Preventing obesity,
eating disorders and related problems

by Frances M. Berg, MS

Prevention efforts need to address both obesity and eating disorders in comprehensive ways that do no harm. They will include preventing the problems of hazardous weight loss, undernutrition of teenage girls, dysfunctional eating and size prejudice.

Comprehensive prevention programs focus on healthy lifestyles for children of all sizes. They encompass the needs at both ends of the weight scale and any extreme of eating behavior. No child is left out. Prevention involves intervention at three levels:

1. Primary aimed at preventing eating and weight problems in the general population
2. Secondary focused on early stage problems or high-risk individuals
3. Tertiary treatment of weight and eating problems ⁽²⁾

Therefore, primary prevention in schools is urgent getting to the problem at an earlier stage. The sooner sound preventive programs that reach all students with the same healthy messages from all school staff can be put in place, the less need there will be for treatment.

Secondary prevention in schools may involve counseling, weighing and measuring students if deemed appropriate, screening for possible eating and weight problems, and referrals to health professionals. Counselors and school nurses are usually key to this process.

For a comprehensive and sustained program a health advisory team is needed. If the team includes health providers as well as school staff, it might address all three levels of prevention.

"Prevention is a marathon, not a sprint," says Linda Johnson, MS, Director of School Health Programs for the North Dakota Department of Public Instruction. "Many prevention programs have fallen short because our approach has been single-pronged and of short duration. Often what is convenient, easy and cheap does not benefit youth."

She contends that a successful prevention program will: develop a needs assessment; build in measurable goals and objectives; use researched, theory based, proven effective programs; deal with problems in a comprehensive way; work with an active advisory council; include ongoing evaluations ⁽³⁾.

"A comprehensive effort that includes school, community and families is most likely to bring about real change," advises Johnson. "Prevention programs also must do no harm to vulnerable individuals. It's clear the wrong kind of prevention is useless and can make matters worse."

What does not work are one-shot programs or prepackaged events used in isolation, with no long-term effort, she says. Information-only programs that change knowledge, but do not teach skills or change behavior, do not make people healthier. Scare tactics don't make them safer. It is illogical to spend time, money, and energy on untested programs or efforts that will not be sustained over time.

Eight components for schools
Most schools use the Comprehensive School Health Program ⁽⁴⁾, developed at the Division of Adolescent School Health, Centers for Disease Control and Prevention in Atlanta, which recognizes that education and health are interrelated and that healthy children who feel safe and accepted in their environment can learn better and achieve more academically.

This program integrates the following eight components, all important in a school program that addresses eating and weight issues:

1. Health education in the classroom. Curricula in nutrition, healthy body image, child development, and family living give all students, K through 12, a solid foundation to incorporate healthy living concepts into their lives.
2. Physical education and activity. Federal guidelines call for daily physical education for all students and that 50 percent of class time be spent actively by every child ⁽⁵⁾. Focusing on life skills, fun and creativity is helpful for all students, especially those who may be physically underdeveloped.
3. Counseling services. School counselors and nurses play key roles in prevention programs and advisory boards, identifying factors that may hinder optimal school performances and adjustment, and connect students to appropriate services.
4. Food service. Nutritious and appealing meals that coordinate with health education help students develop strong healthy bodies and good eating habits. Scheduling adequate time for eating is important. Vending machine offerings may be a concern.
5. Healthy school environment. Physical, emotional and social surroundings that are safe, secure and accepting of each individual enhance the well-being of students and staff. Keeping the school free of bullying and harassment is an important and challenging goal; so is establishing a policy of zero tolerance for size bias in classrooms, hallways, and grounds.
6. Health programs for faculty and staff. Educators with healthy lifestyles and attitudes are powerful role models. They can benefit from in-service training and help with their own weight and eating issues.
7. Health services. The school nurse, public health nurse, and other school health resources provide support and a consistent approach for weight and eating issues. 
8. Parent and community involvement. Successful prevention programs integrate parents into both planning and implementation so that school efforts will be supported and reinforced in the home and community. The challenge is to integrate the prevention of weight and eating problems into each of these eight components. This can do much to stimulate the students' intellectual growth and their ability to learn.

Whether to weigh and measure students is controversial. Some states and school districts regard measuring as necessary for tracking individual growth, screening, establishing comparable group statistics, or evaluating preventive programs. Others are concerned that safeguards may not be in place to protect children. They suggest that if the statistics are not being used or used effectively, perhaps they should not be gathered.

If weight is measured, perhaps eating and other factors may need to be measured and tracked, as well. These might include nutrition, dysfunctional eating, weight loss practices, body image issues, size prejudice, and medical risks. Increases in any adverse effects should be grounds for making changes.

An awareness is needed by the health team that overemphasis on the risks of overweight can quickly escalate for vulnerable children into promoting thin mania, disturbed eating and social discrimination.

Teachers understand this. When the federal agency charged with implementing the Obesity Education Initiative in schools convened a major school conference in 1992 ⁽⁸⁾, it was soon clear that educators were asking for a new approach. They warned policy makers not to rely on traditional thinking, but to provide sound information. They bluntly expressed concern that national messages on obesity can further stigmatize high-risk children and lead to worse problems. And they criticized changes that some conference experts were recommending, changes that focused more on restricting diet than increasing physical activity.

The teachers recommended targeting all youth, not singling out those at high risk for special efforts. "Focus on how to make them healthier, as opposed to thinner, especially because making them thinner often does not make them healthy."

What teachers were asking for in 1992 were preventive programs based on healthy lifestyles for children of all sizes. They still are. Programs with this new approach empower and strengthen all youngsters.

References

1. Piran N. The Last Word: Prevention of eating disorders: The struggle to chart new territories. Eating Dis 1998;6:365-37
2. Omichinski L. Teens & Diets: No Weigh. HUGS International, Portage la Prairie, Manitoba, Canada
   
3. Price RH, Cowen EL, Lorion RP, et al. edits 14 ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Assoc.
4. Johnson, Linda. 1999. Prevention: Does it really work? p3-99. Dept. Public Instruction. Bismarck, ND. 
5. Kolbe L. An essential strategy to improve the health and education of Americans. p55-80. In Cortese P, and Middleton K, eds. The Comprehensive School Health Challenge, Vol 1: Promoting health through education. 1994. ETR Assoc., Santa Cruz, CA.
6. U. S. Health and Human Services, Healthy People 2010, Conf Edition, Jan 2000. Washington, DC.
7. Satter, Ellyn. How to Get Your Kid to Eat . . . But Not Too Much, 1987. Bull Publishing, Palo Alto, CA.
8. NIH Strategy Development Workshop for Public Education on Weight and Obesity, National Heart, Lung and Blood Institute, 1992, p35. Washington, DC.

Adapted from Children and Teens Afraid to Eat: Helping Youth in Today's Weight-Obsessed World, by Frances M. Berg (Chapter 12page 247-272. All rights reserved. CC(Chapter 12, p247-272). Copyright 2001, 1997, 3rd edition. All rights reserved. Healthy Weight Network, 402 S 14th St., Hettinger, ND 58639 (701-567- 2646) website www.healthyweight.net.

Guidelines for Collecting Heights and
Weights in Schools

Others advise that weight status is better determined by the child's health provider, who can assess weight in the context of the child's overall health and well-being. They recommend against screening in schools because of potential stigmatization of youth who may be larger, taller or shorter than the norm, and document many inaccuracies. Further, if children are to be weighed, many experts contend, they need also to be measured and tracked on related problems, such as disordered eating, dieting, hazardous weight loss, nutrition, drive for thinness, body satisfaction, and size attitudes.

Despite this debate, it is generally accepted that screening can have value when there is sound purpose and follow-up -- such as to establish baselines, develop programs and measure progress -- and when sensitive and supportive safeguards are in place.

How can children be measured in schools in a private, respectful way that protects them from abuse and stigmatization? How can accurate heights and weights be established? These questions are answered in the University of California brochure, Guidelines for Collecting Heights and Weights in School Settings, September 2000. The following excerpts are taken from the California guidelines.
 

It may sometimes be necessary to weigh and measure children in school settings. In these situations, it is important to obtain accurate information. At the same time, it is important to avoid encouraging unrealistically thin body images and stigmatizing children as "fat," "heavy," or "skinny." Consider the question, "How can this task be done in a way that will promote body satisfaction, a positive body image, and high self-esteem in youngsters of all sizes and shapes." The following guidelines were developed to help you measure students in a way that is sensitive and supportive as well as accurate.

Growth charts
The purpose of weighing and measuring children is to determine if they are growing "normally." There is a wide range of heights and weights that are considered "normal" since children grow at very different rates even when they are the same age. The Center for Disease Control and the National Center for Health Statistics issued new growth charts for children in June, 2000. The revised growth charts consist of 16 charts (8 for girls and 8 for boys) including two new body mass index (BMI) charts. The charts can be accessed at the following website: http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.ht

Be sure you have the new growth charts before beginning this task.

Setting
Each child should be weighed and measured in private with no other children present. Recruit an adult to record the measurements or do it yourself. Do not have another child do it. Consider having the child face away from the scale if s/he appears anxious about being weighed. (Specific details on how to weigh and measure students are given.)

Comments to children
Do not comment on the height or weight of a child at the time the measurements are being taken. Neutral comments such as, "Thanks, you can get off the scale now," are appropriate. If a child makes a negative comment about his/her body, it is appropriate to say, "Kids bodies come in lots of different sizes and shapes. If other kids are teasing you about your body, let's talk and see what we can do about it."

Teachers and other school staff should discourage teasing by modeling and promoting respectful behavior. The philosophy "We respect the bodies of others even though they are different from our own" should guide words and actions. If a child asks, "Am I too fat?" or "Am I too skinny?" say that you don't know and suggest the child ask his/her doctor this question.

Make no medical diagnosis
Unless you are a licensed health care professional whose scope of practice includes diagnosing medical conditions, refrain from making a diagnosis of overweight or obesity. Labeling a child as "overweight," "too fat," "too thin," or "skinny" based on a single height/weight measurement at one point in time is inappropriate. In order to determine if a child is underweight, overweight, or at risk of these conditions, standard practice is for a physician to gather additional medical information necessary for making a diagnosis.

Notifying Parents/Caregivers
The following is a sample letter which could be used to notify parents about a child's weight status. 

Dear Parent,
We recently weighed and measured the children our school to determine how they are growing. Your child's weight was found to be low/high for his/her height and age. This does not necessarily mean your child is underweight/overweight, but your child may be at risk for this condition. The best person to evaluate your child's weight status is his/her regular doctor or health care provider.

We encourage you to make sure your child has annual medical checkups by a physician. The doctor will weigh and measure your child, may ask questions about your child's growth since birth, and may ask about the heights and weights of your child's close biological relatives. If your child is too thin/heavy, your doctor will tell you so. Ask your doctor for advice about good nutrition and physical activity.

If you do not have health insurance or access to health care, please contact us for information about possible medical services.

Please do not put your child on a weight gain/loss diet. For information on helping an underweight/overweight child [insert information on obtaining a pamphlet].

If you have questions, please call me at [ ].

Research briefs on weight and 

eating in children

Weight loss drugs not approved under age 16

No weight loss drugs are currently approved by the Food and Drug Administration (FDA) for patients under the age of 16. In a recent test, the appetite suppressant drug sibutramine showed some short-term success in teens ages 13 to 17. But because of added risk caused by increased blood pressure and pulse, the medication had to be reduced or stopped in 44 percent of the patients in the first 6 months. Dropout rate was also high at 24 percent.
    In the study, 82 obese boys and girls were randomized to receive either sibutramine or placebo for the first 6 months. All who stayed in the program (62) received behavioral therapy, a 1,200 to 1,500 calorie diet, walked about two hours per week, and in the second 6 months received sibutramine. 
    During the first 6 months patients on sibutramine lost more weight, about 17 pounds compared with 10 pounds for those on placebo, but they began to regain during the next 6 months (regained three pounds), while those who started sibutramine for the first time lost about two more pounds. Thus, in the one-year program total weight loss for the 12-month sibutramine group was 14 pounds compared with 12 pounds for the 6-month sibutramine group; both groups also had behavioral therapy, increased exercise and restricted calories. The study included no follow-up data.
    The authors concede that larger and longer studies are needed to assess the costs and any benefits from using the medication. An accompanying editorial agrees that caution is advised -- even though the number of overweight teenagers has grown to more than 15 percent, along with increases in type 2 diabetes and related health problems. It recommends that drug treatment in adolescents be regarded as investigational. (Berkowitz R, et al. Behavior Therapy and Sibutramine for the Treatment of Adolescent Obesity. J Am Medical Assoc. 2003;289:1805-12. See also Weight-control Information Network, National Institutes of Health, NIDDK, WIN Notes Summer/Fall 2003.)

Youth dieting linked to overweight
An increasing body of evidence suggests that frequent dieting puts youth at risk for obesity. A Harvard study of 5,865 girls and 4,322 boys, ages 9 to 14 years in 1996, followed to 1998, found that over one-fourth of girls of normal weight had dieted to lose weight in the previous year (7 percent of boys). Regardless of their intake of calories, fat or carbohydrate or their physical activity or inactivity, the frequent dieters were significantly more likely to become overweight than those who never dieted. In the year between 1997 and 1998, 2.7 percent of the girls and 5.2 percent of the boys became overweight. Also, normal weight girls who dieted were more likely to report binge eating at least monthly: 12.5 percent of frequent dieters binged, compared with 3 percent of infrequent dieters and 0.5 percent of never dieters. The authors suggest that periods of dieting may be interspersed with periods of overeating or bingeing. They conclude, "We need to promote physical activity and eating patterns that are healthy and not overly restrictive." (North American Association for the Study of Obesity, Annual Scientific Meeting. News release 11/1/00.)

Weight concerns may lead to smoking
Girls who dieted were more likely to smoke, in a Massachusetts study that looked at 932 students in 6th and 7th grade. About 3 percent of both girls and boys were smoking, and 4 to 5 percent were dieting. However, two years later 16 percent of girls and 12 percent of boys reported smoking, and 21 percent of girls and 18 percent of boys said they were dieting at least once a week. Girls who dieted weekly were nearly four times more likely to become smokers than were nondieters, and girls who dieted monthly were twice as likely to become smokers as nondieters. However, obese girls were less likely to report being smokers, either initially or during follow-up. Over one-third of the smoking initiation by girls was attributed to dieting. The researchers say that weight concerns underlie both smoking and dieting behaviors. They advise that to prevent smoking among girls, attention needs to be given to the widespread problems of dieting and unhealthy weight concerns. (Huggins CE, Girls who diet often may be more likely to smoke. Reuters Health. New York, 3/1/01.)

Obesity surgery ethics in question
A recent article in the Journal of the American Medical Associaton assesses the increasing demand for weight loss surgery and questions the ethics of the way it is being promoted in today's health market. Gastric surgeries for treatment of obesity have increased from 47,000 in 2001, to 63,000 in 2002, to about 98,000 in 2003, with the demand so great that many hospitals have year-long waiting lists, and new surgeons are increasingly getting on board. 
    The market is huge. A professor of surgery at the University of Texas, Edward H. Livingston, MD, is quoted as saying this is the highest-paying general surgical procedure there is, with many patients willing to pay cash when refused by their insurer. Cost of the 2-hour surgery reportedly varies from $1,500 to about $4,000, with some surgeons performing up to 400 per year. Increasingly, insurance pays when a physician says the surgery is medically necessary.
    Coupled with this growth are questions about the surgery's safety and effectiveness, and ethical issues such as potential conflicts of interest, patient selection, postoperative care, insufficient reporting, and the intense advertising and promotion going on today.
    The 1991 NIH Consensus Statement on obesity surgery called the research inadequate and this is unchanged. Long-term consequences remain uncertain. Improved reporting is needed. To begin answering the questions, NIDDK is establishing a Bariatric Surgery Clinical Research Consortium which is expected to begin a 5-year study soon, a major step evaluating results. Livingston says he believes the research will show long-term benefits have been over-estimated. Another professor advises that gastric surgery patients today need to be told, "The procedure is investigational, we don't know if it will help you." (Mitka M. Surgery for obesity: Demand soars amid scientific, ethical questions. JAMA 2003;289:1761-1762.)

Children snack more now
Children are snacking more today than 25 years ago. Researchers at the University of North Carolina compared information from three national surveys 1977 through 1996, and found that, while the average size of snacks and calories per snack remain relatively constant, the number of times kids eat between meals has increased. The snacks provided less calcium than regular meals and were higher in calories and fat. Thus the "energy density" of what children eat over the course of a day has risen significantly, from 1.35 to 1.54 calories per gram. Children today take in about 25 percent of their calories in snacks (600 calories), compared with about 18 percent (450 calories) in the late 1970s. Snacks are important in keeping children's energy levels high, said the researchers, but the kinds of snacks kids are eating can be a problem. They note that the biggest changes in snacking patterns have occurred during the past decade and include increased consumption of soft drinks, chips and salty snacks, and decreases in fruit, vegetables and milk.(Williamson D, School of Public Health scientists find US children snack more now. News release 4/6/01. Contact: [email protected], or [email protected].)

Dieting mothers depress self-esteem
Girls as young as age 5 who are overweight already may feel bad about themselves, and parental concerns may make it worse, shows a Pennsylvania State University study of 197 5-year-olds and their parents. The study found overweight girls felt bad about their bodies, and also believed they were less able intellectually and physically. These feelings were intensified if parents restricted food or reported concern about their daughter's weight. Even girls who were not overweight tended to have lower self-esteem when parents worried about their weight. A related study tracked weight and dieting attitudes of 12,000 girls and boys age 9 to 14. In one year the number who were highly concerned with their weight increased from 9 to 15 percent of girls and 4 to 6 percent of boys. The number constantly on a diet doubled from 2 to 4 percent of girls and 1 to 2 percent of boys. Parental attitudes, such as a mother frequently dieting or father to whom thinness was important, as well as media influences, were strong factors in whether a child worried about his or her weight. Children who become obsessed with weight may turn into lifetime dieters or develop eating disorders, the researchers warned. Instead of an over concern with weight, they advise parents to create a home environment where fruits and vegetables are routine and physical activity is encouraged for everyone. (Davison K, Birch L, Weight status, parent reaction, and self-concept in 5-year-old girls. Pediatrics 2001;107:46-53. Field A, Camargo C, Taylor C, et al, Peer, parent, media influences on development of weight concerns and frequent dieting among preadolescent and adolescent girls and boys. Pediatrics 2001;107:54-60.)

When foods are restricted, kids want more
Parents who try to control how much and what foods their children eat may find their efforts backfiring. Their children tend to eat more when not hungry, to choose the very foods being restricted, and may feel intense guilt about eating. In a study of 197 girls age 4 to 7 and their parents, Leann Birch, PhD, of Pennsylvania State University, and colleagues continue their research on child feeding practices. After eating a standard lunch, when not hungry, the girls were offered free access to snack foods. Their intake ranged from 0 to 436 calories, and the more restrictive the parents, the more the girls ate and the stronger were their negative feelings. About half the girls reported negative feelings about eating too much or whether their mother or father would find out. Feelings of eating "too much" were not affected by how much they ate, but rather by whether they felt this food was disallowed. The study measured parental food restrictions, as well as the girls' feelings about eating, hunger, fullness, food preferences. Cited was other research by this group that suggests when children's attention is drawn to a food but their access restricted, they view that food as highly attractive, associate it with parental disapproval, but have less control over their eating of it. In another study they found high parental control of foods is associated with young children's inability to regulate calorie intake, and that this in turn is related to childhood obesity. (Fisher JO, Birch LL. Parents' restrictive feeding practices are associated with young girls' negative self-evaluation of eating. J Am Diet Assoc 2000;100;1341-1346.)

Most teen pregnancies undernourished
Fewer than one-third of pregnant adolescents met the dietary standards for iron, zinc, magnesium, calcium, and vitamins D and E from food sources, even when they had access to US food programs such as Women, Infants and Children (WIC), in a study of patients from Cincinnati prenatal clinics of a University Hospital. Only 6 percent met the recommended amounts of iron. Yet the 97 pregnant adult women studied had even lower intake of calories and 11 nutrients than did the 59 pregnant teens. About 80 percent reported they took prenatal vitamins. (Giddens JB, Krug SK, Tsang RC, et al. Pregnant adolescent and adult women have similarly low intakes of selected nutrients. J Am Dietetic Assoc 2000;100:1334-1340.)

TV ads fail nutrition test
Television today is a major source of nutrition confusion and misinformation. A recent study finds half the nutrition-related information in TV commercials aired in top-rated prime- time network shows and viewed heavily by 2- to 11- year-olds is misleading or inaccurate.During 17.5 of prime-time hours, one-fourth were spent on commercials (4.3 hours). Of the 700 commercials shown, one-third contained nutrition-related information, an average of 13 commercials every hour, and half of this was questionable. High-sugar foods were presented as being a healthy breakfast choice. A dietary supplement ad implied the product was needed to ensure proper growth and development. Nearly half of medicine commercials included nutrition references, such as that cough drops are superior because they contain honey. Other ads promoted behaviors not recommended by nutrition educators. Eating a whole bag of a snack food was encouraged because it was lowfat. A heartburn drug ad suggested that eating too much or eating high-fat foods is no problem because a pill can prevent heartburn pain. Most of the health and beauty aids commercials also contained misleading information, such as that shampoos and cosmetics contain vitamins and other nutrients vital to healthy hair and skin. Public service announcements were virtually absent from prime-time TV. While the impact of all this on food intake has not been fully studied, the researchers report that studies do suggest that beer and cigarette advertisements increase the likelihood that youth will drink alcohol or smoke. (Byrd-Bredbenner C, Grasso D. What is television trying to make children swallow? J Nutr Ed 2000;32:187-195.)

Bone mass drops in anorexia
Body weight, not estrogen deficiency, predicts bone density in anorexic women, according to a Massachusetts study. Thinner women have weaker, less dense bones. Of 130 women with anorexia nervosa, bone mineral density was reduced by at least 1.0 standard deviation at one or more sites in 92 percent of the patients. In 38 percent it was reduced by 2.5 SD, as measured by duel energy X-ray absorptionmetry. Some of the patients were taking estrogen and others had a history of estrogen use, but this did not affect the findings. Bone loss for these women was comparable to that of women many decades older, despite estrogen therapy. The researchers advise that screening for osteoporosis and counseling about the adverse effects of low weight on the skeleton is critical for all women with anorexia. (Bone mineral density reduced in women with anorexia nervosa. Reuters Health, Westport, CT 11/20/00.)