Robert H. Lustig, MD, UC San Francisco Children's Hospital pediatric endocrinologist
Director, Weight Assessment for Teen and Child Health
www.ucsfhealth.org/childrens/medical_services/hdisorder/obesity/index.html

At the Weight Assessment for Teen and Child Health (WATCH) Clinic, there is a three-month waiting list for new patients, a sign of the growing prevalence of obesity in young people.

The first step in treatment is an evaluation of both the biochemical and behavioral factors that dispose a young patient to weight problems. That intersection of biochemistry and behavior is where Lustig finds clues to causes and treatment of obesity.

Blaming the victim. The standard view is that obesity results from pathological behaviors, and that behavior changes are all that are needed. But it simply doesn't apply, says Lustig, especially when dealing with young children. We're blaming kids, when the real culprit is what Lustig calls the "toxic environment" created by the food and beverages we're serving them.

"Fructose is my main nemesis," Lustig says. "In my opinion we have been fructosified and defibertized by the food industry."

While the genetic make up of humans hasn't changed over the last three decades, the food-processing environment has changed, and he links those changes to the rise in obesity. The high sugar content in foods and drinks and the decrease in fiber create hormonal imbalances, particularly in the hormone insulin, that actually cause people to eat more and exercise less, according to Lustig.

Tactics that work. In his clinic, patients and their families are given four basic rules: Cut out all sugared drinks, including fruit juices and sports drinks. Increase high-fiber foods. Wait 20 minutes after eating before deciding you need to eat more and make kids "buy" TV time with the amount of time they have engaged in physical activity.

Regulations needed. While children and their parents can make personal changes in diet and activity, Lustig says the toxic environment won't change until there are stronger regulations on the food industry that pressure manufacturers to cut the high sugar content of foods and drinks.

"We're not going to solve this until government gets involved," Lustig says. "I don't see any ray of sunshine until that happens."

He draws parallels with the way government has imposed restrictions on tobacco and alcohol to protect children.

"We used to sell cigarettes to kids, but we don't anymore," he says. "We can do this if we have a societal will to change. I don't think that change will come anytime soon, but you have to keep trying."

Exercise impacts development

Dan M. Cooper, MD, UC Irvine professor of pediatrics and bioengineering, vice dean of clinical translational science,
Director Pediatric Exercise Research Center
www.gcrc.uci.edu/perc

The Pediatric Exercise Research Center studies the role physical activity plays in child development. Dan Cooper's research focuses on the effect of exercise-activated molecular processes on both healthy kids and those with chronic conditions such as asthma, cystic fibrosis and obesity. The center has studied, for example, the benefits of daily exercise for premature babies.

With grants from the National Institutes of Health, his research center is looking for a deeper understanding of how much exercise is beneficial for kids with chronic diseases and how to motivate all kids to get more physically active.

"We have to change the attitude that an obese child is guilty," Cooper says. "Much of childhood obesity has resulted from changes in our environment and the abundance of cheap, high-fat, high-sugar, high-calorie food, drinks and snacks."

Working with schools. Instead families, schools and communities need to find ways to offer kids a healthy environment. Cooper has instituted a multi-year study that will follow Long Beach Unified School District students from the 6th through the 8th grades to determine if improved nutrition and exercise can prevent obesity and, ultimately, type 2 diabetes.

The center's researchers created curriculum that teachers can use in their classes to incorporate messages about healthy eating and exercise. One of the themes is using water instead of sugared drinks for hydration.

"The guiding principle is an environmental change in the schools," Cooper says.

Fitness fun. He links childhood obesity in part to the changes in lifestyle that encourage kids to become sedentary. Parents today are afraid to let their children ride bikes to school or freely play outside in the neighborhood park, Cooper says, and that lack of safe exercise opportunities is contributing to childhood obesity.

"We need to invest in PE classes in our schools," he says. "We need schools to be open after hours and offering activities. Parks are utilized more when there are supervised programs. It's not going to be a free fix."

Schools join the crusade

Pat Crawford, DrPH, RD, UC Berkeley, adjunct professor School of Public Health, Cooperative Extension nutrition specialist, Co-director of The Dr. Robert C. and Veronica Atkins Center for Weight and Health at UC Berkeley
http://nature.berkeley.edu/cwh

The Center for Weight and Health at UC Berkeley provides independent research and evaluations of obesity prevention programs for communities and schools. For example, the center tested the financial impact on schools for complying with the legislative mandates for limiting junk food and beverages in California schools.

Better choices. Many schools depended on the sale of snacks and drinks to support their food services or raise money for activities. Schools feared that eliminating the tasty but unhealthy snacks and drinks kids crave would cost them revenue. The center's pilot study found that most schools saw an increase in food service meals revenue after snack foods were no longer available.

Liquid pounds. Another center study evaluated sports drinks and concluded that even for kids who exercise vigorously, water is a better choice than high-sugar sports drinks. A child who consumes one 20-ounce sports drink a day for a year can gain 13 pounds.

"We need to make it easier for children to find healthy choices than unhealthy choices," says Pat Crawford, the center's co-director.

She believes attacking the obesity crisis in schools to be one of the most powerful interventions society can make in its battle against the weight epidemic. Schools provide one-third of the calories children consume, she says, and some parents look to the schools to learn what kind of food to serve at home.

"Mothers think if the schools are serving it, it must be healthy," she says.

Everyone's responsibility. Parents, schools, politicians, city planners all have a role in creating environments for our children, communities where healthy food choices are the norm, and safe streets and parks that encourage physical activity, she says.

Policy-makers can take the lead by evaluating public food programs like WIC to make sure they offer sound nutrition, finding better ways to work with low-income families and imposing stronger legislation on the food industry.

Dennis Styne, MD, Rumsey Band of Wintun Indians Chair, UC Davis Department of Pediatric Medicine
Director Fit Kid and Fit Teen Weight Management Clinics

With more than $1.1 million in grants and endowments from the Rumsey Indian Rancheria, Dennis Styne is studying the rise in type 2 diabetes, hypertension, obesity and other conditions that only a few decades ago were uncommon in children. Today unhealthy eating and lack of exercise are creating an epidemic of weight-related chronic conditions in kids.

"It used to be unheard of for children to have type 2 diabetes," Styne says. "Now children as young as 4 years of age are getting it."

If not treated, diabetes can lead to vision problems, heart disease and amputations in later life. Styne established a 10-week after-school weight-management program called Fit Kids and Fit Teens at UC Davis. It's the only childhood obesity program in Northern California outside the Bay Area. The program uses behavior modification strategies to teach kids and their families about nutrition, exercise and habits that can better manage weight issues.

Rural outreach. Using the ground-breaking telemedicine program at the UC Davis Children's Hospital, he's found ways to transport weight education clinics to remote rural communities and Indian rancherias. A two-way camera is set-up in a rural clinic to give at-risk young people one-on-one conversations with doctors who talk about healthy eating, ways to avoid greasy fast food and replace it with fruits and vegetables. Styne has found the telemedicine sessions just as effective, and in some cases more effective, as in-person weight-management clinics. The telemedicine outreach is also used to educate health practitioners in the rural locations.

"Almost everything we've done to make life better is part of the problem," Styne says of the cause for the rapid rise in childhood obesity and overweight problems.

"I don't blame the parents too much," Styne says, but he does blame TV for bombarding children with ads for unhealthy food.

TV's influence. According to one of his research studies, on a Saturday morning kids are exposed to ads for more than 2,500 calories an hour. There's no one strategy that holds the magic answer to curbing childhood obesity, he says, but there are changes parents can make: "Turn off the television, get the television out of the child's bedroom and start taking charge of your child's life."

But parents need support from their communities and policymakers, he says.

"We need to foster access to fresh fruits and vegetables in the inner cities," Styne says. "We need to improve access to adequate parks that are safe, and not just in the rich neighborhoods. We need safe after-school care, and we need to institute more physical activity in our schools."