fried Cheese Sticks, Hot Dogs and Fries, etc. I have regularly sent my son with a packed lunch, however, cafeteria workers give out the leftovers during their lunch period, they allow kids to purchase multiple snacks and my son says some kids purchase 2 lunches. I called the principal, who I could tell felt my concern is frivolous. We live in a rural community, but I see obese kids everyday at the school. How can school lunch policies be improved?

Susan: It’s not easy, but concerned parents like you have made progress in a number of states and school districts. Unfortunately, a rural life is no guarantee that children will be more active and less prone to overweight – there’s considerable research showing very high rates of obesity among rural children, especially in the South, and starting at very young ages.

Elizabeth ontario canada: Are there any plans to to have junk food ads pulled from children's TV shows? I understand this has been started in Great Britain.

Susan: Yes, there is a campaign underway in Great Britain to put new controls in place on junk food ads aimed at kids. It's hard to imagine that happening here in the near term, though it seems like a great idea. Parents are up against so much in the culture when it comes to keeping their kids healthy, and they don't have the advertising budgets that the food companies have.

Kathryn (K.D.) Harmsen, Health Educator: Is there any research being done on small children (2-5 years of age) who eat sweet cereals, candy and lots of sugar and the relationship to obesity? If children are born fat and continue to stay fat, does this mean they will have the same problems as an adult?

Marlene: There is some research that has been done by David Ludwig and his colleagues at Harvard that examines the role of sugared soft drinks and childhood obesity. One study, published in the Lancet in 2001, found that the more sugared soft drinks children drank, the higher their body mass index (BMI). I do not know of research specifically examining sugared cereals and candy, but it is logical to hypothesize that children eating those foods are taking in more calories than children who eat non-sugared cereals and snacks other than candy.

Regarding the health complications of childhood obesity, it appears that they are similar to the health complications of adult obesity. An example of this is the steep rise of Type II diabetes among children in recent years. This type of diabetes is linked to being overweight. This used to be called "adult onset diabetes" but it cannot be called that anymore because so many children have developed it.

Kelly, Gettysburg, PA: Regarding the comment about getting children used to new foods via repeated exposure: do you have any thoughts on whether getting children interested in learning about/trying less common, culturally-specific foods (either of their own or their classmates' cultures) would be more or less successful than exposing them to more "familiar" foods?

Marlene: My guess is that the more familiar the food, the more likely kids will try it. With that said, I think it's a great idea to expose kids to less common, culturally-specific foods. I'm reminded of when my kids' preschool celebrated Chinese New Year and one parent brought in some Chinese foods for the kids to try. I think kids were excited to try the food because it was part of a whole learning experience and they were doing it together.

Leslie-Ann Catona, Academy street School Guidance Counselor: How might you advise school employees especially teachers, nurse and counselor and cafeteria aides best help the children who are presently in this young age group? Are there any state agencies for assistance?

Marlene: I think there are two ways that school employees can help children. The first is to take a hard look at the food environment at school. What is being sold in the cafeteria? Is the school selling unhealthy food to keep its food service financially solvent? Do teachers give out food in class as a reward or celebration? Are parents allowed to bring in snacks for the whole classroom? These are all problems to address. It is completely unreasonable to expect young children to be able to limit their own intake of unhealthy foods when they are handed out in their classroom and sold in their cafeteria. Concerned school employees should form a committee and approach the school and district administration to begin a discussion on food policies for their schools. The idea is to make the school a place where it is easy to eat healthy foods and difficult to come across unhealthy foods; right now it is the other way around in most schools.

The second way that school employees can help is to create an environment that does not tolerate any bullying or teasing among the children. Overweight children are often the targets of bullying, and because we live in a society where obesity is stigmatized, school employees need to be particularly alert to this problem and intervene immediately. School employees should also be particularly aware of casual comments they make about themselves or others regarding body size and shape. It is common to say things like, "Oh, I feel so fat today" or "I was good today, I didn't eat that much." When these sorts of comments are heard by children they may contribute to their preoccupation with body weight and belief that self worth is dependent on what you look like.

One place to look for assistance is your state Department of Education. In Connecticut, there is a nutrition education coordinator within the Department of Education. She is an excellent resource for schools in Connecticut who are interested in addressing childhood nutrition in their schools.

Susan: That’s all we have time for! Thanks, everyone, for joining in, and thank
you, Irene and Marlene, for sharing your expertise with us today. The
archive will be on the Connect for Kids homepage.