It's never too early to prevent obesity - or is it?
By Betsy McKay
The Wall Street Journal
According to new guidelines from the World Health Organization, the answer is yes.
The WHO, the United Nations' health agency, is urging every country to adopt its new growth charts, which delineate ideal growth in a child's first five years of life.
The new guidelines also include for the first time measurements for body mass index, or BMI, for babies age 2 and younger - a weight and height calculation used to determine whether people are overweight or underweight.
But the charts - and particularly the new BMI standards - are raising concerns that parental fear of obesity will be pushed into infancy - a time when adequate nutrition is crucial for brain development and other important growth.
As a result, pediatricians and health officials in the U.S. say they aren't sure whether the WHO guidelines should replace those currently used in this country. The WHO charts are based on children from affluent, educated families in six countries. The U.S. charts are based on a broad sampling of U.S. children.
The skeptics say they are concerned that the WHO growth curves generally make U.S. infants and toddlers look heavier than the current charts American pediatricians use. The WHO growth curves are based on babies who were breast-fed for at least a year, while the American charts are based on children who were primarily formula-fed after the first few weeks.
Formula-fed children tend to be bigger than breast-fed children in late infancy. So a 1-year-old boy who weighs a little more than 25 pounds would rank approximately in the 85th percentile for his weight on current U.S. pediatric growth charts, which are compiled by the Centers for Disease Control and Prevention. But he would hit the 95th percentile on the new WHO charts.
Currently, about 14 percent of U.S. toddlers ages 2-5 years old are estimated to be overweight, according to the CDC. Currently, BMI doesn't appear on U.S. growth charts until age 2. The WHO estimates that under its new guidelines, the number of U.S. children from birth to age 5 who are considered overweight could rise by as much as 30 percent.
The issue is not whether American kids are too fat - regardless of which charts are used, there's a general consensus that obesity is a problem among American children.
"The problem is here, right here in our towns," says pediatrician Dr. Paul Mark Baker of Hudson Valley Pediatrics in Middletown. Baker says one of his colleagues conducted a random survey of more than 200 children at their practice and, using BMI, found 40 percent of those over the age of 2 were overweight or obese.
But the question is, how early is it appropriate to start tracking a baby's BMI? When it comes to babies, weight often fluctuates in infancy, making it hard to determine whether they are too heavy or just going through a growth spurt.
"With those under the age of 2, I'm not too aggressive," Baker says. Still, "It's certainly a good idea to start thinking about it early on, get them active and eating healthy," he says.
A baby's size usually has little bearing on whether he or she grows up to become obese, researchers and pediatricians say. But creators of the new WHO charts argue that with rising rates of obesity, prevention needs to begin as young as possible.
"I would rather put a tool in the parents' and health-care providers' hands rather than say we think this may worry you, so we're going to keep this information from you," says Cutberto Garza, academic vice president at Boston College and chairman of the steering committee that developed the new charts. "Health means much more than just the absence of disease."
Indeed, the debate over whether to adopt the new growth charts comes as pediatricians and public-health officials are already searching for better ways to identify signs of poor diet or budding obesity in young children, as weight-related diseases such as Type 2 diabetes appear at young ages.
In a new set of well-child guidelines to be released at the beginning of next year, the American Academy of Pediatrics plans to recommend that doctors measure their patients' "weight/length ratio" starting at 1 month old, says Joseph Hagan, a Vermont pediatrician who is co-chairman of the committee writing the guidelines. The measurement is similar to BMI.
"A lot of parents ask if their child is overweight," says Dr. James Wapshare, a pediatrician at Chester Pediatrics in Goshen. "I'm looking at all the percentiles, like weight, height and head size.
"If a child is in the 95th percentile in all categories, he's a big child but he's not overweight in comparison. If he's in the 95th percentile in weight and the 50th in height, that tells you your child is overweight."
Rather than depicting babies relative to their peers, the WHO data set "ideal" conditions for infants who are properly fed and cared for. By setting up breast-feeding as an ideal, the new report offers one of the strongest endorsements yet for the practice. But the push can breed anxiety for some parents.
"Some moms feel like failures if they can't breast-feed," Baker says.
While about 70 percent of U.S. infants are breast-fed in the first few weeks of life, the number drops sharply as their mothers return to work and by 12 months, just 18 percent are breast-fed.
But breast-feeding advocates hope the WHO charts will breathe new life into their efforts to promote exclusive feeding with human milk for the first six months of life and continued doses of human milk for at least a year. Breast-feeding reduces the incidence and severity of infectious disease, infant mortality, ear infections and other maladies, the pediatrics association says.
"A lot more babies are formula-fed nowadays," says Julie Tresco, a health educator who specializes in nutrition at Maternal Infant Services Network in Central Valley. These children tend to eat more, she says, as food from a bottle is more free flowing than a mother's milk from the breast.
The formula-fed crowd may also develop more of an affinity for sweetness when they move on to solid foods, she says, looking for something that is close in taste to the formula, which tends to be sweeter than breast milk.
Doctors are concerned that a high weight-length ratio could prompt some parents of formula-fed babies to put their babies on diets - a dangerous move. A high BMI should raise a red flag only if a child measures that high on the growth chart several times, Hagan says.
While the fear of being too restrictive with a diet is there, Baker says, "I have rarely seen a family restricting the diet of their very young child. I see more of the overfeeding."
The new charts could raise questions in the pediatric community about whether formula-feeding schedules need to be altered in order to slow growth in later infancy, Hagan says. While the WHO and CDC charts diverge in infancy, they grow more similar for average-sized children above age 3.
A heavy baby won't necessarily become an obese adult. There are few links between overweight in children under age 3 and adult obesity, says Robert Whitaker, a senior fellow at Mathematica Policy Research. In a 1997 study in the New England Journal of Medicine, he and colleagues found that overweight toddlers face a significant risk of becoming obese adults only if their parents are obese. A 2005 study done for the U.S. Preventive Services Task Force, a panel of experts that reviews and develops recommendations for the government for clinical preventive services, found insufficient evidence to support screening children under 12 or 13 years old for BMI.
U.S. government officials and representatives from the pediatrics association are convening this summer to pore over the new charts and discuss the possibility of adopting the WHO guidelines, or parts of them. "People are raising lots of questions," says Laurence Grummer-Strawn, chief of maternal and child nutrition at the CDC, who helped develop both the CDC and WHO charts. "We're not ready just to say yes or no."
But guidelines serve only as a yardstick anyway. Many experts will tell you the key is prevention, and the battle for healthy eating begins early on, before the age of 2.
A 2002 survey revealed 1 in 5 babies was eating candy every day by the age of 2, and the No. 1 vegetable for toddlers was french fries. "I have a lot of parents who think that Kool-Aid is a juice," Tresco says. "And that's obviously all sugar."
As part of her job as health educator, Tresco goes into the community to talk nutrition. When she shows people the recommended serving of pasta - a half-cup - she says it often draws laughter. "They'll tell me, 'A 2-year-old eats more than that.'
"I say, 'Well, they shouldn't.'"
Information for this story was contributed by Times Herald-Record staff writer Heather L. Connors and wire reports.
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