Old terminology

• 85^th to 94^th percentile classified as at risk of overweight
• ≥ 95^th percentile classified as overweight

New terminology

• 85^th to 94^th percentile classified as overweight
• ≥ 95^th percentile classified as obese

The reason for the recommended change in terminology, as stated in the article, is because “the term obesity denotes excess body fat more accurately and reflects the associated serious health risks more clearly than the term overweight, which is not recognized as a clinical term for high adiposity. Overweight denotes high weight from high lean body mass as well as from high body fat levels and so is appropriate for the 85^th to 94^th percentile category, which includes children with excess body fat as well as children with high lean body mass and minimal health risks.”

Read the full article.

Also, with in the article, the expert committee recommends families follow these evidenced-based health habits:

• Limit consumption of sugar-sweetened beverages
• Encourage consumption of diets with recommended quantities of fruits and vegetables; the current recommendations from the US Department of Agriculture (USDA) are for 9 servings per day, with serving sizes varying with age
• Limit television and other screen time by allowing a maximum of 2 hours of screen time per day and removing televisions and other screens from children’s primary sleeping area (although a relationship between obesity and screen time other than television viewing, such as computer games, has not been established, limitation of all screen time may promote more calorie expenditure) (the American Academy of Pediatrics recommends no television viewing before 2 years of age and thereafter no more than 2 hours of television viewing per day)
• Eat breakfast daily
• Limit eating out at restaurants, particularly fast food restaurants (frequent patronage of fast food restaurants may be a risk factor for obesity in children, and families should also limit meals at other kinds of restaurants that serve large portions of energy-dense foods)
• Encourage family meals in which parents and children eat together (family meals are associated with a higher-quality diet and with lower obesity prevalence, as well as with other psychosocial benefits)
• Limit portion size (the USDA provides recommendations about portions, which may differ from serving sizes on nutrition labels, and a product package may contain >1 serving size).

Reference:

Barlow S.E. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics. 2007;120;s 164-s 192

As it states we are what we eat, meaning eating high fat, high sugar unhealthy food will make us fat, unhealthy people. In turn, this will lead to increasing number of obesity-associated diseases such as diabetes, hypertension and heart disease.

In fact along with a dramatic decrease in physical activity, dietary habits are the cause of what is now know as this century’s epidemic: obesity.

What is more alarming is that this epidemic is now affecting younger age groups with increasing proportion of infants and children being in the overweight zone compromising their health as children and future adults.

Food choices are one major culprit in this situation, the ready availability and low cost of high fat, high simple sugar foods with no real nutrient value makes them an attractive food option, both for their palatability and relative low cost. To further highlight this point, results from a recent survey of more than 3000 children and teenagers showed that almost half of children’s total energy intake came from non-essential sugar and fat and that the intake of only 1% of children met all dietary guidelines. In other words, children consume too much energy rich non-nutritive foods and not enough low-energy nutrient-rich foods.

What make a person choose a specific food item instead of another? Food choices are a result of different interplaying conditions, what a child chooses to eat or what makes his daily diet plan is the sum of his genetic, cultural, social and economic status. In addition to that, food preference, commonly confused with taste preference plays a major role. This is a very important point because it can have major lifelong consequences, meaning, it is possible that food preferences formed early in life persist to affect adult food selection; that is what a child learns to like in his early years can built his food preferences and food choices as an adult. This is why shaping food preferences early in life can have major health effect for a whole generation and for their lifetime.

What is food preference?

Food preference is the selection of one food item over the other. While this selection in adults can be affected by cost, healthy nutrition awareness and personal preference, in children it is mostly affected by personal liking, knowledge and money concern not being yet applied. So, what a child chooses to eat is usually what he likes and what he is used to. So, many questions arise in this situation: What if liking of certain foods can actually be learned? Can it be possible to make children actually like their fruits and vegetables? Can carrots and broccoli be the new treat for a more trained youth? Can low sugar, low fat, whole carbohydrate food choices become the first choice of children? The answer to these questions is YES, but first we have to understand how food preference is acquired and what is the best way to positively shape it.

How is food preference built? Is it an innate or learned process?

So what initially shapes or affects child’s food preferences?

Food preferences develop very early, even since the womb depending on the mother’s diet. When we are born, we already have innate taste preferences: newborn infants respond positively to sweet tastes and negatively to sour and bitter tastes.

So, at birth, sweet taste is preferred and sour and bitter are rejected; as for preference for salt, it emerges by approximately 4 months of age. And by early childhood, children’s most preferred level of salt is more concentrated than that preferred by adults, a pattern similar to that noted for sweet solutions.

Another food preference of young children is that for high-fat foods. This preference is possibly due to fat’s pleasant feeling of satiety in response to hunger and its association in many foods containing sugar and salt, both of which are preferred tastes among children. This also highlights another point for food preference, children tend to like or dislike foods according to postingestive feeling, meaning a food that lead to nausea or discomfort will be hereon avoided, wheras food associated with pleasant feelings will be liked and chosen subsequently.

Also, it is known that children tend to prefer foods that are familiar and tend to reject any new food, a process termed Neophabia or fear of the new, this happens independently of the foods’ sensory characteristics.

In summary, we have inborn genetic predispositions that initially constrain food preferences, and these are:

• Predisposition to prefer foods that are sweet and salty and to reject those that are sour and bitter
• Predisposition to reject new foods (neophobia) and to learn preferences for the more familiar
• Predisposition to learn preferences by associating foods with the contexts and consequences of eating them.

This might suggest that food prefernce is "built-in" and difficult to change, but lukily research does not support this conclusion. Responses to basic tastes change with a child’s repeated experiences with foods. In fact, children’s preferences develop over time and are acquired via experience. The early years are a key time for experimenting with and establishing dietary habits.

So the major question is how can parents and caregivers positively and effectively change children food preferences towards a healthier and more nutritious direction.

The Do’s and Don’ts in shaping children food preferences:

Although genetic predisposition, as mentioned above, have a role in shaping initial food preferences, studies suggest that environmental factors are more important in the established food preferences of humans.

Parents should know that young children are capable of learning to like and accept a wide variety of foods, even those foods that people automatically assume children will never like, and this learning occurs rapidly during the first few years of life. So, it is very important to understand how early learning and experiences lead to the development of food-acceptance patterns, and how this in turn can help create healthful patterns of eating.

After an exclusive milk diet in the first month of life, the challenge begins with the introduction of new foods.Given the predisposition that we are born with, meaning tendency towards sweet and salty taste and energy dense food, and rejection of sour and bitter taste and rejection of any new food, introducing vegetables and complex carbohaydrates which are neither sweet, salty, nor energy dense, is initially rejected by children. Fortunately, studies have shown that repeated exposure to a new food can reverse rejection to acceptance. But parents should be aware that this process may require a long time and sometimes as many as 10 exposures are necessary in order for a child to start appreciating a new food.

Therefore, in order to make a child accept a new food repeated exposures are needed. In addition to that, the context and the way the child is exposed to a new food are very important.

A new food should be presented in small amounts along with other already known foods. The child should be encouraged without too much fuss and no punishment behavior to try the new food, along with his meal. This behavior should be repeated on several occasions until the food is accepted. In addition, the social context in which foods are presented influences whether they are accepted. Children are more likely to eat in emotionally positive atmospheres. Also, siblings, peers and parents can act as role models to encourage the tasting of novel foods, a child observing a closed person consuming a certain food will be more likely inclined to try it.

Since the ultimate aim is to shape food preference that can last through adulthood, some parental behavior that are extremist might have negative effects in the long run. Restricting access to particular foods increases rather than decreases preference and forcing a child to eat a food will decrease the liking for that food. So the popular concept of restricting children’s access to snack foods actually make the restricted foods more attractive, and leads to children’s greater selection and intake of restricted than unrestricted foods.

Also, using the reward approach cannot help creating lifelong good eating habits. If a child is given foods as rewards for approved behaviors, they will like and accept this food better, whereas when children are offered rewards for eating (for example “If you eat your vegetables, then you can watch TV”), the foods eaten to obtain rewards become less preferred.

Conclusion:

So far, traditional strategies to improve dietary habits consisted in providing people with basic nutrition knowledge hoping that it will help them make the right choices in selecting their and their children food intake. These strategies have not proven to be very efficient since we are still witnessing an increase in the prevalence of obesity and consumption of energy-dense foods, high in sugar, fat, and salt still constitute the bulk of the American diet for all age groups.

Given these reasons, it is quite logical that an alternative strategy would be to teach parents about child taste development that can help them use better strategies in trying to shape the new generation food preferences and implement lifelong healthy dietary habits

What is an Eating Disorder?

Eating disorders are serious, life- threatening conditions that tend to be chronic. Eating disorders usually arise in adolescence, sometimes even in childhood. They affect females more than males although the number of affected males is not negligible.

Eating disorders are expressed as extreme emotions, attitudes, and behaviors surrounding weight and food issues. Eating disorders include anorexia nervosa, bulimia nervosa, and binge eating. Another group is referred to as “eating disorder not otherwise specified” EDNOS, this pertains to those who do not meet the criteria for neither anorexia nor bulimia but have problematic eating habits, this condition is mostly seen in adolescents.

Why are Eating disorders in adolescents a major source of concern?

Eating disorders effect individuals on multiple levels: physical, psychological and social. These include weight preoccupation, inappropriate eating behavior, and body image distortion. Many people with eating disorders experience depression, anxiety, substance abuse, and childhood sexual abuse, and may be at risk for osteoporosis and heart problems. Moreover, death rates are among the highest for any mental illness.

The consequences of eating disorders can be severe – one in 10 cases of anorexia nervosa leads to death from starvation, cardiac arrest, other medical complications, or suicide.

Some of the health complications resulting from chronic eating disorder are:

• Heart problems caused by low heart rate that might lead to weakening of heart muscles. Also heart failure may be result of electrolyte depletion due to frequent vomiting.
• Stomach and intestines complications such as stomach rupture.
• Hormonal problems leading to absence of menstrual cycle.
• Increased risk for suicidal behavior.
• Reduction of bone density (osteoporosis), which results in dry, brittle bones.
• Muscle loss and weakness.
• Severe dehydration, which can result in kidney failure.
• Fainting, fatigue, and overall weakness.
• Dry hair and skin and hair loss.
• Tooth decay and staining from stomach acids released during frequent vomiting.

Who and how many do these disorders affect in the population?

Currently, eating disorders affect almost 5 percent of all young women in the United States. In addition more than 15 percent of young women have unhealthy attitudes and behaviors about food. Of those women diagnosed with an eating disorder, around 90 percent are adolescents. Anorexia nervosa one of the listed Eating Disorder, ranks as the third most common chronic illness among adolescent females in the United States.

Some Statistical figures and numbers:

In this era of esthetic importance and reference of thinness as the acceptable body image girls are starting to be weight conscious at very early stages of their development. Indeed, different studies showed that:

• Seventy percent of sixth-grade girls surveyed said that they first became concerned about their weight between the ages of 9 and 11.
• Thirty to fifty five percent of surveyed school girls said that they started dieting when they were in middle school.
• In a study of children aged 8 to 10, approximately half the girls and one-third of the boys were unhappy with their size.
• In a study of girls aged 9 to 15, slightly more than half reported exercising to lose weight, slightly less than half reported eating less to lose weight, and approximately 1 out of 20 reported using diet pills or laxatives to lose weight.
• A study showed that 40 percent of fourth graders have been on a “diet” once in awhile. About 1 out of every 100 females between the ages of 10 and 20 are not eating enough and should be seeing a doctor.

What causes the development of an eating disorder?

So far experts and research do not know the exact reason on how people get an eating disorder. What is known is that the development of these disorders is the result of many factors.

Many people with eating disorders have low self-esteem and suffer from depression and feel a lack of control over their own lives. They usually experience the following emotions; fear of becoming fat, feelings of not measuring up to other people’s expectations and feeling of helplessness.

People with eating disorders often use food and the control of food in an attempt to compensate for overwhelming feelings and emotions. Controlling food intake using any of the following techniques such as dieting, bingeing, and purging may begin as a way to cope with painful emotions and to feel in control of one’s life. Dieting is a major player in the development of eating disorder as it has been identified as common entry point in both anorexia and bulimia nervosa, with the greatest risk being the group of severe dieters. Eating disorders often run in families. Current research is indicates that there are significant genetic contributions to eating disorders.

What are the different types of eating disorder?

Anorexia Nervosa

Anorexia Nervosa is an eating disorder in which people intentionally starve themselves. It causes extreme weight loss defined as at least 15 percent below the individual’s normal body weight. Food and weight become obsessions. Compulsiveness may cause strange eating rituals or the refusal to eat in front of others.

Symptoms include:

• Refusal to maintain body weight at or above a minimally normal weight for height, body type, age, and activity level
• Intense fear of weight gain or being “fat”
• Feeling “fat” or overweight despite dramatic weight loss
• Loss of menstrual periods
• Extreme concern with body weight and shape
• Low body weight (less than 85 percent of normal weight for height and age)
• Distorted view of one’s body weight, size, or shape; sees self as too fat, even when very underweight; expresses feeling fat, even when very thin
• Excessive physical activity
• Denial of hunger
• Preoccupation with food preparation
• Bizarre eating behaviors

Bulimia Nervosa

Bulimia Nervosa is defined as uncontrolled episodes of overeating (bingeing) and usually followed by an extreme behavior to get rid of ingested calories. The most common technique is purging (self-induced vomiting), other adopted methods include misuse of laxatives, enemas, or medications that cause increased production of urine, fasting, or excessive exercise to control weight.

Symptoms include:

• Repeated episodes of bingeing and purging (usually secretive)
• Feeling out of control during a binge and eating beyond the point of comfortable fullness
• Frequent dieting
• Extreme concern with body weight and shape
• Usually have a normal or low body weight (sees self as overweight)
• Excessive exercise or fasting
• Peculiar eating habits or rituals
• Inappropriate use of laxatives, diuretics , or other cathartics
• Irregular or absence of menstruation
• Anxiety
• Discouraged feelings related to dissatisfaction with themselves and their bodily appearance
• Depression
• Scarring on the back of the fingers from the process of self-induced vomiting
• Overachieving behaviors

Binge Eating Disorder

Binge Eating Disorder is defined by periods of uncontrolled, impulsive, or continuous eating beyond the point of feeling fullness. Usually the episodes of overeating are not followed by a compensatory behavior such as seen in bulimia. Body weight may vary from normal to mild, moderate, or severe obesity.

What are the current treatments for eating disorders?

Eating disorders are treatable and people do recover from them. They are most successfully treated when treated early. Eating disorders are usually treated with a combination of individual therapy, family therapy, behavior modification, and nutritional rehabilitation.

Treatment is always tailored according to the patient needs and his environment, mainly his family. Individual therapy usually includes both cognitive and behavioral techniques. In the cases where the patient suffers from depression or anxiety, medications (usually antidepressants or antianxiolytics) are helpful.

Although the treatment of eating disorders involves a group of professionals such as physicians, nutritionists, psychiatrists and social workers, families play a vital supportive role in any treatment process.

Indeed, the latest intervention strategies for the treatment of eating disorders are family-based outpatient strategies which involve the direct participation of parents in their home setting. One of these interventions is referred to as the Maudsley Approach. The Maudsley approach is an intensive outpatient treatment where parents play an active and positive role in order to:

• Help restore their child’s weight to normal levels expected given their adolescent’s age and height
• Hand the control over eating back to the adolescent
• Encourage normal adolescent development through an in-depth discussion of these crucial developmental issues as they pertain to their child.

How to get help?

If you think that you or somebody you know may have an eating disorder, get help! Don’t wait and don’t try to deal with the problem by yourself. Talk to a parent or other trusted adult like a counselor, coach, relative, or teacher.

There are many organizations and associations that can help people, parents or friends facing these problems. A list of these are provided on the Girl Power! web site.

For further information and helpful links go to:

• The National Women’s Health Information Center – Fact Sheet: Eating Disorders
• NIMH – Eating Disorders: Facts About Eating Disorders and the Search for Solutions
• ANRED – Eating disorders prevention
• Maudsley Parents – Family-based Treatment of
  Adolescent Anorexia Nervosa: The Maudsley Approach
• Yale-New Haven Teachers Institute – Eating Disorders and Adolescents: Conflict of Self Image
• National Eating Disorders Association
• National Association of Anorexia Nervosa and Associated Disorders
• Girl Power! – Facts about Eating Disorders

Current recommendations for physical activity in youth:

The American Heart Association recommends that children and adolescents should engage in at least 60 minutes of moderate to vigorous physical activity every day (activity that causes some increase in breathing and heart rate, such as brisk walking, dancing, swimming, or cycling on flat terrain).
Physical activity should be developmentally appropriate, enjoyable and involves a variety of activities. The 60 minutes can be accumulated throughout the day meaning that any activity during school, PE, recess and in before and after-school programs can be added up at the end of the day for the required 60 minutes.

Importance of physical activity in youth:

Being physically active or not living a sedentary lifestyle is very important for children and adolescents in many aspects.
The Surgeon General’s report indicates that physical activity in children/adolescents:

• Leads to improved body composition: increased lean muscle mass, reduced total body fat
• Reduces heart disease risk factors among children and adolescents.
• Plays a substantial role in the development of bone mass during childhood and adolescence and helps maintain the structure and functional strength of bone throughout life.

In addition, participating in regular physical have emotional and psychological benefits as it has been shown to:

• Enhances psychological well-being.
• Reduce symptoms of depression and anxiety and improve mood.

Example of chronic diseases prevented by physical activity in youth:

Osteoporosis

Osteoporosis is the state of low bone density or porous bones in adults. This condition may cause serious and disabling bone fractures in older adults.
Osteoporosis may result if too little bone building occurs during childhood and adolescence.
In addition to optimal dietary habits with adequate calcium and vitamin D content, physical activity contributes in building greater bone density in childhood and adolescence and maintaining peak bone density in adulthood.
The physical activities that mostly increase bone strength are referred to as Weight-bearing activities. These activities require children and adolescents to move their own weight. Weight-bearing activities include jumping rope, walking, playing soccer or basketball among other.

Obesity

Obesity is a state of excessive fat mass. The prevalence of this condition is reaching alarming levels in children and teenagers. Physical activity is crucial for obtaining and maintaining a healthy weight.
Studies have proven that including physical activity in a weight loss program along with family intervention and a moderate reduction in caloric intake produces significant reductions in the prevalence of childhood and adolescent obesity.
Participating in physical activity helps children and adolescents expend energy (calories), which helps them obtain and maintain a healthy weight. Physical activity favorably affects body fat distribution.
Aerobic activities such as distance running, swimming and biking are best for expending calories.

Hypertension

Hypertension is a state of abnormally high blood pressure. This causes many diseases in adults including strokes, renal and heart failure. Essential hypertension, which usually develops during childhood, is often the cause of these diseases. Regular physical activity has been shown to lower blood pressure in children and adolescents.
Activities such as running, biking, and swimming for 30 minutes three times a week promote cardiorespiratory fitness and help decrease resting blood pressure in children and adolescents with hypertension.

Mental Health

Regular physical activity has the potential to promote psychological health in children and adolescents. Participating in regular physical activity appears to enhance self-esteem and reduce symptoms of depression and anxiety in children and adolescents with emotional disorders or developmental disabilities.

Concerning facts about youth and physical activity:

Although the role of physical activity is well recognized, still the number of youth engaged in regular physical behavior or meeting the recommendations for physical activity is alarming. In fact:

• Nearly half of American youths aged 12-21 years are not vigorously active on a regular basis.
• About 14 percent of young people report no recent physical activity. Inactivity is more common among females (14%) than males (7%) and among black females (21%) than white females (12%).
• Participation in all types of physical activity declines strikingly as age or grade in school increases.
• Only 19 percent of all high school students are physically active for 20 minutes or more, five days a week, in physical education classes.
• Daily enrollment in physical education classes dropped from 42 percent to 25 percent among high school students between 1991 and 1995.

Ways to promote physical activity in youth:

The surgeon General report on Youth and physical activity concluded that:

• Well designed school-based interventions directed at increasing physical activity in physical education classes have been shown to be effective.
• Social support from family and friends has been consistently and positively related to regular physical activity.

How can parents help promote physical activity for their children:

• Physical activity should be increased by reducing sedentary time (e.g., watching television, playing computer video games or talking on the phone).
• Physical activity should be fun for children and adolescents.
• Parents should try to be role models for active lifestyles and provide children with opportunities for increased physical activity

For more tips to parents go to: http://www.knackonline.org/parents/children/move-more.php

How can the community help promote physical activity in children:

• Provide quality, preferably daily, K-12 physical education classes and hire physical education specialists to teach them.
• Create opportunities for physical activities that are enjoyable, that promote adolescents’ and young adults’ confidence in their ability to be physically active, and that involve friends, peers, and parents.
• Provide appropriate physically active role models for youths.
• Provide access to school buildings and community facilities that enable safe participation in physical activity.
• Provide a range of extracurricular programs in schools and community recreation centers to meet the needs and interests of specific adolescent and young adult populations, such as racial and ethnic minority groups, females, persons with disabilities, and low-income groups.
• Encourage health care providers to talk routinely to adolescents and young adults about the importance of incorporating physical activity into their lives.

For more tips to community worker on evidence-based programs promoting physical activity in youth go to: http://www.knackonline.org/information/evidence-based-programs.php

The above information was adapted from:

http://www.americanheart.org/presenter.jhtml?identifier=4596

http://www.brightfutures.org/physicalactivity/intro/006_011.html

http://www.cdc.gov/nccdphp/sgr/adoles.htm

These serious complications explain the amount of interest and effort geared towards the prevention and treatment of adolescent obesity. Because of this critical period in a person’s development, much assessment should be made by clinicians in order to determine specifically which individuals should be treated and how.
The Society of Adolescent Medicine states that “…adolescent weight management programs should support overall health as well as optimal growth and development”.

The treatment of choice for childhood and adolescent weight problems is the conventional behavioral and lifestyle modifications. In those cases where the child/adolescent is severely overweight and conventional weight reducing programs are not working, pediatricians and health care givers are turning to therapeutic drugs –in conjunction with behavioral and lifestyle modifications– in hopes that it will be beneficial.

Though few drugs are FDA approved for the treatment of obesity in adults mainly Sibutramine (trade name Meridia) and Orlistat (trade name Xenical). So far, the only drug currently FDA approved for treatment of adolescent obesity is Orlistat. Orlistat is a digestive inhibitor; it reduces the amount of dietary fat absorbed in the gut and thus decreases calorie absorption, leading to weight loss. Studies on efficacy and safety of Orlistat in obese adolescents lead to the approval of its use in 12-18 year old adolescents in 2003 in the US and later in the European Union. The study results showed that patients treated with Orlistat plus diet had a significantly reduced BMI compared with those who were on the dietary plan alone.
The specific conditions for Orlistat prescription in adolescents are:

• At least 12 years of age.
• BMI more than two units above the 95th percentile.

Some physicians are even more restrictive on the use of drugs, they reserve drug therapy for very obese patients whose behavioral therapy fails to work alone. In addition, one must keep in mind the other conditions for prescription of this drug that apply to both adults and adolescents, namely this drug should be prescribed by the physician as a conjunct to a behavioral weight loss plan consisting of a low-fat, reduced caloric diet and a physical activity regimen. Orlistat should NEVER be prescribed or taken as a sole treatment option.
Orlistat has reported side effects which are shared between both adults and adolescents taking this drug. Patients taking Orlistat may experience:

• Gas with oily discharge,
• Increased bowel movement
• Fecal incontinence.

A major point of concern in this digestive inhibitor drug is the potential decrease in fat soluble vitamins’ absorption, which may lead to some vitamin deficiencies, a major point of concern especially in the growing adolescent. The FDA has strongly suggested the inclusion of a multivitamin in the product packaging for use in the adolescent population. The conclusion is that adolescents taking this drug SHOULD take a multivitamin supplement.
It is worth noting that NO clinical studies addressed the long-term effects of Orlistat in adolescence. The longest intervention study was for one-year and no follow-up was done afterwards. In a recent editorial in the Annals of Internal Medicine, Dr. Dietz suggested that clinicians should carefully weigh the decision to prescribe drug therapy for the treatment of adolescent obesity, because the long-term effects of drug therapy in children and adolescents are unknown at this time.
Given this information and lack of sufficient data, more regulations and guidelines are needed in the area of pharmacotherapy for adolescent obesity. In a recent paper addressing drug therapy in childhood obesity, Dr. Molnar states:

“In extremely obese adolescents with obesity-related comorbidities being resistant to conventional weight-reducing programs… a rationale for pharmacological treatment could easily be established, but in the majority of cases the indication of drug therapy, the evaluation of benefit/risk ratio is much more difficult.”

Du to this lack on universal guidelines regarding the issue of drug treatment for children/adolescent obesity, it is to set guidelines addressingthe following points:

• Indications of treatment
• Who should indicate and supervise the treatment (obesity expert or general practitioner)
• Duration of treatment
• Safety measures

A final note on the use of Orlistat in adolescents is the ongoing FDA approval decision on the release of Orlistat as an over-the-counter drug. The North American Association for the Study of Obesity(NAASO) has reviewed that decision and expressed the following concerns –stated verbatum:

• Safety concerns: Orlistat has a strong safety record. There is a major need for a multiple vitamin supplement (fat soluble vitamins) and there is some interference with absorption of other lipid soluble drugs. It is essential that any OTC bottle clearly note very carefully both concerns and strongly recommend that multiple vitamin supplements be taken with Orlistat OTC.
• Potential for abuse: As an OTC drug, there is concern that this availability will lead to abuse by people who are suffering from eating disorders. Furthermore, this drug is only advisable as an adjunct to individuals engaged in an active weight loss program that focuses on a healthy diet, caloric restriction, and increased physical activity. The 60 mg dose of Orlistat will be less effective than the currently prescribed higher dose.
• OTC availability will most likely increase significantly Orlistat usage since doctors uncommonly prescribe anti-obesity drugs. The FDA must require a careful monitoring system be established to study the uses and abuse of Orlistat as an OTC drug.
• Age limitations on Orlistat use: Orlistat must be limited to persons aged 14 and older. The research seems to indicate that trials have been done with adolescents and there were no serious problems. This research found that “Orlistat, in combination with diet, exercise, and behavior modification, improves weight management in obese adolescents”(Chanoine, Hampl et al. 2005). Again there is concern that normal or even anorexic and bulimic adolescents will use and abuse this drug.

Myth: Certain foods, like grapefruit, celery, or cabbage soup, can burn fat and make you lose weight. Fact: NO food can burn fat. These foods are very low in calories with almost zero fat content. In addition, some of those foods may contain caffeine which might speed up the metabolism (the way your body uses energy or calories) for a short time, but they do not cause weight loss, nor do they cause loss in fat mass.

Myth: Natural or herbal weight-loss products are safe and effective.
Fact: “Natural” or “Herbal” does not always mean safe, especially in health related products. These products are not usually scientifically tested to prove their safety and efficacy. So far there are no FDA regulations on these products to control their claims and commercialization. One example of an unsafe “Natural” weight loss product is ephedra now banned by the U.S. Government. Ephedra have caused serious health problems and even death.

Myth: Low-fat or fat-free means no calories. You can eat more foods if they are low fat or fat free.
Fact: Low fat or fat free does not mean calorie free. A low-fat or fat-free food is OFTEN lower in calories than the same size portion of the full-fat product. But many processed low-fat or fat-free foods have just as many calories as the full-fat version of the same food—or even MORE calories. Usually, when the fat is taken out, sugar and other carbohydrates are added in to keep the taste. This brings the low-fat version to usually the same caloric content as the regular full fat version. When shopping, make sure you read nutrition labels of the regular versus the low-fat product and compare the calories per serving size. Remember that weight comes down to calories, not fat!

Myth: Skipping meals is a good way to lose weight.
Fact: One popular approach used to lose weight is skipping a meal, usually breakfast. Many people think that by skipping a meal, they eat less food and therefore lose weight. Studies show that people who skip breakfast and eat fewer times during the day tend to be heavier than people who eat a healthy breakfast and eat four or five times a day. This is partly due to the fact that when skipping a meal, you feel hungrier and tend to overeat at the next meal and pay less attention to your satiety cues. Often times, skipping a meal results in an increase in total caloric intake than just eating more frequently throughout the day. A better approach is to eat smaller frequent healthy meals and snacks to keep blood sugar balanced.

Myth: Eating after 8 p.m. causes weight gain.
Fact: It does not matter what time of day you eat. It is what and how much you eat and how much physical activity you do during the whole day that determines whether you gain, lose, or maintain your weight. No matter when you eat, your body will store extra calories as fat.

Myth: Sugar Causes Diabetes
Fact: The most common nutrition myth is probably the misconception that sugar causes diabetes. If you have diabetes, you do need to watch your sugar and carbohydrate intake, to properly manage your blood sugar level. However, if you do not have diabetes, sugar intake will not cause diabetes. So far, a diet high in calories, being overweight and an inactive lifestyle are the main risk factors for Type 2 diabetes.

Myth: All Fats are bad
Fact: Fat are an essential part of the diet, the USDA recommends that around 30% of total daily caloric intake comes from fat (with less than 10% coming from saturated fatty acids). Fats help nutrient absorption, nerve transmission and maintain cell membrane integrity just to name a few functions. However, when consumed in excessive amounts, fats contribute to weight gain, heart disease and certain types of cancers. Also, one must keep in mind that fats differ in their effect on the body. Some fats promote our health positively while some increase our risk for heart disease. The key is to replace bad fats (saturated fats and trans fats) with good fats (monounsaturated fats and polyunsaturated fats) in our diet.

Myth: Brown Sugar is better than White Sugar
Fact: The brown sugar sold at the stores is actually white granulated sugar with added molasses. Yes, brown sugar contains minute amounts of minerals. But unless you eat a gigantic portion of brown sugar everyday – the mineral content difference between brown sugar and white sugar is absolutely insignificant. The idea that brown and white sugar have big differences is another common nutrition myth.

Myth: Margarine has fewer calories than butter.
Fact: Regular stick margarine and stick butter contain the same number of calories: about 36 per teaspoon.

Myth: High-protein/low-carbohydrate diets are a healthy way to lose weight.
Fact: The concept of high protein/low carbohydrates diets comes from the assumption that starches (carbohydrates) are fattening. This is a nutrition myth because starchy foods (bread, rice, pasta, cereals, beans, fruits, and some vegetables) are low in fat and calories. They become high in fat and calories when eaten in large portion sizes or when covered with high-fat toppings like butter, sour cream, or mayonnaise. In addition, the long-term health effects of a high-protein/low-carbohydrate diet are unknown. But getting most of the daily calories from high-protein foods like meat, eggs, and cheese is not a balanced eating plan. These foods are usually increase fat consumption especially saturated fats. which may raise heart disease risk. Also this kind of diet contains too few fruits, vegetables, and whole grains, which may lead to constipation due to lack of dietary fiber, and vitamins and minerals deficiencies. A well- balanced diet is still the best option for weight loss.

Myth: “Going vegetarian” means you are sure to lose weight and be healthier.
Fact: Research shows that people who follow a vegetarian eating plan, on average, eat fewer calories and less fat than non-vegetarians. They also tend to have lower body weights relative to their heights than nonvegetarians. Choosing a vegetarian eating plan with a low fat content may be helpful for weight loss. But vegetarians—like nonvegetarians—can make food choices that contribute to weight gain, like eating large amounts of high-fat, high-calorie foods or foods with little or no nutritional value. The term vegetarian is not synonymous with health. Healthy nutrition comes down to choosing nutritious foods within the recommended amounts and limiting foods high in fat, sugar and calories. These facts hold true for those people who choose to include animal products into their diets as well as those who do not!

Common nutrition myth related to adolescents and children taken from The Yale Guide to Children’s Nutrition

• Myth: Potato chips count as a vegetable in the Food Guide Pyramid.
  Fact: While potatoes are found in the vegetable group, potato chips are not. Potato chips are extremely high in fat and should, therefore, only be eaten occasionally.
• Myth: “Starve a fever; feed a cold,” or is it “feed a fever; starve a cold”?
  Fact: Neither! Fevers and colds both require adequate nutrition. While children may not have an appetite for many foods when they are sick, it is still important to frequently encourage food and fluid intake.
• Myth: Chocolate and fried foods cause acne.
  Fact: Research has not shown a connection between the consumption of chocolate and/or high fat food intake and the appearance of acne. Acne is primarily associated with hormonal changes in adolescence.
• Myth: Fish is brain food.
  Fact: Fish provides many excellent nutrients and is an excellent food choice. However, it does not have any special effects on brain development or learning.
• Myth: Sugar causes hyperactivity.
  Fact: Sugar has not been shown to cause hyperactivity. A modest intake of sugar is acceptable in the context of a balanced, nutritious diet.

“Parents, schools and even health care providers should be thinking more critically about TV watching,” Dr. Fleming-Moran said. “Some doctors have even written prescriptions for their younger patients to reduce their TV watching.”

As prevalence of childhood and adolescent obesity is witnessing a sharp increase, researchers are trying to identify the major causes of this epidemic. Two main factors are recognized as the major contributors to this century’s epidemic in the young population:

• Accessibility of high-energy food
• Increased time engaged in sedentary activities such as watching TV and playing video game.

Television viewing is a major activity for children and adolescents. Children in the United States, ages 8 to 18, spend 44.5 hours per week in front of a computer, television, and video game, more time in front of a screen than doing any other activity in their lives except sleeping. It has been estimated that by the time of high school graduation, adolescents will have spent more time watching TV than they have in the classroom.

This is a matter of concern because it has been shown that watching more than two hours of television per day increases adolescents’ chances of being overweight. A study done at Indiana University found that TV watching ALONE added a 50 percent risk of being overweight for high school students.

The question is:
HOW DOES TELEVISION VIEWING AFFECT BODY WEIGHT?
This topic has been one of the highlight themes of the annual North American Association for the Study of Obesity (NAASO) meeting in 2004. Television watching was demonstrated to promote teenage obesity by:

• Preventing physical activity
• Promoting unhealthy snacking and consumption of less nutritious meals

Preventing Physical Activity:

Children who use a lot of media have a lower activity level. Watching television will cut down the time expanded doing any other more energy expanding activity.

As Dr. Fleming-Moran Millicent Fleming-Moran, an associate professor Indiana University explains it:

“Watching TV may be the most inactive behavior next to sleeping. When you watch TV you tend to be totally still and may even lie down. Sitting at the computer is not active behavior, but at least you are upright and moving your arms to type or use the mouse.”

Promoting unhealthy snacking and consumption of less nutritious meals:

As for food habits associated with TV watching, current estimates suggest that 20-25% of daily energy is consumed in front of the television. Both children and adults increase their intake of high-calorie foods while watching television.

Two of the mechanisms through which television viewing is thought to promote childhood unhealthy dietary behaviors are:

• Increased dietary intake from eating during viewing
• Eating highly advertised foods

Adolescents who watch more television eat more high-fat foods and fast food, drinks more soft drinks, and consume fewer fruits and vegetables. In addition, in households in which the television is on during meals, children consume more red meat, pizza, snack foods, and soda and fewer fruits and vegetables.

Second, several studies showed that foods, especially high-fat or high-sugar foods, are frequently advertised on children’s television programs. Incorporation of these adds in children or adolescents TV program led to the children choosing the advertised brand of food over an unadvertised product. Since food advertisements during these programs are mainly for high-fat or high-sugar foods, children will end up eating and choosing more from these foods than other more nutritious option.

This information suggests that reducing television exposure has as strong an influence on adolescent obesity levels as increasing exercise and healthier eating.

Given this information and the ongoing spread of childhood obesity and it associated health problems, it is increasingly important to encourage children to become more active and limiting their screen time by encouraging them to a more physically active lifestyle.

Some figures and facts about Television watching and associated weight and food behaviors

Adapted from National Institute on Media and the Family.

• Obesity in children increases the more hours they watch television. These results were reported in a study by researchers at the University at Buffalo, Johns Hopkins University, The National Cancer Institute, and the Centers for Disease Control (Crespo, 2001).
• A more recent study found that children who watch more than three hours of television a day are 50 per cent more likely to be obese than kids who watch fewer than two hours. These researchers conclude that “more than 60% of overweight incidents can be linked to excess TV viewing” (Tremblay, 2003).
• Lack of physical activity is a large contributor to this problem. Physical education, once an important part of every child’s school day, has been cut back at many schools. Less than half of U.S. schoolchildren have access to daily physical education classes (Squires, 1998).
• Children who use a lot of media have a lower activity level which is linked to a higher rate of obesity (Vandewater, 2004).
• In analyzing the data from a national survey between 1988 and 1994, researchers found that the 26% of children who watched four or more hours of television a day had significantly more body fat than those who watched less television. The more time children spent watching television, the greater their weight increase (Andersen, 1998).
• Another study found that 60% of the overweight in children, ages 10-15, may be due to excessive television viewing (Gortmacher, 1996).
• Dietz in his study also found that the incidence of obesity increased by 2% for every additional hour of television watched (Dietz, 1985).
• In another study of preschoolers (ages 1-4), a child’s risk of being overweight increased by 6% for every hour of television watched per day. If that child had a TV in his or her bedroom, the odds of being overweight jumped an additional 31% for every hour watched. Preschool children with TVs in their bedroom watched an additional 4.8 hours of TV or videos every week (Dennison, et al., 2002).
• In related studies on significant health issues, researchers are finding that increased television viewing and subsequent lack of exercise affect children adversely in two areas.
  • Early childhood is a time of tremendous growth for children and the amount of physical activity positively affects the strength and amount of bone mass developed. A study of pre-schoolers found that girls who watched more television measured lower in the amount of hipbone density (Janz, 2001).
  • Another study on the relationship between metabolic rates and television viewing found that metabolic rates during television viewing were significantly lower than during resting periods for a group of obese and normal weight children, ages 8 to 12 years old (Klesges, 1993).
• A study from Stanford University, researching the relationship between television viewing and weight, set out to measure body weight differences between two sets of third and fourth graders. One group was taught how to lessen their time watching television and playing video games. The second group received no such instruction and their TV and video game playing time went on as usual. For the first group, the instruction sought to establish a seven-hour a week limit on television and video game time. This would free up 14 hours to do something else. The results showed that the children who watched less television and played fewer video games had a significant reduction in measures of obesity, such as body mass index. The children who watched their usual amount of television had higher indicators of obesity. The only difference between the two groups was the amount of television and video game playing (Robinson, 1999).

Tips for parents and caregivers for controlling negative effects of television viewing on children:

• Set guidelines for the amount of time your children can spend watching television or playing video games. Watching TV can use less energy than simply sitting and resting! Also, we tend to snack on high calorie foods during these inactive times.
• Substitute the rest of leisure time watching TV with physical activity.
• Plan family activities that involve exercise. Instead of watching TV, go hiking or biking, wash the car, or walk around a mall. Offer choices and let your children decide.
• Eat meals together as a family and eat at the table, not in front of a television. Eat slowly and enjoy the food.
• Remove or avoid having television sets in children’s bedrooms

For more tips go to Helpful Ways to Reduce Screen Time.