Friday, February 02, 2007

When is a Child Too Fat?

A recent Diet Blog entry, Fat Kid Phobia: A Personal Rant, has provoked an interesting discussion in the comments section.

The center of the debate is the recent finding, published in the October 2006 issue of Public Health Nutrition, that 90% of parents of 5 to 6-year olds did not recognize their child was overweight. As Yahoo News brutally headlined it, Parents Blind to Fat Children, Study.

Jim (author of Diet Blog) wrote, "When my daughter looks up at me with her concerned eyes and asks "Daddy is my tummy too big?" - my answer is - "You are just beautiful the way you are".

Or I could glare at her with stern eyes. I could inform her that she is in the grip of an obesity epidemic. That she had better start eating less. That I would be watching everything she puts in her mouth. That she isn't quite good enough.

I have no doubt that I could annihilate her fragile self-esteem in a few minutes with such careless words.

I'm not ignoring the fact that there is an obesity problem and that there are many very real health consequences -- but who gets to decide my child is overweight -- and by what definition? Certainly parents and families can be educated about healthier lifestyles - but is fear-mongering and guilt a good way to do this?

Do I tell my daughters that they are not allowed to have round tummies or big thighs? Because if they do it might mean they are overweight. And if they are overweight then they are... what...? Sick? Unhealthy? Lazy? Unacceptable?"

Considering the full-court-press the issue of childhood obesity is getting in the media, schools measuring the BMI of children and sending home BMI report cards, public service messages targeting parents of overweight children, mandates for wellness programs in schools, and a plethora of other initiatives to reduce the indidence of childhood obesity, Jim's question and underlying concern is valid - it isn't only adults whom are hearing and seeing the messages that children are in trouble, kids are hearing and seeing those messages each day too.

And here we have a survey confirming what many have been saying for years - parents are blind to their childrens weight problem.

I wondered, just how is it possible not to recognize a child is overweight or obese?

For that answer I had to go to the full-text to read everything rather than depend on the short abstract, which didn't provide enough information to understand the protocol of the survey or how the research team crunched the numbers to reach their conclusions.

An interesting thing emerged in the full-text - the researchers used an international set of cut-offs for overweight and obese in children, first proposed in May 2000 in the British Medical Journal; so the CDC's calculator for children and teens is not useful here. In the BMJ article we find the standard used for this survey in Table 4 which provides the BMI points of overweight and obese:

Five year old boys:
BMI of 17.41 or less = normal/healthy weight
BMI of 17.42 to 19.29 = overweight
BMI of 19.3 or more = obese

Five year old girls:
BMI of 17.14 or less = normal/healthy weight
BMI of 17.15 to 19.16 = overweight
BMI of 19.17 or more = obese

For simplicity here, let's work with girls since one fear many parents have with daughters is the worry about creating eating disorders in their future if they send the wrong messages about weight and body image.

So let's use an example of a five-year old girl who is 3' 8" - 44" tall.

At what weight does she transition from normal to overweight? At what weight does she transition from overweight to obese?

Using the CDC BMI Calculator, to enter height and weight and find BMI, here are the results:

47-pounds = 17.1 BMI (normal/healthy)

47.5-pounds = 17.2 BMI (overweight)

53-pounds = 19.2 BMI (overweight)

53.25-pounds = 19.3 BMI (obese)

Of the 134 five-year-old girls measured in the survey, 21 were found to be "overweight" and 5 were found to be "obese".

As we can see from above, a half-pound can have a profound difference - a child weighing 47-pounds is normal/healthy, a child weighing 47.5-pounds is overweight, and a child somewhere between 47.5-pounds and 53-pounds is overweight...a very small margin of just six pounds difference between normal/healthy and obese.

Six pounds - is it any wonder parents might not think a child classified as "overweight" by the BMI isn't overweight?

I really have to wonder how many of the 21 girls classified as overweight were within a pound of normal/healthy? How many were within two pounds? Three?

This is just one example of many potential scenarios for a little girl who is five years-old; she may or may not have more or less lean body mass (muscle) compared with her peers; may or may not be laying down fat to enable a growth spurt in her near future; and may or may not have the same stature of another girl of the same height, where one little girl may be "sturdy" another might be "dainty".

But, these are things the BMI cannot measure. And this is where adult judgement has to come into play.

It's noteworthy that the researchers didn't try to measure the perception of other adults, specifically pediatricians or family doctors who are tasked with keeping an eye out for problems. Perhaps they could have taken it a step further too and asked the parents of the children in the study - ask them if looking at child A, B, or C would they consider the child, who is not their own, normal/healthy weight, overweight or obese?

I think that type of insight would be useful - I know if I were trying to judge between a child who is 47-pounds and one who is 48-pounds, I'd probably not recognize the 48-pound child as overweight - it's simply not a big enough difference to be an overt difference between the two children. Even a few pounds probably wouldn't set off alarm bells for most people when they're looking at two or three children who are close to the same weight.

But with the BMI standard, those few pounds make all the difference.

Jim said it nicely, "I'm not ignoring the fact that there is an obesity problem and that there are many very real health consequences...but is fear-mongering and guilt a good way to do this?"

This is a question we all need to ask ourselves and consider as we continue to turn up the volume in an effort to convince parents to pay attention to their child's weight.

We also need to be aware of what messages we are unwittingly sending to children - often very young children - as we adults try to find a solution to reverse the trends of overweight and obesity affecting our children.

As a parent I know it's hard to objectively assess my child - in my eyes he's perfect in every way.

It's hard to the assess my neice and nephew, my young cousins, and my cousins' children too. But then, when I step beyond the circle of family into the circle of friends it's much easier to "see" a problem, but then again, if we're talking a pound here or there, no way! Quite frankly, unless the child is really way to heavy, or having trouble in daily activity it's a tough call to make, especially since we're talking about kids who are growing and always changing right before our eyes!

I don't have the answer to how to reverse the trend of childhood obesity - I do see it, I do recognize it....and I do worry that how we're going about the solution may do more harm than good in the coming years.

I know it pains me to hear my five year-old neice say she doesn't want to get fat - she's tall and slim, but just barely registering in the 10th percentile for BMI-for-age; just as it pains me to see a little girl struggling at the playground because she's carrying too much weight on her little body.

There are no easy answers here. But if we get this one wrong - what will we have done to our future generation?

What are your thoughts?


  1. Anonymous4:53 PM

    Well my kids are grown. None obese, although I am. (I used my own story as a bad example and it worked).

    but if I were raising kids today?

    First, if they were genetically sensitive to carbs, I would use DesMaisons' Little Sugar Addicts as a how-to book to prepare them to live in a hostile carb world.

    Next, I would not work with a doctor who uses such a flawed measure as BMI. I'd find another doc.

    Schools, if they sent a BMI report card, I would not put up with that, one way or another, and talk to teachers and with the child about why.

    As you wrote earlier, clean food at home will go such a long way in prevention, it's amazing.

  2. Anonymous8:58 PM

    Its very sad when your child is judged because of his or her weight. My son has Duchenne Muscular Dystrophy which is a progressive muscle-wasting disease which will see him end up in a wheel-chair. He takes steroids to slow the progression and one of the side-effects is cushings syndrome which is fat accumulation around the face and neck which gives his head a moon-shaped appearance. Also it is causing fat build up in his torso. He can't help his weight problem but that doesn't stop the fat teasing at school.

  3. Anonymous3:27 PM

    Five year old girls:
    BMI of 17.14 or less = normal/healthy weight
    BMI of 17.15 to 19.16 = overweight
    BMI of 19.17 or more = obese

    I tried to understand the gobbledygook... I mean information in the articles you linked to, but it was just too technical for me.

    Can you possibly explain in plain English exactly why it is that the BMI classifications for children are so much lower than those for adults? I mean if an adult had any of those BMI numbers, we'd consider them to be underweight - well, the BMI of 19.17 would be considered on the very low side of normal, thin enough to be a runway model, but certainly not obese!

  4. My two are also grown, both tall and slim (ages 22 &24).

    When growing up, my DD was always very thin, and I was harrassed about her weight by many. Luckily my doc was understanding and supportive. My son was always heavier, but not too bad. He grew rapidly (3+ inches in less than 2 yrs) and weight never caught up with him. I think in his case he needed that extra weight. He went from overweight to almost underweight as his hight increased but his weight didn't change!

    I fear the amount of artificial and processed foods that parents are encouraged to feed their children (Nutripals comes to mind). The way they encourage sugar and carbs in place of healthy fat and protein also concerns me, especially the high amounts of HFCS and transfats (and now soon our "new" fake fat).

    When mine were little I didnt' allow aspartame. I feared the effect on their sexual development as many women had stated they had irregular menses and other problems when they used it. Today we have more and more women having trouble there a realationship? I don't know, but I'm still glad I restricted it!

    Until the powers that be get over their fat phobia and their love affair with carbs and grains, we will not see a solution. Especially children, who require fat for brain development and protein for muscle and cone development!!!

  5. This is such a hard issue! I grew up feeling bad about myself and my body. If there were a way of teaching children (and adults) that people come in different shapes and sizes and that we should all be striving to take care of our bodies by making healthy food choices and exercising regularly that would be ideal. By making a narrow window of "healthy" weight those who are outside that window are made to feel like there's something wrong with them even though they're making healthy choices in their life. On the flip side, those who are within that window don't feel like they have to make healthy choices because their weight is within a certain parameter.

    My own children are genetically slender (from their dad's side) and they have no societal incentive to eat well and exercise (10 & 15 y.o. boys). I can only lead by example and have healthy food around while they're at home. I talk to them about making healthy choices and I hope that some of it is sinking in. They both choose not to eat fast food or school cafeteria food, so maybe there's a glimmer of hope:-).

    Also, the debate rages on about what's healthy and what's not. Kids still get a lot of low-fat indoctrination at school. Telling kids they're fat and then putting them on low-fat diets could be counter productive and even harmful.

  6. Can you possibly explain in plain English exactly why it is that the BMI classifications for children are so much lower than those for adults? I mean if an adult had any of those BMI numbers, we'd consider them to be underweight - well, the BMI of 19.17 would be considered on the very low side of normal, thin enough to be a runway model, but certainly not obese!

    Almost every source I've read about determining child/teen BMI cites one source again and again:

    Cole TJ. The LMS method for constructing normalised growth standards. European Journal of Clinical Nutrition, 1990, 44:45-60

  7. Anonymous2:19 PM

    If you want to read an interesting first-person account of childhood obesity, check out: