An Ounce of Prevention is worth a pound

1
An Ounce of Prevention is worth a pound

• Shaping Habits That Shape Obesity

Ohio Chapter, American Academy of
Pediatrics Ohio Department of Health Ohio
Dietetics Association
2
Prevalence of Obesity U.S. Adults 2001-2

• Obese 1/3 (30.6)
• Overweight 2/3 (65.7)
• Extreme obesity (5.1)

All ages Both sexes All ethnic groups All
socioeconomic levels
Source Hedley et al. 2004 Freedman et al. 2002
3
Prevalence of Overweight in U.S. Children 2002
At Risk ( 85) () 22.6 31.2 30.9 31.0
Age, yrs 2-5 6-11 12-19 All 6-19
Overweight ( 95) () 10.3 15.8 16.1 16.0
Overweight among non-Hispanic Black (20.5) and
Mexican-American (22.2) increased much more
rapidly than among whites between NHANES in
88-94 and 2002
Source Hedley et al. 2004
4
Obesity Among African-American Adults 2002
Age, yrs Males 20-39 40-59 Females 20-39 4
0-59
Overweight BMI 25 55.4 65.0 70.3 81.5
Obese BMI 30 24.7 29.7 46.6 50.6
Extreme BMI 40 4.1 2.9 11.8 15.1
Source Hedley et al. 2004.
5
Overweight Status of African-American Children
2002
Percentile Males 85 95 Females 85 95
All Ages 31.0 17.9 40.1 23.2
2-5 yrs 23.2 8.0 25.6 9.6
6-11 yrs 20.9 17.0 37.9 22.8
12-19 yrs 32.1 18.7 41.9 23.6
Source Hedley et al. 2004.
6
Class 3 Obesity in the U.S.1990 through 2000

• Class 3 BMI 40
• 2-fold higher risk of mortality than BMI 30
• High likelihood of bariatric surgery
• Those over age 20 yrs
• In population 4.9
• In black females 13.5

BMI
50

25-29.9
30-34.9
10
Prevalence,
5
35-39.9
40
1
1990
1992
1994
1996
1998
2000
Year
Prevalence increased 3-fold in only a decade and
continues to rise
7
Medical Consequences of Obesity

• Psychosocial
• Cardiovascular
• Lipidemia
• Diabetes mellitus
• Hypertension
• Respiratory
• Cardiac

• Medical
• Polycystic ovary disease
• Gall bladder disease
• Osteoarthritis
• Cancer
• Pregnancy and postpartum ???
• Mortality

Diseases that begin in childhood amplify
morbidity and costs
Source Krebs Jacobson 2003 Dietz 1998a Dietz
1998b Must 2003.
8
Prevalence of Diabetes in US Has Risen
Dramatically 1990 to 2001
And how many overweight adults and kids have
pre-diabetes?
Source Narayan et al. 2003 Sinha et al. 2002
Weiss et al. 2003.
9
Life-Years Lost from Diabetes in the US

• If diagnosed at age 40 years
• White
• male 1.01 yrs
• female 13.5 yrs
• Hispanic
• male 11.5 yrs
• female 12.4 yrs
• Black
• male 13.0 yrs
• female 17.0 yrs

• If diagnosed at age 10 years
• White
• male 16.5 yrs
• female 18.0 yrs
• Hispanic
• male 19.0 yrs
• female 16.0 yrs
• Black
• male 22.0 yrs
• female 23.0 yrs

Source Narayan et al. 2003
10
Because of the increasing rates of obesity,
unhealthy eating habits, and physical
inactivity,we may see the first generation that
will be less healthy and have a shorter life
expectancy than their parents
Richard H. Carmona, MD, MPH, FACS Surgeon
General U.S. Dept of Health and Human Services,
2004
11
Obesity Risk Increases with the Age of the Child

• Obese at 6 years
• 50 risk of obesity at 35 yrs
• Obese at 10 years
• 70 - 80 risk

Obesity is a pediatric disorder with adult
consequences
Source Bray 2002, Dietz 1998a, Dietzs 1998b,Guo
et al. 2002 Kvaavik et al. 2003 Must 2003,
Whitaker et al. 1997
12
The State of Ohios TeensYouth Risk Behavior
Survey 2003

• 57 participate in organized after-school
  activities
• 68 reported participating in vigorous activity
  in any given week only 41 attend PE classes
• 32 watch 3 or more hours of TV per average
  school day
• 14 report being overweight, up from 10 in 1999
• 30 report eating fruits one or more times per
  day in the past week
• 38 report eating vegetables one or more times
  per day in the past week (includes potatoes)
• 20 report drinking the recommended 3 glasses per
  day of milk

Source Bray 2002 Ohio Dept of Health
www.odh.state.oh.us
13
Nutritional Gaps in U.S. Children
Children Consuming Daily Recommended Intake
Critical Age
Iron
Phosphorus
Zinc
Vitamin C
Vitamin A
Magnesium
Folate
Calcium
NHANES, CFSII data compiled by Dr. John Lasekan,
Ross Labs
14
Children grow up In 3 environments
HOME
COMMUNITY
SCHOOL
15
The issue of obesity Is multifactorial but
parents, especially mothers, have an opportunity
to create a healthful home environment
16
Babies are Getting Bigger
Births 37 wks GA
Source Kramer 2002
17
Babies Are Getting BiggerAnd Moms Are the Reason

• McGill University database 1978-1996
• Mean birth weight and z-score increased over two
  decades (p
• No trends in premie birth weights
• Prepregnancy obesity from 4.7 to 10.6
• Gestational diabetes a 20-fold increase

18
Prenatal

• Maternal weight gain
• An important predictor of later obesity in the
  child
• Breastfeeding
• Encourage breastfeeding
• Lower incidence of obesity in breastfed infants

19
Is Breastfeeding Protective against Obesity
Later in Life?

• Von Kries, 1999 German 5-6 yr olds
• Hediger, 2001 US 3-5 yr olds
• Gillman, 2001 US 9-14 yr old
• Liese, 2001 German 9-10 yr old
• Armstrong, 2003 Scottish 3-4 yr olds
• Bergman, 2003 German 6 yr olds
• Toschke, 2003 Czech 6-14 yr old

20
Healthy People 2010 Breastfeeding Recommendations

• Increase the proportion of mothers who breastfeed
  to 75 in the postpartum period
• Increase rates to 50 at 6 mos
• Increase rates to 25 at 12 mos

21
In-Hospital Breastfeeding Rates1965-2001
69.5
61.9
51.5
55.0
46.3
43.5
24.7
21.7
22
Breastfeeding Rates at 6 Months1971-2001
32.5
27.1
17.6
19.8
17.2
10.4
23
Largest Increases in In-Hospital
Breastfeeding1996-2001
Demographic African American participant 20-24 yrs of age High school
education National
1996 37.1 43.3 46.6 52.7 49.2 59.2
2001 52.9 57.2 58.2 65.9 61.1 69.5
Change 42.6 32.1 24.9 24.5 24.2 17.4
Source Ryan 2002
24
Obesity (Pre- or In-Pregnancy Weight) Threatens
Breast-feeding (BF)

• Pediatric Pregnancy Nutrition Surveillance
  Surveys
• 51,329 women and babies
• Pregnant and gestational weight gain BF
• Both pre- and in-pregnancy obesity resulted in
• Less initiation of BF
• Shorter duration of BF
• Increasing obesity may threaten recent gains in
  breast-feeding

Source Li 2003
25
How do We fix The Problem?
Train parents in how and what to feed their baby
26
Where Do Parents Look for Nutrition Information?

• 1 Pediatrician/ Family MD
• Social environment
• Magazines
• Internet
• Dietitian
• TV
• Nutrition Center
• Food labels
• Media

Source Van Dillen 2003
27
The 12 Well-Child Visits
8
11
4
12
7
3
9
2
5
6
10
Anticipate problem feeding and activity practices
28
Newborn/First Visit

• For Breastfed and Formula Fed Infants
• Help sustain breastfeeding by building skills and
  offering resources for support
• Iron-based formulas only
• Hunger and satiety cues
• Babies should regulate their own intake
• Crying does not always represent hunger
• It is normal for 1-3 month old babies to cry up
  to 3 hours per day

29
How are Infants Fed? Milk Feeding 2000
Source Ryan et al. 2002
30
Infants Adjust Their Calories
200
180
160
Volume of Intake (mL/kg/day)
140
120
100
130
By 6 weeks, the baby regulates its own energy
intake
120
Calorie Intake (kal/kg/day)
110
100
90
8
14
28
42
56
84
112
Age (days)
Source Fomon 2004.
31
From birth to 24 months, the child assumes the
eating habits of the family
The Feeding Infants And Toddlers Study (FITS)
SourceDwyer, 2004
32
FITS Study Methodology

• Adds critical information to augment NHANES,
  CFSII, Ross Mothers Survey information
• 5 Gerber sponsored FITS surveys over 30 yrs
• Snapshot of eating habits in first 2 years (2002)
• Random sample of 3022 (Experian database)
• Recruitment and household review
• 24-hr dietary recall and subject information
• Second dietary recall for subset (n703)
• Response rate for recalls 94

Source Devaney et al. 2004a
33
FITS Nutrient Intakes 0-24 months of age

• Examined transitional times for feeding
• 4-6 months
• 7-11 months
• 12-24 months
• Diets found to vary widely day-to-day
• Nutrition is good over the first 24 months

• Exceeds adequate intake for all nutrients, 0-12
  months and almost all nutrients, 12-24 mos
• Vitamin E low 12-24 mos
• Fiber low in toddlers
• But energy intake exceeds Estimated Energy
  Requirement (EER) at all ages

Source Devaney et al. 2004 b
34
Energy Intake Infants and Toddlers

• Energy intake exceeds EER
• 4-6 mo 10
• 7-11 mo 23
• 12-24 mo 31

• Feeding
• Breast
• BF/ formula EER
• Formula ERR
• Solids and cereals add to energy intakes,
  especially when coupled with formula

35
Two-Month Visit

• Infant Feeding
• Set expectations
• the baby will increase to 24-28 oz/day over the
  next 2 months
• Provide 4 oz four to six times per day
• No cereal, no baby food, no juices
• Nothing added in the bottle

36
Not all Crying Needs FoodTwo Months

• Learn to interpret the infants cries
• Parents eager to empty the bottle encourage
  overeating
• Satiety cues between 4-12 weeks
• Turns head away or releases nipple
• Falls asleep
• Comfort the baby
• Rocking, massaging, cuddling, or listening to
  music

37
Recommendations for Iron

• Healthy People 2010 reduce iron-deficiency
  among children aged one to two years to 5
• AAP Committee on Nutrition
• Supplement breastfed infants with iron
• Iron-fortified formula is the appropriate
  substitute for breastfeeding in the first 12
  months
• Iron fortified infant cereals and grains, as well
  as meats are important sources of iron,
  especially for infants who continue to breastfeed
  beyond 6 months of age

38
Physical ActivitiesTwo Months

• Minimize stationary devices
• Use crib mobiles
• Encourage reaching, kicking, stretching, and
  belly play time
• No T.V.

39
4-Month Visit

• The addition of cereal
• No solids until developmentally ready to use a
  spoon, usually 4-6 mos of age
• Cereal only with a spoon, not in the bottle
• Start a single grain, iron-fortified cereal
• Portion increase to 1-2 Tbsp twice daily
• First baby food vegetables at 6 mos

40
Excessive Juice is a Risk for Obesity

• Both short stature and obesity are tied to
  excessive intake of juices
• Only 100 juice
• Only after 6 months of age
• Only from a cup, not from a bottle
• Limit to 3 oz initially with a maximum of 4-6 oz
  / day for 1-6 year olds

41
Promote Vegetables for Infants Toddlers

• Fail to consume vegetables as a discrete food
• 9-11 months 27
• 12 months 18-23
• Dark Green Vegetables are consumed by fewer than
  10 of toddlers
• Deep yellow vegetables decrease from 39 at 9
  mos to 14 at 18 mos

• Potatoes consume daily
• 4-6 mos 3.6
• 7-8 mos 12.4
• 9-11 mos 24.1
• 12-14 mos 33.2
• 15-18 mos 42.0
• 19-24 mos 40.6
• By 24 mos 25 of toddlers consume fried potatoes
  on any day

Source Fox et al. 2004
42
Feeding the Baby

• Infants innately prefer sweet and salty.
• Infants may reject bitter and sour
• Infants tend to resist new foods (neophobic)

43
Implications

• More than 10 exposures may be needed to establish
  a new food.
• Children like and eat what is familiar
• Parental eating habits influence the babys
  choices at this age

44
Physical ActivitiesFour Months

• Non-restrictive play
• Belly play time
• Sits with support
• Reaches and holds objects
• Play gyms
• No TV

45
Top 5 FruitsFITS Study, 2004
Source Fox et al. 2004
46
Six-Month Visit

• Start vegetables and offer first at each meal
• Add one new food every 3-4 days
• Portion sizes
• Cereal 2-4 tablespoons twice per day
• Vegetables 2 tablespoons twice per day
• Fruits 2 tablespoons twice per day

47
Meats Proteins for Infants Toddlers
Source Fox et al. 2004
48
Common Early Feeding Traps

• Anticipate that daily milk intake will fall as
  babys food intake increases
• Avoid combo dinners and baby desserts
• The extrusion reflex is normal and does not mean
  that the baby doesnt like the food
• New foods require multiple presentations
• Focus on new eating experiences and skills

49
Physical Activities Six Months

• Minimize stationary devices
• Sits without support
• Starting to crawl
• First signs of independent mobility
• No T.V. until after 24 months of age

50
Nine-Month Visit

• Offer many new foods and textures
• Introduce a cup as the diet advances
• Discuss choking hazards
• Never use food as reward or bribe
• Offer variety finger and table foods
• New food types and textures
• Veggies fruits at every meal
• Establish a variety of meats

Aim to Develop Self-feeding Skills
51
What Infants Toddlers Drink
Source Skinner et al. 2004
52
Nine-Month Visit

• Continue breastmilk and/or iron-fortified formula
  until 12 months
• 100 fruit juice, 4-6 oz maximum and only from a
  cup
• Avoid all other sugary drinks
• ¼ cup (2 oz) fruits and vegetables daily
• Promote textures to improve skills

53
AAP Recommendations Cows Milk and Fat Intake

• Delay the introduction of cows milk until one
  year of age
• Calcium intake for 1-3 year olds should be 500
  mg/day
• Cows milk should be whole milk - not reduced-fat
  or non-fat - during the second 12 months of life
• Fat intake should not be restricted in the first
  24 months of life

54
And now, a word aboutTV
Children watching 2 hrs a day at age 2 yrs were
more likely to watch 2 hrs a day at 6 yrs too.
55
Television and Obesity Are Linked

• TV 2 hrs/ day in 5-15 yr olds is associated
  with adult overweight, high cholesterol, and low
  fitness
• Even brief exposure to TV ads can influence a
  preschoolers food choices
• Mean TV watched by 3-4 yr olds 2.2 hrs/ day
• Maternal obesity and depression correlates with
  the highest TV viewing by their children

56
Physical ActivitiesNine Months

• Begins to hold cup
• Spoon feeds with help
• Encourage crawling
• Pulls to stand
• No T.V.

57
Twelve-Month Visit

• Introduce regular milk
• Whole milk - not skim or 2
• Taper from 24 oz. to 16 oz. per day
• All fluids from a cup
• Continue to wean from the bottle
• Fluids
• Avoid sweetened drinks
• Water is best for extra fluid

58
CerealsInfants Toddlers
Source Fox et al. 2004
59
Twelve Months

• Solid foods
• Emphasize eating skills and experiences
• 3 regular meals 2-3 planned snacks
• Avoid grazing throughout the day
• Emphasize vegetables and fruits
• Appropriate serving size is 1/2 cup of fresh (or
  1/3 cup canned) fruits/ vegetables per serving
  per meal

60
Parental Control Measures Usually Backfire

• Restricting bad (ie, palatable and enjoyable)
  foods encourages their consumption and raises a
  desire for future intake
• Avoid a mixed message that forbidden foods are
  bad except on special occasions
• Avoid food as a comfort or a reward
• Categorical thinking about good and bad
  foods is common and inappropriate

61
Physical Activities Twelve Months

• Push toys
• Walking
• Running
• Unrestrictive play
• Never inactive for more than 60 mins
• No T.V.

62
15- and 18-Month Visits

• No more bottle
• Whole milk from a cup in four 4-oz servings / day
• Milk limit 16 oz/day
• 100 fruit juice 6 oz/ day
• No bottle and no sippy cup
• Snack times
• 2-3 planned snacks per day
• Watch portion size, nutritional value
• Meal times
• 3 meals per day
• Variety of color, texture, and tastes
• New foods at the start of the meal
• 10 exposures of each new food

63
Caution Choking Hazards!

• Nuts
• Grapes
• Apple chunks, slices
• Sausages

• Popcorn
• Round candies
• Hard chunks of uncooked veggies
• Hot dogs

Some foods are dangerous because the infant cant
chew or coordinate swallows and lacks a full set
of teeth.
64
Safe Snacks for the Toddler

• Cheese
• Yogurt
• Saltines
• Graham crackers
• Pretzels
• Bagel, bread, toast
• Whole wheat crackers

• Fruit (watch for seeds and peels)
• Fruit smoothies
• Steamed veggies
• Puddings
• Unsweetened cereals
• Mashed/ finely cut meats or fish

Avoid the habit of snacking in the car and on the
go
65
Desserts and Sweets
Infants Dont Need Desserts
Source Fox et al. 2002 ???
66
15- and 18-Month Visits

• Meals are social occasions
• Establish family meals
• Adults should act as role models during meals
• Milk with meals
• Limit desserts, avoid candy
• TV off during meals

67
National RecommendationsFiber Age plus 5

• Fiber should equal the age of the child plus 5
  grams a day
• For a 2-year old that would be 2 5 g 7 g/day
• Maximum age 10 g/day
• Emphasize whole grains to boost fiber

68
Dietary Fiber Intake of 4 to 10-yr-old US Children

• Children who meet the Age plus 5 rule
• 4-6 year olds 45
• 7-10 year olds 32
• Children who meet this rule consume more breads,
  cereals, fruits, vegetables, nuts, legumes and
  seeds
• Low fiber intakes are associated with higher fat
  and cholesterol

69
Recommendations for Grains and Whole Grains for
Children

• Healthy People 2010 Increase the proportion of
  persons aged 2 and older who consume at least 6
  daily servings of grain products, with at least 3
  being whole grains
• Serving is defined by the USDA Dietary Guidelines
  for Americans 2005 3 or more ounce equivalents
  of whole grain products per day (at least ½ of
  grains from whole grains)
• Primary sources of whole grains for children
• Ready-to-eat cereals Yeast breads
• Corn other chips Popcorn
• Hot breakfast cereals crackers

70
Whole Grain Intakes are PoorContinuing Survey
of Food Intakes by Individuals 1994-6
Source Harnack et al. 2003.
71
The Parents Role

• It is the parents responsibility to offer the
  child a healthful variety of foods and a
  supportive eating environment ...

Satter, J Am Diet Assoc. 1986 16355
Source Satter 1986
72
The Childs Role

• and it is the childs responsibility to decide
  when and how much to eat.

Source Satter 1986
73
Two Years

• Activity
• Only planned TV only 1 hour per day
• Planned time outdoors every day
• Milk
• Milk at every meal
• Switch from whole milk to 2
• Meals
• Begin to decrease the fat content of foods
• Appropriate portion sizes at home and away 1
  Tbsp per year of age

74
Subjects for More In-Depth Discussion with Parents

• Parents bias a childs food choices
• The picky eater grows up just fine
• Food jags are normal
• Plate and glass sizes alter intake
• Food dislikes over time
• The problem of dessert
• Avoid in-car snacking
• Food rules should be shared with daycare
  provider, grandparents
• Eating out with a child
• Letting the child direct their own intake

75
The Problem of Dessert

• A place in a balanced meal for dessert foods
• Not a required part of meal planning though
• Not necessary at every meal
• Not a reward or bribe for eating other foods
• OK to use fruit, yogurt, cheese
• OK for celebrations away from home

76
Eating at Restaurants

• Split meals between kids or share yours
• Recall portion size ¼ the adult portion
• Buffets promote overconsumption
• Drinks ask for milk with the kids meals
• Pre-meal watch out for breads crackers
• Salad dressing serve on the side, use as dip

77
Two-Year Visit

• Meals All 5 food groups daily
• Begin to decrease the fat content
• Appropriate portion sizes at home and away 1
  Tbsp per year of age or ¼ of an adult portion
• Plate and cup size matters
• Food jags are typical normal
• A variety of textures, colors, flavors
• Dont bias your childs food choices

78
Top 10 Sources of Dietary Fats for Children 2-5
yrs
Source Thompson Dennison, 1994
79
Milk Intake of Infants Toddlers
Source Fox et al. 2004
80
Drinks Matter Early Food Preferences Predict
Future Food Preferences

• The displacement theory is real
• Calcium intake falls as milk is replaced
• Vitamin C rises as juices replace milks
• Beverages are important
• They provide 1/3 of daily calcium, Vits A, C, D,
  protein and zinc
• Fruit drinks are too common
• By 2 years 40 drink them daily and 5 drink 16
  oz/d
• Soft drinks are unnecessary
• 11 toddlers 15-24 months consume them daily

Source Skinner et al. 2004
81
Physical Activites Two Years

• Encourage active play with other children
• Marching
• Jumping
• Climbing
• Limit T.V. to 1-2 hours per day
• Get outside

82
Three- and Four-Year Visits

• Meal times
• Planned meal snack times
• Establish a family mealtime free of TV
• Move toward skim milk
• Variety fruits, vegetables, whole grains
• Limit potatoes
• Avoid the TV Food habit
• Limit TV to 1-2 hrs per day
• Help child choose what to watch

83
Physical ActivitiesThree / Four Years

• Throwing and bouncing balls
• Jumping
• Running
• Ride tricycle
• Unstructured play at least 30 minutes/ day
• Structured play at least 60 minutes/ day
• T.V. limited to 1-2 hours per day

84
Five- and Six-Year Visits

• Daily diet suggestions
• A nutritious breakfast every day
• School lunch or a quality brown bag lunch
• Milk and dairy at every meal
• Fruits and vegetables in abundance
• Plan healthful snacks for after-school time
• Limit soft drinks and fruit drinks
• Caution when eating at restaurants share your
  meal with your child

85
Eating a School Lunch Promotes Better
Nutrition?Eating a Lunch While at School ? - or
take out pic of lunch box from home

• Consume twice the servings of fruits and
  vegetables
• Higher intake of milk and dairy
• Larger amounts of meat
• Greater amount of grains
• More vitamins and minerals
• NSLP impact holds true for lunch and for 24-hour
  intake

USDA Food and Nutrition Report No. CN-01-CD1
86
Five Years

• Daily activity suggestions
• Plan outdoor time and reading time daily
• Limit screens to 1-2 hrs/ day, including
• computers
• games
• TV
• movies

Decreased TV viewing has been proven to alter
obesity
87
Obesity Psychological Issues

• Victimization/ bullying
• Sense of alienation
• Depression
• Behavioral problems
• Lifelong psychological issues
• Low self-esteem
• A cycle of food, depression and inactivity

88
Energy-Dense Nutrient-Poor FoodsDefinition

• Tip of the Food Pyramid fats, oils, sugars
• NHANES III 1988-94 4,265 foods classified
• Foods are considered to be in the EDNP group if
  they are not part of the following food groups
• Dairy milk, buttermilk, cheese yogurt
• Fruit fresh, frozen, canned, juice
• Grains bread, cereal, pasta, rice
• Meat Beans meat, fish, poultry, eggs, beans,
  nuts, seeds
• Vegetables raw, fresh, frozen, canned, juices
• Mixed foods from several groups

89
Energy-Dense, Nutrient-Poor FoodsNHANES III

• EDNP foods nearly 1/3 of daily energy intake
• As EDNP foods increased
• Mean daily total calories increased
• Percent energy from carbs increased
• Percent energy from fat increased
• Fiber, protein, vitamins, decreased
• carotenoids, iron, calcium, folate decreased

As EDNP foods increase, nutrition from other 5
food groups falls displacement
Source Kant 2000
90
Snacking Among Children1977 to 1996

• 3 dietary surveys in children 2-18 yrs (N
  21,236)
• Snack foods grouped outside of meals
• Snacking adds 30 kcal to the diet
• Highest snack intake is among 2-5 year olds
• Energy per snack rose only 3 in 20 yrs
• Energy density is greater than meals
• Increased frequency, not size of snacks is the
  trend in America

Source Jahns et al. 2001
91
American Dietetic Association Snack Guidelines
Preschool-/ School-Age

• Continue 2-3 planned snacks for preschool age and
  1-3 for school age children
• Aim for variety of texture, taste, and color
• Adjust portion size to age
• Allow the child to respond to internal cues of
  hunger and fullness
• Healthy snacks are whole grains (breads, cereals,
  crackers), fruits and veggies, lean meats, and
  dairy products (low-fat cheese, pudding, yogurt)

92
Eating Out with Your Child

• Include at least two different food groups
• Limit sweets to one per meal
• Only one fried food per meal
• Assure that all foods, especially desserts and
  drinks, are child-sized

Source Satter 1986
93
Control Portion Sizes When Eating Out

• Share your meal or order a half-portion
• Order an appetizer as an entrée
• Take half your meal home
• Be aware and stop eating when you feel full
• Avoid super-sized sweetened drinks
• When traveling, pack nutritious snacks

Weight Control Information Network, NIDDK, Jan
2003
94
More Tips for Portion Control

• Before eating, assess your hunger
• Eat slowly and appreciate your food
• Eat small meals more frequently to avoid hunger
• Measure your food portions to hone your portion
  perception
• Skip family style servings except for veggies
• Always serve salad dressing on the side
• Interpret labels in terms of single servings

Susan Burke, MS, RD, CDE
95
Menu Hints While Eating Out

• English muffin, toast, bagel NOT croissant,
  biscuit, pastry
• Ham NOT sausage
• Low-fat milk, fruit juice or water NOT soft
  drinks or shakes
• Baked, broiled or poached NOT fried
• Catsup, mustard, BBQ sauce, salsa NOT mayo and
  cheese on burgers
• On the side low-fat dressing, sour cream, gravy,
  sauces
• With (NOT before) the meal bread, non-water
  drinks, chips

American Dietetic Association, If your Child is
Overweight A Guide for Parents
96
Summary

• Childhood obesity can be prevented
• No one factor causes obesity and no one
  intervention will stop it
• Physicians most important role will be in
  developing sound eating and activity habits
• At each well-child visit review the childs BMI
  status and deliver core messages
• Advocate for better school community policies
  that support your well-child advice