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Tipping the Scales

overcoming childhood obesity illustrationThe fight to overcome childhood obesity, the top goal of First Lady Michelle Obama, has become a national imperative—an effort that is well under way at Rutgers. By Leslie Garisto Pfaff

It’s Dinosaur Day at the Nutritional Sciences Preschool on the Douglass Campus. At the snack table, Frank Cesaro, a student teacher, is trying to sell a group of 4-year-olds on the idea of today’s healthy snack, Dinosaur Toast. He helps the kids cut stegosaurus shapes out of low-fat cheese and plop them on slices of whole wheat bread for grilling, asking if they’d like to nibble on the leftover cheese bits. Some of the kids resist; others are more adventurous and take tentative bites. So Frank pops some into his own mouth. “Mmmm,” he says. “Cheese is good for you.” Another pop, bread this time: “Mmmm, whole grain.” A few more kids grab slivers of cheese and eat with increasing gusto. Meanwhile, at the sand table across the room, half a dozen preschoolers are filling a pail to the brim. “Mrs. Worobey, Mrs. Worobey!” they call to the school’s director. “We’re making you a snack—a giant cupcake!” And so it goes at the preschool, where Harriet Worobey and her staff are teaching the benefits of healthful eating to kids who, in spite of the best efforts of the school and their families, are likely to be confronted with high-fat, high-salt, high-sugar food at every turn.

The ubiquity of what nutritionists term “energy-dense” foods is one part of a complex equation that’s resulted in an epidemic of childhood obesity. In 1980, 5 percent of children ages 2 to 5 were classified as obese, according to a study conducted by the Centers for Disease Control and Prevention (CDC); by 2008 that figure had more than doubled. Among 6- to 11-year-olds, nearly one in five children is now considered obese, and nearly one-third of all children are officially overweight (at or above the 85th percentile on the CDC’s growth chart). The implications are staggering. According to Carol Byrd-Bredbenner, a professor of nutritional sciences and an extension specialist at the School of Environmental and Biological Sciences (SEBS), “we know that kids who gain unnecessary amounts of weight are exposed to risks later on, and even in youth,” including heart disease, high blood pressure, diabetes, and cancer. In addition, overweight kids go through puberty earlier, which can interrupt growth.

Sobering facts like these prompted First Lady Michelle Obama to launch a national initiative in 2009 to address childhood obesity. And Rutgers considered the problem so critical that it recently founded the Institute for Food, Nutrition, and Health, directed by noted biomedical scientist Peter J. Gillies, to tackle the issues of childhood obesity, as well as adult-onset diseases like cancer and heart disease. Across the university, nutritionists, researchers, educators, and extension specialists are studying the problem to determine the causes of the trend and the most effective ways to reverse it.

Skewing the Energy Equation
Nearly everyone involved in researching childhood obesity agrees that it’s a “multifactorial disease,” in Byrd-Bredbenner’s words, with a complex variety of causes. Nevertheless, John Worobey, professor of nutritional sciences at SEBS (and husband of Harriet), notes that it’s essentially the result of “an imbalance in the energy equation—calories in, calories out,” where the intake of calories far exceeds the calories, or energy, expended. He cites a number of factors that have unbalanced the equation, including the dramatic rise in consumption of sugar-sweetened drinks like soda, which, thanks to federal subsidies for corn (and corn sweeteners), is now considerably cheaper than milk. And then there’s the proliferation, over the last 30 years, of fast-food restaurants.

“They’re very reasonably priced,” John Worobey notes, “and they’re offering food that’s high in fat, sugar, or salt, all three of which make food tasty.” In fact, you no longer need to stop by a fast-food franchise for energy-dense food. “Everywhere you go, from the car mechanic to the gas station, you can buy food—and we’re not talking about bananas; we’re talking about candy bars, things that are high in calories and easy to eat,” says Byrd-Bredbenner. She notes, too, that a “very affordable food supply” has resulted in a dramatic increase in portion size. In fact, the CDC reports that most ready-to-eat foods now exceed federal serving-size standards.

Cultural and sociological factors have also helped to skew the energy equation. “More mothers are working, and fewer parents know how, or want, to cook,” says Daniel Hoffman, associate professor of nutritional sciences at SEBS. Combine this with the availability of convenience foods, and you have a situation that’s turned the idea of the family dinner on its head. Today, says Hoffman, “children may reject whatever’s offered and then have several alternatives provided.” (Don’t like the meatloaf? How about microwavable chicken nuggets?) He hypothesizes that, “where the alternatives gradually become less healthy but more palatable, every child will negotiate his way to just french fries.” He may be joking about the fries, but the effect of those negotiations is the cultivation of “an entire population of people who’ve been exposed to, crave, and seek only high-fat, high-sugar, salty foods.”

As it happens, though, childhood obesity may begin even before a child eats his first Big Mac. Hoffman has researched growth in infancy and discovered that children who are born small for gestational age grow more rapidly than normal-weight babies, which can result in obesity in later childhood. Infants born small, he explains, are generally fed more to prompt them to grow, which in turn may have an effect on metabolism. And through the Rutgers Infant Nutrition and Growth Project, John Worobey has studied the diets of several hundred children beginning in infancy and found that an additional feeding of formula a day led to weight gain between the ages of 6 months and 1 year, presaging a tendency to childhood obesity.

Then there’s the “energy-out” side of the equation. Technology has transformed the landscape of childhood: where kids once spent most of their time playing outdoors, “play” increasingly means immersion in electronic games. “Children are spending seven and a half hours daily on media; for minority children the number is closer to nine,” says Nurgul Fitzgerald, extension specialist in health promotion and behavior for the Department of Family and Community Health Sciences at Rutgers Cooperative Extension (RCE), part of the New Jersey Agricultural Experiment Station.

Sociological and cultural changes factor in as well: “Sidewalks are no longer as plentiful in the suburbs,” says John Worobey, “and for reasons of distance or safety, kids are either driven to school or take a bus.” When both parents work outside the home, children are less likely to play outdoors after school. And a more dangerous environment—or the perception of danger—keeps kids away from parks, playgrounds, and bike paths. Economics and politics also play a role: physical education and recess have been whittled away because of budget woes and an emphasis on preparing for standardized tests. This adds up to fewer calories expended when the intake of calories continues to increase.

Finding the Solutions
Like the causes of childhood obesity, its fixes are likely to be numerous. “We’re going to need many ap­proaches, looking at individual, family, and environmental factors,” says Fitzgerald. The logical place to start is in­fancy, where the roots of obesity begin to grow.

Encourage breastfeeding. “Research has shown that exclusive breastfeeding for the first six months of a child’s life can be a significant part of reducing childhood obe­sity,” says Kathleen Morgan, assistant director of RCE. As a member of Shaping NJ, a statewide initiative through the Department of Health and Senior Services that addresses obesity and chronic disease, RCE is helping to promote breastfeeding with online advice and resources and community outreach programs.

Reduce the intake of energy-dense foods. Nearly half of 6- to 11-year-olds in the United States consume 80 gallons of soft drinks annually, prompting a growing number of medical professionals to call for a tax on sugar-sweetened beverages. Morgan isn’t convinced a soda tax is the answer, “but we do have to find ways to reduce consumption.” One way of doing that might be through social marketing campaigns like the one launched recently in New York State. The ad features a young man drinking what looks like soda, but a closer look reveals it to be liquid fat. “It makes you think twice,” Morgan says.

Another line of attack is the school vending machine, a source of revenue for schools. “If there are working water fountains in schools and vending machines offering healthy beverages, children are less likely to consume sugar-sweetened drinks,” says Punam Ohri-Vachaspati, assistant research professor at the Rutgers Center for State Health Policy. A growing number of schools have banned soda as well as high-sugar, high-fat snacks. Reducing federal farm subsidies that promote the production of corn syrup would have the same effect as a soda tax, boosting the price of sugar-sweetened beverages and foods and discouraging their consumption.

Encourage healthier alternatives. Ultimately, suggests Morgan, it may be easier to go with the carrot over the stick, literally and figuratively. “I prefer that our faculty have a positive message—‘eat more of this,’” she says. RCE has community programs in most New Jersey counties, delivering proactive messages about nutrition. The extension is also working with the state to help implement its Farm to School program, an effort to get more fresh produce into school cafeterias by working directly with local farmers. School lunch is a particular area of concern in the battle against childhood obesity—and represents an example that change is possible. In 2004, the federal government mandated that all schools with a federally funded lunch program implement a wellness policy to address deficiencies in nutrition and physical activity. In New Jersey, RCE helped schools design their policies, leading to fewer energy-dense foods in the cafeteria and more fruits, vegetables, and whole grains.

“What can we do to make the healthy choice a default?” asks Byrd-Bredbenner. One possibility, she says, is to “increase availability,” something that the federal government hopes to do in the near future. Because rates of obesity are higher in minority communities, the Obama administration recently announced a $400 million Healthy Food Financing Initiative aimed at bringing grocery stores to those neighborhoods, long considered “food deserts” for their lack of outlets for fresh produce and other healthful foods. The New Brunswick Community Farmers Market, a collaboration involving Rutgers, Johnson & Johnson, and the City of New Brunswick, was introduced last summer for residents of the city, and is open twice a week through the fall. William Hallman, director of the Food Policy Institute, led Rutgers’ effort to create the market, which was conceived to serve neighborhoods with limited access to nutritious fresh food and food education.

Promote physical activity. A combination of approaches, including targeted public policies and increased community outreach, is probably necessary to change long-entrenched behaviors. Locally, suggests Ohri-Vachaspati, communities can maintain playgrounds and ensure their safety and encourage the construction of sidewalks to help motivate children to walk to school, an idea that’s been implemented or considered in cities like Louisville and Atlanta. States can mandate physical education and recess; earlier this year, Congress began considering legislation that would do just that. And policymakers can find ways to make walking “the default option.” “Can we make the stairs a more pleasant alternative to the elevator by lighting them differently or labeling them so they’re easier to find? Can we encourage people to get off the bus a stop early and walk home?” asks Byrd-Bredbenner. To promote walking among schoolchildren, RCE instituted the program Walk New Jersey Point to Point. They gave pedometers to 1,000 students, challenging them to take a 200-mile virtual walk from High Point to Cape May, an exercise during which students walked the equivalent mileage. “Research shows that kids will be more active if you make it fun,” says Marilou Rochford, an associate professor at Rutgers–Camden as well as a family and community health sciences educator at RCE in Cape May County.

Consider individual and community differences. Although the current epidemic of childhood obesity can be explained largely by social, cultural, and environmental changes, there’s mounting evidence that genetics play a role as well. “Something that’s not talked about so much is that the drivers of obesity are different for different people,” says Beverly Tepper, professor of food science at SEBS. Her research in food sensory science looks at taste preferences and how they’re acquired, along with their influence on children’s eating behavior and dietary patterns. To determine which children possess a genetic sensitivity to bitterness, for instance, Tepper and her colleagues expose them to a compound called 6-n-propylthiouracil (or PROP, for short) and sort them into nontasters (those who can’t discern the taste of PROP), tasters (those who can), and supertasters (those who have an especially high sensitivity to the compound). What they’ve found is that nontasters are less sensitive not just to bitter tastes but also to sweetness, hotness, pungency, and the texture of fat (which they tend to crave), and they are likelier than tasters to be overweight. Supertasters, on the other hand, tend to be picky eaters as children and are less susceptible to obesity. And it turns out that bitterness sensitivity varies among ethnic groups: 25 to 30 percent of Caucasians, for example, are nontasters, whereas among Japanese and Chinese, who tend to weigh less overall, the percentage is much lower—about 10 percent. Researchers have identified the gene that affects the ability to taste bitterness as well as other genes affecting body weight. Ulti­mately, understanding a child’s genetic makeup, suggests Tepper, will be a way to customize a weight-loss program and could help parents choose healthful foods that appeal to their children.

Communities have to be evaluated case by case as well. Michael Yedidia, research professor at the Rutgers Center for State Health Policy, is leading the New Jersey Childhood Obesity Study, collecting data from five New Jersey cities so community coalitions “can target their efforts and tailor their interventions to children most at risk.” Because obesity disproportionately hits those in lower socioeconomic neighborhoods, where families have less money to spend on healthful food and less opportunity to spend it, economic standing is likely to affect the study’s results. “We can’t change the problem,” says Fitzgerald, “without doing something about the economics.”

No one who has studied childhood obesity believes that reversing the trend will be easy. While the energy equation itself couldn’t be simpler, getting it back in balance, says Rochford, “will require families to make significant lifestyle changes.” Her use of the word “families” is telling, because childhood obesity isn’t caused by the behavior and attitude of children alone. Parents need to set examples of healthful eating and physical activity; school administrators must ensure an environment promoting health; and politicians and policymakers have to put children’s well-being over corporate profits. Most researchers believe it can happen, and must, when something as critical as the health of a generation is at stake. Just do the math. •