America’s kids get fatter and fatter

Type 2 diabetes in kids may have quadrupled or more

There’s an epidemic in America that is taking a terrible toll and will take its toll for decades to come. Our children are becoming fatter and fatter — and as a result, they are being consigned to a debilitating adulthood.

Obesity is condemning them to heart disease, diabetes, depression, and social ostracism — all adding up to "a public health crisis of enormous proportions," says Fran Kaufmann, MD, head of the division of endocrinology at Children’s Hospital in Los Angeles, and president-elect of the American Diabetes Association in Alexandria, VA.

U.S. Surgeon General David Satcher agrees with that assessment: Childhood obesity has reached epidemic proportions in the United States.

A generation ago, fewer than 4% of children diagnosed with diabetes were Type 2, the type of diabetes once known as adult-onset diabetes. Now doctors estimate the proportion of new patients younger than age 18 diagnosed with diabetes has climbed as high as 45%, and virtually all of them are obese, says Kaufman. There are some estimates that Type 2 diabetes in children and adolescents is rising at the rate of 5% annually.

Worse yet, 20% of the overweight kids have a second risk factor for cardiac disease, and they double their risk of high cholesterol and increase their risk of developing insulin resistance 12-fold over those who are in normal weight ranges.

The Centers for Disease Control and Prevention (CDC) in Atlanta issued a preliminary report on childhood obesity in 1999 that estimated that 13% of American children ages 6-11 are overweight, up from 11% in a study conducted from 1988 to 1994. That means 5 million children and teenagers are at risk for diabetes and heart disease.

The American Heart Association in Dallas has even grimmer numbers: It estimates the incidence of obesity in 6 to 11-year-olds has risen by 48% in the past 30 years.

Continuing on this course inevitably will subject these children to complications of diabetes and heart disease decades earlier than the ages at which such complications arose in their parents and grandparents. Imagine the hundreds of thousands or millions of 35-year-olds with diabetic nephropathy who will need dialysis in 20 years. Imagine coronary bypass surgery becoming routine for 30-year-olds. Imagine life expectancy dropping dramatically. That’s the road America is taking.

Yes, our society has changed dramatically in one generation. And those changes have presented a double-edged sword of progress and regress.

The Internet revolution has given us the miracle of instant information at our fingertips. At the same time, it has snared our children in its web of intrigue. Computers are gluing kids to their ergonomically correct chairs, frying their close-up vision long before its time, giving them carpal tunnel syndrome, and worst of all, keeping them indoors when the sun is shining and the bike trails and soccer fields are beckoning.

Television can be even more destructive.

With hundreds of channels to choose from on virtually every television, pay per view with an endless supply of movies, and parents’ willingness to use the TV as the "electronic baby sitter," it’s little wonder that children become couch potatoes even before they can walk. And even though the kids on Sesame Street may be dancing around Big Bird, the kids on the other side of the box are sitting glassy-eyed and motionless in front of the boob tube. (See "The Boob Tube," below.)

Schools are built without playgrounds and sometimes even without gymnasiums. The numbers are shocking: In 1999, only 29% of American’s students attended physical education classes, compared with 42% in 1991, according to the CDC.

"Never before in human history has there been so little reason to move around," says William J. King Jr., MD, assistant professor of pediatrics at Temple University in Philadelphia.

"Our children are much more sedentary than they were 20 years ago," says King. "Kids don’t necessarily want to sit around, but there is so much to keep them entertained that they are not motivated to do anything else. There are hundreds of television channels, video games, and the Internet. Even most toys do the moving rather than inspiring kids to move."

In the meantime, children also have become increasingly dependent on fat- and calorie-laden fast food — served in portions Kaufman calls "obscene" — even in their school cafeterias.

In Orange County, CA, middle- and high-school cafeterias sell food from Papa John’s Pizza, Pizza Hut, and Subway. The county also has contracts with Coca-Cola and Pepsi to sell a variety of their beverages in all middle schools and high schools.

Vending machines selling soft drinks, chips, and candy bars have been staples in schools for years. In fact, many schools rely on vending machine sales to fund marching bands, scholarships, field trips, and computer centers. These machines are the source of junk lunches for many students.

And when they leave school, kids in search of an after-school snack or dinner load up with 1,000 or more extra calories of fast food, adding to the junk they already have consumed during the day, yet still leaving them hungry for quality nutrients.

How many parents take the easy way out and take the kids to McDonald’s for a fat-, cholesterol-, and calorie-laden lunch or dinner? And how many times a week are they doing this? How many let their children suck down gallons of soda, juice, and other sugary concoctions every week? Remember when a soda was a treat, not a beverage with which to wash down dinner?

"The fast-food industry has always been there, but they’ve increased the size of their meals. It’s obscene. That’s not what one person should eat," says Kaufman. "And I think the average family no longer understands what an appropriate portion size or a balanced meal is. So we need to start educating in our schools. Why are we selling soft drinks that are loaded with sugar, contain sodium phosphates, and have zero nutritional value?"

This burgeoning epidemic is not a children’s problem, not even really a family problem, says King. "It’s a social problem that we have to address as a society."

Kaufman agrees. "This is a serious public health issue, and we need to come up with a public health solution."

Kaufman, King, and many of their colleagues agree that something has to be done.

Long-term studies show that comprehensive, family-based behavioral programs for children are effective in reducing obesity. Successful programs involve the child and the parents and address lifestyle modification, nutrition, and physical activity.

A 1998 Israeli study designated parents as the exclusive agents of change, resulting in greater weight loss than in programs that give children responsibility for their own weight loss.

"Parents and adult caregivers, besides serving as role models, exert a powerful influence on young children’s eating habits and activities. The powerful influence is due to the fact that parents usually control the children’s exposure to food stimuli and food selection and they establish the emotional and physical environment in which obesity may or may not be discouraged,"1 wrote the study’s lead author, Moria Golan, PhD, of the Sackler Faculty of Medicine at Tel Aviv University.

Golan and her colleagues studied 60 obese children who were 20% over ideal weight for age, height, and gender and asked both parents to complete a questionnaire that included sociodemographic information as well as family eating and activity habits.

Participants were randomized to two groups for the yearlong study: parents as agents of change and children as agents of change.

Hour-long support and education sessions were conducted, and individual sessions were held when necessary. In the active group, only parents participated; the children were not involved in the process of change and had no responsibility concerning the process. The parents’ role was to control the quality and pattern of the food environment, but not to restrict the amount of food eaten. Many of the parents also were obese.

Through the course of the study, children in the parent-directed group lost twice as much weight as those in the self-directed group. Neither group significantly increased its exercise time, and neither group decreased its television-viewing time.

The major difference was that parents did not bring tempting high-calorie, high-fat foods into the house. They asked the child if he or she was hungry when he or she requested food, and they asked the child to sit at the table and eat all food from a plate without the presence of outside stimuli such as television or reading.

Golan’s group implemented a list of criteria for eating, called the "Five Onlys," which it credits with a substantial portion of the weight loss among the children in the parent-directed group. (See "The Five Onlys," below.)

"Our results support the argument that parents play an important role in the weight status of their children, and intervention for obesity should be family-based," wrote Golan. "We suggest that the responsibility for behavioral change in the obese young child should lie exclusively with the parent."

Health care professionals and even legislators currently are working on a wide range of creative ways to encourage healthy eating and healthy weight among children:

  • Sen. Tom Larkin (D-Iowa), chairman of the Senate Agriculture Committee, has introduced a bill that would subsidize the cost of giving fruit to school children every day in an effort to get them to eat less junk food.
  • Cut back, or cut off, the juice, says King. "We’ve made our kids into juice-aholics under the mistaken impression that juice is good for them. Even pure fruit juice is calorically dense and consists of concentrated fruit sugar. The average American child drinks 24 ounces of juice a day — that could provide an additional 500 calories a day or more, which actually is about 200 calories more than 24 ounces of Coca-Cola. That’s a substantial portion of the 1,800-2,000 calorie intake recommended for children.

"It’s deceptive to see how many calories you can build up drinking juice — calories that you’d never dream of consuming as fresh fruit," says King.

"For example, to get 24 ounces of cranberry juice, it would take almost a bushel of cranberries. Nobody would eat that many cranberries, but many parents think it’s healthy to let their children sip juice all day long," he explains.

The American Academy of Pediatrics recommendations on juice consumption include:

— Juice should not be given to infants younger than 6 months of age.

— After 6 months of age, infants should not get juice from bottles or cups that allow them to consume juice easily throughout the day.

— Infants should not get fruit juice at bedtime.

— For children ages 1-6, intake of fruit juice should be limited to 4-6 ounces a day.

— For children ages 7-18, juice intake should be between 8-12 ounces a day.

— All children should be encouraged to eat whole fruits.

King also offers a few practical tips for parents:

  • Don’t force your children to eat all the food on their plates. Put less food on their plates to begin with.
  • Make fruits and vegetables more palatable by making veggie casseroles and fruit salads. "Nobody wants to eat that dried up apple or the wilted lettuce on the back of the refrigerator shelf," King says.
  • Make sure every dinner has at least two vegetables, preferably one dark green and one yellow-orange. "If the child has had a piece of fruit for breakfast and perhaps some salad or a few carrots for lunch, you’re almost home with the five-a-day fruit and veggie regimen," he says.
  • Pack nutritious lunches. School lunches and "Lunchables" are convenient, but "You might as well buy your child a membership to the chubby farm right now if that’s what you’re sending for lunch," King adds.
  • Parents should be encouraged to learn a sport with their children and stick with it. "You should all be doing this at least every weekend and preferably at least once during the week," he says.
  • Limit television and computer time to no more than one to two hours a day.

Kaufman recommends a public approach to the problem. "We need to take the bull by the horns and mount a public health campaign on an even bigger scale than the anti-smoking campaign. There should be junk-free zones in places where kids gather, most particularly in schools. We need better labeling of foods so the calorie, fat, and sodium contents are easy to understand. We need better education programs across the board. This is a tremendous opportunity for public and private entrepreneurs, and it needs to be done now."


1. Golan M, et al. Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change. Int J Obes Relat Metab Disord 1998; 22:1,217-1,224. 

Key Points

  • Childhood obesity has reached epidemic proportions.
  • With increasingly heavier children, diabetes and heart disease are on the rise in children and adolescents.
  • A sedentary lifestyle most often is blamed for the increase in obesity.
  • The American diet has become increasingly fat-laden and calorically dense, with larger and larger portions, feeding the obesity epidemic.

The Boob Tube

The average American child spends 36 hours in front of the tube a week, according to a 1999 study by the Minneapolis-based National Institute on Media and the Family (NIMF).

Time in front of the screen breaks down to 25 hours of television, seven hours of computer or video games, and four hours on the Internet.

"There have been several studies that have correlated time spent watching television to risk for diseases like diabetes and heart disease," says David Walsh, PhD, president of NIMF.

Walsh recommends what he calls the "TV Diet," which includes taking TV sets out of children’s bedrooms (studies have shown that kids with TVs in their bedrooms don’t do as well in school as those with TV-free zones); making appointments for television watching; choosing as a family shows everyone wants to watch; and sticking with the decisions to limit time spent in front of a screen.

The Five Onlys

A study from Tel Aviv University in Israel offers keys to weight control for all ages:

  • Only eat when hungry.
  • Only eat in the dining room or kitchen.
  • Only eat while sitting down.
  • Only eat food placed on a proper plate.
  • Only eat. Don’t watch TV or read.

Source: Golan M, et al. Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change. Int J Obes Relat Metab Disord 1998; 22: 1,217-1,224.

Parents’ Quiz

This quiz for parents of overweight children should be used as a tool for discussion of effective weight-management techniques:

  • I do not permit my children to watch television while eating.
  • I limit television and/or computer time to one or two hours daily.
  • I encourage my children to be physically active and participate with them in some form of physical activity three to four times weekly.
  • I discourage the consumption of non-nutritive beverages, such as sodas, iced tea, and fruit drinks, and encourage them to drink water instead.
  • I provide meals and snacks at regular times or arrange for regular meal or snack times.
  • I encourage and model a slow, attentive eating style.
  • I do not use family mealtime as a forum for family quarrels.
  • I make nutritious snacks such as fresh fruits, vegetables, pretzels, and low-fat cheese available for my children.
  • I encourage my children to participate in meal planning, shopping, and preparation.