Lucy Atkins 

Too much, too young

Our children have never been fatter. Nor have they ever been so prone to eating disorders like anorexia. What can parents do? How do you steer your kids away from one danger without pushing them towards the other? Lucy Atkins has some practical advice.
  
  

Child eating chips
If your school is untouched by the Jamie Oliver revolution, try packed lunches. Photograph: Martin Godwin Photograph: Martin Godwin/Guardian

Some parents are very good at kidding themselves that their overweight child is fine. "It's just puppy fat," is perhaps the most common excuse. Some panic and impose crash diets. Others simply call the child "fatso" and laugh it off. None of this is helpful. Indeed, our collective ineptitude on the subject of our children's expanding girth is such that a parliamentary watchdog has called for the appointment of an "obesity tsar", in part to give parents clearer guidelines about what to do if their children are fat. A few pointers would certainly come in handy.

Recent research shows that an overweight or obese pre-teen is likely to stay that way for life. "The correlation between childhood weight and weight in adulthood seems to be becoming stronger earlier and earlier in a child's life," says Professor Jane Wardle, director of the Cancer Research UK health behaviour unit at University College London, who led a study into childhood obesity. Since more than a quarter of schoolchildren are now overweight or obese by the time they go to secondary school, puppy fat packs quite a punch: our children are stacking up health problems for later life that include unprecedented rates of diabetes, heart disease and cancer.

There is a common perception that rising childhood obesity is something to do with a British underclass putting fizzy drinks in the baby bottle or using burgers as a staple food. This is a national delusion, says Wardle. "While the most deprived socio-economic groups do have higher levels of overweight and obesity," she says, "there has been a huge rise in childhood obesity across all social groups. Go to any private girls' school and you'll find far more girls with larger waistlines than ever before."

Yet parents of all social backgrounds seem oblivious to the problem. One study found that only a quarter recognise when our child is overweight. Most, of course, are concerned to give our children the best nutritional start. Wardle works with families to tackle children's weight problems. "It is definitely not the parent's fault alone," she says. "We are programmed by evolution to maximise food consumption and minimise action." And in this slothful, super-sized age, the problem of "stone-age genes in the digital era" has become really serious.

"There is also a proven genetic component to weight," says Wardle. Studies of twins and of adopted children show that we pass down our "responsiveness to food cues" and "sensitivity to internal cues of fullness" along with our blue eyes or curly hair. In other words, some children are born to eat. But, according to Wardle, "this does not have to be deterministic. Anyone can maintain a healthy weight if they do the right thing."

That includes exercise - but our children seem to be turning into couch potatoes. One problem is that exercise simply is not a normal part of life any more. According to the Department of Transport, only one in 10 UK children now walks to school. The number of children being driven to school has doubled in the past 20 years, along with obesity levels. On average, children spend more time in the car than they do in PE lessons. And although all pupils should be offered PE on the UK curriculum at least twice a week, this is nothing like enough exercise for a child, who should be running around for an hour or more a day.

At the other end of the scale from all this over-eating and slouching lies another, equally disturbing trend: the dizzying rise in eating disorders. While levels of anorexia have grown in line with population increase, the rates of bulimia "are rising significantly ahead of population growth", says Steve Bloomfield of the Eating Disorders Association (EDA). The pressure on young women to look skinny - confirmed in recent months by catwalk models dying of anorexia and celebrities such as Lindsay Lohan admitting to eating disorders - has created a cocktail of unease and low self-esteem in our girls. The number of boys feeling this pressure is escalating, too.

All of this can make attempts to encourage your child to eat more healthily and do more exercise very tricky. Well-meaning parents who impose strict diets, police the dinner table and create an atmosphere of terror around "bad" foods could well be compounding the problem. Certainly, bluntly telling your child she is fat - or, worse, putting her on a diet - could screw her up. "There is good scientific evidence that parents have a strong influence over their children's behaviour around food and eating, particularly unusual patterns of eating, or dieting," says Bloomfield. How you eat can have a direct impact on how your children view food. Many mothers eat separate foods from the rest of the family, or yo-yo between faddy diets. This sends messages to their children - particularly daughters - that food is dangerous and complex and adults can't handle it either.

The truth is that many of us simply do not know what we should be doing to foster in our children a healthy lifelong relationship with food. So here is a basic guide to get you from infancy to adolescence - without damaging your children's psyche in the process.

Birth to 18 months

Flab-fighting starts at birth: by breastfeeding. According to Professor Tim Cole, a child growth specialist from London's Institute of Child Health, "Breast-fed babies are less likely to be fat later in life than bottle-fed babies." While there is, he says "a strong socio-economic component" to this (better educated mothers in the UK are more likely to breastfeed), even when adjusted for social class there is a difference. This could be because a breastfed baby is more likely to learn how to eat according to appetite: "Breastfed babies control the flow of milk themselves," says Cole, "while bottle-fed ones take what they are given."

However, do not despair if your baby is bottle-fed: the relationship between feeding methods and future weight gain is relatively small, and there many other hugely important things you can do, from now on, to increase your baby's chances of being a healthy weight for life. Weaning is one major hurdle. The key to healthy eating is variety. "Most overweight and obese kids are very fussy and faddy: they may eat only three things, and those things will be chicken nuggets, chips and pizza," says Paul Sacher, a specialist paediatric dietician at Great Ormond Street hospital, and research director of the "Mind Exercise Nutrition Diet" (Mend) programme, which works with obese children and their families. "This is often because they are not weaned properly."

Parents tend to give up the first time a baby rejects a new taste or texture, not realising that it can take 10-14 tastes before a food will be accepted. "Studies show that the earlier lots of tastes are introduced, the more willing a child is to eat a wide variety later on," says Wardle. Many parents are also inadvertently cultivating a sweet tooth. For instance, Sacher says, Petit Filou fromage frais is thought of as a great weaning food "but it actually contains a lot of sugar". Label-reading is therefore a vital skill.

Most parents are more worried that the baby is not getting enough food than about over-eating. But, says Sacher, "It is unheard of for a healthy child to starve itself." The rules are simple: never offer a pudding to a baby or child who has refused the healthy first course. Instead, stay nonchalant and simply get your baby down from the table, offering nothing more until the next meal.

Parents of chubby babies, meanwhile, should never restrict healthy food. "Not even an experienced paediatrician can tell just by looking at a baby whether that baby is overweight," says Sacher. "There are too many variables, in height, age, sex, and length." If you are concerned about your baby's weight, get your GP to assess your child and offer advice.

While exercise is not the main concern with babies, it is still important to give yours regular time to move around. Babies - as soon as they are happy to be put down - need space to wriggle, roll and, later, crawl, safe and unfettered. Clear a baby-friendly space and let them get on with it. Even tiny babies love lying on a towel without a nappy to wiggle their legs, wave their arms, and try to touch their toes. Some parents swear by baby yoga classes or other baby-focused activities. These can stretch and exercise small limbs, but really all your baby needs is a little space and time, and your watchful eye.

Preschoolers

Faddy eating often kicks in with toddlerhood, and research shows that fussy eaters are worst when it comes to fruit and veg. This is largely down to your child's quest for world domination. "Very young children quickly pick up on adults' anxiety about what they are eating," says nutritionist Dr Toni Steer from the Medical Research Council's human nutrition research centre in Cambridge. "Food is one of the very few things - if not the only thing - that a small child has control over." Refusing to eat, eating slowly and rejecting certain foods or textures are all common "assertive" behaviours among toddlers.

The key is never to show you care. Remember: "You decide what goes on the plate; your child decides what goes into her mouth." Again, keep trying with healthy foods even if they are rejected at first. Wardle did a trial with children aged three and up who were offered tiny bits of cucumber or red pepper. Initially, there was outraged disgust but after two to 10 "tasting sessions", the preschoolers were actually jostling for them.

Family eating is also important from now on. "Do not cook your child separate 'kids' meals'," says Sacher. Chicken nuggets, fish fingers or other pre-packaged kids' meals "will not teach your child about variety or about fruits and vegetables" - and are less likely to be nutritious. Practise "model good eating", ideally having healthy family meals together whenever possible. "If you are not eating your veggies," Sacher says, "you can't expect your child to."

Some parents go the other way, demonising anything remotely unhealthy. In fact, your child needs to learn about moderation - even toddlers can start to learn that unhealthy foods such as chocolate or chips are occasional treats (once or twice a week) but not daily fare, and that a couple of biscuits are OK, but 10 are not.

The way to tell whether your toddler is overweight is not to look anxiously at his chubby little knees or big pot belly. Toddlers can look extremely fat - think Sistine chapel cherubs - when they are merely short and stocky but a perfectly normal weight. The only way to tell whether your toddler is overweight is to get him checked by your GP. Your GP will weigh and measure him, plotting the measurements against a detailed child growth chart to see what percentile he is in for his age and size.

If your child does turn out to be overweight, "hidden sugars" may be one culprit. According to Sacher, a preschooler should have no more than 150ml (a small cup) of fruit juice a day. Exercise may also, even at this age, be a problem. "No one thinks of exercising toddlers," says Sacher, "and there are no official recommendations for minimum daily or weekly activity for this age group." But there are many things you can do: give your child an area in the house in which to play physically, provide active toys such as tricycles, go to the park regularly, or to toddler activity groups and, crucially, limit TV and video games to less than one hour a day.

Crucially, no matter how much of a sloth you are personally, you need to participate, and make this exercise something your toddler will love doing with you. There is no point in dragging him screaming and kicking round the block to "get exercise", or sitting scoffing an ice-cream while he toddles around the park. Exercise means physical play - things he loves doing, not things you think he should do.

Equally, it is perfectly possible to give harmful messages about shape or size even at this age. If you say harshly, "No! don't eat that biccie - it will make you yukky and fat", the message he is getting is that he is bad for eating the biscuit, and possibly even bad for "being fat" too. Guilt, blame and reproach should be kept out of the equation, even when your child is two foot nothing, with a vocabulary of animal noises.

Children at primary school

According to the charity Weight Concern, few younger children benefit from talking about weight per se. It is better to focus on messages about healthy eating and activity. The main challenges for this age group are school dinners, increasing autonomy and persisting fussiness. Up to 30% of a child's food intake is consumed during school hours. If your school is untouched by the Jamie Oliver revolution, try packed lunches. The odd treat is fine - one day have fruit, another put in a mini chocolate bar - but never cave in to requests for daily unhealthy foods or sweets. Also, exert your control where you can. Sacher says that one in three children now spends their pocket money on chocolate, soft-drinks, crisps and snacks on the way to school; it is up to you to lay down the law.

"You can't change the world, but you should see your home as a 'micro-environment' and clean it up," says Wardle. "Whether or not your child is chubby, you should keep unhealthy triggers such as crisps, biscuits or chocolate well out of their way. Changing family habits is key - for instance, make it a rule never to eat in front of the TV as this can become a habit, triggering the desire to snack every time your child sits down in front of the telly.

Parties and playdates can be a hurdle. You can't control everything they eat, but you can use damage-limitation tricks. A healthy meal before your child sets off will ensure she is not starving on arrival and therefore likely to binge on chocolate fingers. If your child is genuinely overweight or obese at this age - and again, the only reliable way to establish this is to have it confirmed by your GP, who will calculate her Body Mass Index - professional help is important. "It is really, really hard for parents to make the rules," says Sacher.

Do not be tempted to ignore your child's "puppy fat" though. Research shows that children as young as seven can be unhappy about being overweight. They may even try to lose weight without asking their parents for help, and are more at risk of developing eating problems than children who can talk openly about being overweight and feel supported by their parents. Broaching it in a low-key way is a good idea. Rather than sitting down for the "big talk", which may be off-putting, you can open the topic by asking how your child feels about buying bigger clothes than his age group, or how he feels about being teased.

A dietician can help parents unpick the many factors that converge to make a child overweight, and to do something about them. Sacher's Mend programme teaches parents "to differentiate between a child's hunger, and their cravings. If your child is asking for a particular food, such as chocolate, and refuses alternatives - a sandwich or a piece of fruit - this is a craving. If they were genuinely hungry, they'd eat the sandwich." Studies show that cravings last about 20 minutes, so if you can distract your child for that time he is likely to forget he wanted the chocolate.

"Obese kids have higher rates of low self-esteem and even depression than healthy weight kids," says Sacher. So it is crucial to avoid making your fat child feel bad or as if she has disappointed you. Never call her greedy, or criticise her eating habits - instead talk to her about healthy eating and activity, praise her for it - and make sure you do it too.

Putting your overweight child on a "diet" without professional guidance can be one of the quickest ways to mess her up. One 2003 study found that the more children and teenagers dieted, the more likely they were to become obese as adults. According to Bloomfield, your own dieting habits can also give your children negative food messages. "If, for instance, a girl grows up with a mother who is always dieting, or not eating, or saying how fat she feels, she is likely to see this as something that 'women do' - and to develop the same complex and dysfunctional relationship with her food and body."

One positive thing you can do, in addition to eating healthy food together, is to control portion sizes: one portion of meat or fish, for instance, should be the size of one-third of the palm of your hand, while a portion of carbohydrates is two small new potatoes or a single bread roll (fill up on healthy vegetables and fruit instead).

You can also control the TV. Childhood obesity experts are now calling for government guidelines for children of no more than two hours of TV watching a day. Seventy per cent of our children now have a TV in their bedroom, yet one recent study from the Institute of Child Health found that for five-year-old children, every hour of TV watched at weekends increased their risk of obesity by 7%. Another study last year from Harvard University found that watching television for an hour a day can add more than 6.4kg (1 stone) to their weight over a year. The endless ads for junk food can't help. But here, at least, there is some good news, with the broadcasting regulator Ofcom due to announce rules to curb children's exposure to TV adverts for food and drink high in fat, salt and sugar.

The Department of Health does recommend that children have at least one hour of moderately intense physical activity that involves getting warm and breathing faster every day (some of this should be vigorous). Again, it is down to you to get involved. Research shows that many children say they would like to go to the park but their parents are too busy to take them. "It is important to make physical activities a reward, not a punishment," says Sacher, "and to do things together that your child enjoys."

Many overweight children, of course, hate any form of activity as it feels unpleasant, but even a 10-minute walk in the park with the dog is a good start. Building exercise into your day will give your child lifelong good habits: whenever you can, walk or cycle instead of using the car.

Eleven-plus

Weight Concern says that this age group tends to have relatively sophisticated views on nutrition and health and strong feelings about what weight "looks good". They may have more dietary autonomy but, on the plus side, they can understand the principles of managing weight, and with support, can come up with creative ideas for doing this.

"If your child is overweight or obese over the age of 11," says Wardle, "the evidence is that they will not spontaneously slim down." You are going to have to tackle the problem. Adolescents tend to be very resistant to parental interference, or any suggestion that they are not being "accepted" and, says Wardle, "they are extraordinarily self-conscious." Getting professional help is therefore crucial.

To see a specialist dietician (who may be hard to find, but should come via your GP, initially), you first have to broach the topic with your teen. Most parents find this immensely hard. One study found that most parents avoided talking to their overweight teen for a long time until the issue finally erupted - usually in an extreme, critical, angry or otherwise unhelpful way.

Many parents - particularly of girls - avoid the topic of eating or weight for fear of provoking a "complex" or eating disorder. "There is not a shred of evidence that families that encourage healthy eating have an increased risk of eating disorders," says Wardle. In fact, she says, "we are guarding against an imaginary fear" if we avoid discussing weight and eating at any age. The key is how you talk about these things. Calmly educating your child about healthy choices, or gently raising the subject of their escalating weight is totally different from telling your child she is revoltingly fat and must go on a diet.

In the Traffic Light programme - a diet and exercise programme to tackle childhood obesity, run by Great Ormond Street and the Institute of Child Health - researchers have looked carefully to see if the children taking part develop a worse body image or become less happy. "The results suggest the opposite," says Wardle. "Facing up to the issues and developing a healthy lifestyle makes children feel significantly better about themselves." Crucially, all your emphasis should be on the whole family having a healthy lifestyle together - never on singling out your child as having to do something different, or eat different things from the rest of you.

Usually, if a child is overweight the whole family can benefit from being re-educated about healthy living. In the Traffic Light programme, for instance, families are taught to classify foods: "green" indicates foods that can be eaten without worrying (such as vegetables); "yellow" indicates healthy foods that should form the bulk of the diet, but not be eaten to excess (such as bread, pasta, rice, lean meat, fish and dairy foods); and "red" indicates occasional rather than everyday foods (such as biscuits, cakes, chips). This approach is deemed so successful that the Food Standards Agency has just launched a Traffic Light food-labelling system, which is already on some food products.

Exercise is also a huge issue. "Studies show that activity rates drop off sharply in the teenage years, particularly among girls," says Ken Fox, professor of exercise and health science at Bristol University. "It can be very hard to get them active again, as sport may be seen as uncool, and girls tend to feel more self-conscious." Your role as a parent is to encourage them whenever possible. "It is vital to facilitate activity," says Fox. "If they show any interest in any sport, game or active pursuit, you should jump on that, and help to make it happen for them."

"Many kids have already been put off sport at primary school PE," agrees Professor Paul Gateley, an exercise and obesity specialist at Leeds Metropolitan University. Having lost them, it can be hard to get them back when activity is competing with computer games, TV, homework, eating and socialising. As parents, we are not helping this. In one recent Ofcom study, 39% of UK parents of 12-15s said there are no house rules about watching television.

"It's vital to be a good role model," says Gateley. "If you sit in front of the TV every night, your teenager will see inactivity as the norm." But if your teen still will not budge, do not give up hope. Gateley, who has worked with 6,000 overweight and obese children (the heaviest, at 14 years old, weighed 267kg/42 stone), says: "Not a single one of them could not be engaged in physical activity. It's about finding something they like." So think about fun stuff - go ice-skating together, or encourage them to take up something they think is "cool", such as a martial art.

Above all, do not ignore the subject if you have an overweight teen. "It's a farce to pretend that everything is fine," says Wardle. The basic rules for talking are tact and support. "Raise the subject gently and tell them you'll support them in whatever they want to do about it," says Wardle. "Continue to show them that you are responding to them as an attractive and lovable person." And if you are struggling, says Wardle, "It can be helpful to acknowledge, maybe with a bit of humour, that there is a strong genetic component." After all, nobody is perfect.

· First-Time Parent by Lucy Atkins (Collins, £17.99) covers how to feed babies and small children sensibly. From Kid to Superkid (Vermilion, £8.99) by Paul Sacher, deals with healthy eating from five years. Weight Concern 020-7679 6636; www.weightconcern.org.uk includes details on the Traffic Light Programme (see Children's Treatment Trial). For the Mend programme, call 0870 609 1405 or visit www.mendprogramme.org

 

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