Is Your Child in the Obesity Danger Zone?

Roughly 1 in 3 kids in America is overweight or obese, but millions more "borderline" kids are on the cusp of a weight problem and need our help just as much. Doctors and proactive parents share their advice about how to fight fat without shaking a child's self-confidence. 

how to tell if your child is overweight Luci Gutiérrez
A good mom doesn't make a big deal out of it when her little girl carries a few extra pounds. That's what Rebecca Lawson thought to herself when she first noticed that her daughter, Grace, then nearly 3, seemed to be a bit heavier, and a lot hungrier, than most of her preschool peers. "Grace had always been somewhere on the higher end of the weight charts," she recalls. "But the portions were becoming out of control. Rather than eating just a few carrots, she'd eat the whole bag—and a container of hummus too." A former dancer who was well aware of how body-image hangups can lead to disordered eating, Lawson didn't intervene—until Grace had her 3-year-old well visit. The pediatrician checked Grace's BMI (body mass index, which shows how heavy a child is relative to her height) and revealed that she was around the 80th percentile, just five points shy of "overweight," according to growth charts. "The doctor said that she was one of those borderline kids who could either stay at a high but normal weight or cross over into having a weight problem," says Lawson.

The pediatrician preferred to try to head off a potential weight problem early on. To this mom from outside Boston, it just made good sense. Never mentioning the word weight, Lawson started taking subtle steps to help Grace be healthier. She talked to her daughter about recognizing her hunger cues—and to stop eating before getting that uncomfortable, "belly-bursting" feeling. Then, after realizing that Grace's dance and gymnastics classes involved more sitting around than heart-pumping activity, she started encouraging Grace—as well as her younger son and her husband—to join her in backyard soccer games, weekend hikes, and bike rides. Today, Lawson is happy with her family's healthier habits. But she's hesitant to tell too many other parents what inspired them (in fact she asked that we use pseudonyms for this article). "At parties, parents automatically give Grace a second piece of cake when she asks for it. They'll say, 'She's a growing girl. Feed her!' You don't want to be the fanatical mom, but having a child who's on the verge of a weight problem but not obviously obese is sort of a lonely place to be."

Indeed, in the public conversation about the obesity crisis, you don't hear much about kids who are simply a little chubby. Media reports and political campaigns focus on the children who are clinically obese (with a BMI above the 95th percentile) and, to a slightly lesser extent, overweight (at or above the 85th percentile). Each year, efforts to help these kids—through behavioralintervention programs, medications, and treatments for weight-related health problems—cost the U.S. around $14 billion. But returns on this investment are scant. While childhood obesity has recently dipped in certain subgroups, such as low-income preschoolers, it remains stubbornly high overall. To make a real impact, say many experts, we need to focus on children like Grace, often referred to in research circles as having a "highnormal" BMI. These kids may not look worrisomely heavy, but they're at risk for becoming so. Children age 41/2 and under who have a BMI between the 75th and 85th percentile are six times more likely to become overweight or obese by age 12 than kids with a BMI in the 50th percentile or lower, according to a study from the National Institute of Child Health and Human Development.

By then, the slippery slope becomes even steeper: 8 in 10 kids who are overweight or obese upon entering adolescence will remain so as grown-ups. It's much easier to fix a budding weight issue than an established one, so intervening before these kids slide into a long-term problem is crucial. "This is true not only because bad habits are harder to break, but also because of the way that obesity alters your metabolism," explains Stephen Cook, M.D., a pediatrician at Golisano Children's Hospital, in Rochester, New York, and associate director of the American Academy of Pediatrics' (AAP) Institute for Healthy Childhood Weight. "The longer you have excess body fat, the more your body will fight to keep your metabolism at that new 'set point.' " In revised guidelines to help combat obesity published last summer, the AAP emphasized the importance of identifying kids early. Describing the success of treatment programs for heavy kids as "modest," the AAP report suggested that obesity-prevention interventions should begin before a child approaches a BMI in the 85th percentile. "The earlier you start, the better," agrees Parents advisor David Ludwig, M.D., Ph.D., who runs the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital. "Children have a unique advantage over adults: They're still growing, so they don't have to lose weight to grow out of a minor problem; they just need to slow their rate of weight gain."

For a generation of parents reared on body-acceptance messages, the idea of red-flagging a little childhood chub may not sit right at first. My own 7-year-old's BMI percentile in the low 90s caused some concern at a recent well visit, and it initially struck me as extreme to swap his favorite chips out of his lunch box or scrap dessert because of what looked to me like a little leftover baby fat. But the science shows us that small steps like these may be the most important investment we can make in our kids' future. Big weight problems come with big health problems. Obese teens are more likely to have pre-diabetes, high cholesterol, fatty liver disease, bone and joint problems, and sleep apnea. Adult obesity is linked to heart disease, Type 2 diabetes, stroke, arthritis, and several types of cancer. And despite how common it is, "being fat" is the primary reason kids are bullied, according to University of Connecticut researchers. This may be one reason why childhood obesity is strongly linked with low selfesteem and depression in adulthood. "Obesity has now surpassed tobacco as the biggest threat to overall well-being," says Dr. Ludwig. "Children are beginning life at greater risk for disease than any prior generation. Primary prevention is the key to reversing that."

Mom Reading Fitnessgram Manual Luci Gutiérrez
He Isn't Heavy... or Is He?

It can be tricky to differentiate between a child who's at risk for obesity and one who's naturally big-boned or muscular. Studies show that we are poor judges of our own child's weight status, even when a problem is seemingly obvious. In a recent study published in Childhood Obesity, researchers found that more than 96 percent of parents of overweight preschoolers and 78 percent of parents of obese preschoolers thought their child was the "right" size. Chalk it up to shifting perceptions. There are more heavy people in all walks of life, and many things from clothing to stadium seats are getting roomier to accommodate them. "Overweight has become so common that there's a tendency for parents to view children carrying excessive weight as 'normal,' " says Dr. Ludwig. "So many parents discount significant problems—it's even harder for them to acknowledge developing ones."

Enter your pediatrician. In its newest recommendations, the AAP calls on pediatricians to calculate and plot BMI in children every year from age 2 onward, and to counsel families of kids who are overweight or at risk. While a high BMI alone doesn't necessarily signal a health hazard—certain tall, muscled kids can healthily hover in a high percentile—it's an important and easy-to-obtain screening tool. "Pediatricians need to look not just at BMI, but at other factors," says Stephen Pont, M.D., M.P.H., medical director of the Texas Center for the Prevention and Treatment of Childhood Obesity at Dell Children's Medical Center of Central Texas, in Austin. "If a child is quickly crossing BMI percentiles, that could signal that he's changed his eating or physical-activity practices. Having parents with obesity, excessive screen time, disordered sleep, and low household income also increase the risk of obesity." And yet recent data show that less than half of pediatricians regularly plot a child's BMI, let alone counsel parents about risk factors.

Some pediatricians aren't properly trained in obesity or feel they don't have the time in a short appointment to discuss weight, says Dr. Ludwig. Also, weight remains an incredibly touchy topic. When moms on parenting message boards report being told by a pediatrician that their child's BMI is too high, "Find a new doctor!" is a common retort. One of the most controversial issues in education right now is school-based BMI screening, which many states have adopted to alert families who may not regularly see a pediatrician. What began as a well-intentioned initiative has become a lightning rod for criticism. Parents' chief complaint is how the results, often called "Fitnessgrams," are stuck in kids' backpacks rather than mailed home. "Everybody is beautiful," reads one online petition to the U.S. Board of Education to stop weight checks in schools. "Students should not be told you have to look like 'this' or you fail."

Never Too Early 

Ideally, say doctors, we should be taking steps to ward off weight problems well before children are able to read and react to a Fitnessgram. In fact, the latest research suggests that the earliest interventions may have the greatest impact. Along with insisting on regular BMI checks through your child's pediatrician, you can follow these tips to help lower your own child's risk at any age.

BABIES
Many doctors think obesity prevention begins in the womb. Overweight women are more likely to have bigger-than-normal babies, and those infants are at high risk for growing up to be obese. "It appears that some degree of genetic programming can set a child up for obesity," says Dr. Pont. A report last year from the University of Colorado School of Medicine revealed that stem cells in donated umbilical cords from babies of obese mothers that were cultured in a lab were more likely to accumulate fat than were cells from babies of normal-weight moms. Luckily, there are things bigger moms can do to help protect their babies. A 2014 Australian study showed that overweight or obese women who faithfully followed a nutrition and exercise program during pregnancy were less likely to have oversize infants. Breastfed babies tend to be at healthier weights as they grow. But whether you offer breast or formula, resist force-feeding. "It's important, especially during this age of distraction, that we tune in to our babies, and watch their cues," says Lara Field, R.D., founder of FEED, a private nutrition-consultation practice in Chicago. "When they turn away and seem less engaged in eating, they're done."

cartoon children playing outside Luci Gutiérrez
TODDLERS AND PRESCHOOLERS
This may be the "sweet spot" for reducing obesity risk. When a 2- to 5-year-old develops a habit—good or bad—it tends to stick. The recent reduction in obesity levels among low-income preschoolers can be explained, in part, to the simple, healthy habits that are promoted in federal initiatives like Head Start, in which preschoolers typically have plenty of outdoor playtime and limited access to snack foods and screen time. To help your child, Field recommends you allow him to stop eating when he's full, and set firm snack- and mealtimes. When Katie Murdock discovered her 21/2-yearold daughter's weight gain was outpacing her height, she looked closely at her diet. "She was eating all the time!" she says. After Murdock added more fiber and protein to her daughter's meals, she complained less about being hungry. "Instead of just eating a huge pile of strawberries for breakfast, she'd have berries with yogurt and a few tablespoons of granola," says Murdock. "It kept her satisfied, and she began eating less throughout the day."

Consider serving low-fat milk or water instead of juice. Fruit juice makes up 44 percent of preschoolers' beverage intake, on average, though pediatricians recommend that kids under 6 drink no more than 4 to 6 ounces per day. To make water more appealing, Rebecca Lawson adds sprigs of mint and serves it in a glass pitcher. She also displays cut-up fruit and veggies on a pretty white platter—it helps compete with brightly colored, character-laden packaged snack foods. "When I take time to prepare healthy treats in a fun way, my kids are always more interested in them," she says. Above all, follow the healthy habits you encourage in your child. "This is an age when kids absolutely look to Mom and Dad for cues," says Saba Khan, M.D., medical director of the Healthy Weight Program at Children's Hospital of Philadelphia. "If you're drinking cans of diet soda and insisting your child drink tap water, that's not going to go over well. Ideally, every member of the family should follow the same food rules, regardless of their size—and the whole family will be healthier for it."

BIGGER KIDS
Older children who are at risk for or who already have a weight problem can learn to practice better habits. "I always tell my patients that it's never too early nor too late to make a healthy change," says Dr. Pont. (The same goes for parents who might want to work toward a healthier weight alongside their child: "I've seen adults adopt relatively few smarter choices and lose a substantial amount of weight and keep it off," Dr. Ludwig adds.)Two big non-dietary changes that can help protect older kids: dialing back on screen time and increasing sleep time. For instance, it's been well documented that as television watching increases, so does weight, and that's especially true for children who have a TV set in their bedroom. And newer research shows that getting too little sleep can lead to too many pounds; sleep duration affects the hormones that regulate hunger, and it may also make kids too tired to be active during the day.

Whether your child is overweight, obese, or at risk for becoming so, it's key to find a balance between encouraging healthier habits and not making her anxious about her size. Erika, a mom from Phoenix who has an 8-year-old son with a BMI that fluctuates between the 70th and 90th percentile, has made sure that she offers only milk or water and has established "dessert nights" rather than feeding her kids treats every day. However, when her son came home from school worried that he was "fatter than his friends," Erika focused on the positive. "I told him that the most important thing is that he has healthy habits, no allergies, is rarely sick, and is able to keep up with anyone on the playground and swim in the pool for hours," she says. "I want him to know that I see his whole self—and that I want his whole self to be happy and healthy."

Grace Lawson, now 7, is around the 75th percentile BMI, which is a healthy number for her body type. She still loves food—but she has a slightly different relationship with it since her mom started talking, back in Grace's Pre-K days, about the fact that food is fuel. "I always told her, 'You need just the right amount of good food to run well, just like a car," says Lawson. "She's now more conscious about what she eats than other kids her age. It took some hard work early on, but she's learning how to make her own good choices."