Increasing Fruit and Vegetable Intake andDecreasing Fat and .docx

Increasing Fruit and Vegetable Intake and
Decreasing Fat and Sugar Intake in Families at
Risk for Childhood Obesity
Leonard H. Epstein, Constance C. Gordy, Hollie A. Raynor,
Marlene Beddome, Colleen K. Kilanowski, and
Rocco Paluch
Abstract
EPSTEIN, LEONARD H., CONSTANCE C. GORDY,
HOLLIE A. RAYNOR, MARLENE BEDDOME,
COLLEEN K. KILANOWSKI, AND ROCCO PALUCH.
Increasing fruit and vegetable intake and decreasing fat and
sugar intake in families at risk for childhood obesity.Obes
Res.2001;9:171–178.
Objective:The goal of this study was to evaluate the effect
of a parent-focused behavioral intervention on parent and
child eating changes and on percentage of overweight
changes in families that contain at least one obese parent
and a non-obese child.
Research Methods and Procedures:Families with obese
parents and non-obese children were randomized to
groups in which parents were provided a comprehensive
behavioral weight-control program and were encouraged
to increase fruit and vegetable intake or decrease intake
of high-fat/high-sugar foods. Child materials targeted the
same dietary changes as their parents without caloric
restriction.
Results:Changes over 1 year showed that treatment influ-
enced targeted parent and child fruit and vegetable intake
and high-fat/high-sugar intake, with the Increase Fruit and
Vegetable group also decreasing their consumption of
high-fat/high-sugar foods. Parents in the increased fruit and

vegetable group showed significantly greater decreases in
percentage of overweight than parents in the decreased
high-fat/high-sugar group.
Discussion:These results suggest that focusing on increas-
ing intake of healthy foods may be a useful approach for
nutritional change in obese parents and their children.
Key words: fruits, vegetables, pediatric, prevention
Introduction
The prevalence of obesity in children (1) is increasing.
Although pediatric treatment has been relatively successful,
many treated children also regain weight during follow-up
(2). Given difficulties in changing established eating and
exercise behaviors, research is needed to prevent obesity
during development. Primary prevention may involve mod-
ifying intake and/or increasing expenditure, but the biggest
effect on energy balance will come from modifying intake,
because research suggests that obese and non-obese chil-
dren have similar activity levels (3,4).
Most dietary approaches for obesity treatment or preven-
tion attempt to limit intake of high-fat, low-nutrient dense
foods. This may be perceived as a dietary restriction by
people who find these foods reinforcing. The perceived
restriction can lead to increases in preference for these foods
(5), thereby increasing the probability of relapsing to pre-
vious eating habits when structured interventions are re-
moved. An alternative approach would be to teach children
to increase intake of healthy high-nutrient dense foods, such
as fruits and vegetables, which has been the target of large
public health interventions (6).
Components of programs to prevent obesity in at-risk

children can include modifying environmental cues leading
to positive energy balance, changing parental eating habits,
thereby providing healthy models for children to observe,
and teaching new parenting skills that reduce using food as
a reward (7). Because parental obesity represents one of the
major risk factors for pediatric obesity (8,9), many at-risk
children will live in families with obese parents. The inclu-
sion of parental behavior change as a target for obesity
prevention programs may have benefits beyond prevention
Submitted for publication March 28, 2000.
Accepted for publication in final form October 27, 2000.
Department of Pediatrics, School of Medicine and Biomedical
Sciences, State University of
New York, Buffalo, New York.
Address correspondence to Dr. Leonard H. Epstein, Division of
Behavioral Medicine,
Department of Pediatrics, State University of New York, Farber
Hall, Room G56, 3435
Main Street, Building No. 26, Buffalo, NY 14214-3000. E-mail:
[email protected]
Copyright © 2001 NAASO
OBESITY RESEARCH Vol. 9 No. 3 March 2001 171
of pediatric obesity, because a change in the eating habits
related to parental obesity may result in a reduction in
parental obesity. If obese parents of at-risk children reduce
access to low-nutrient dense foods available in the shared
family environment, model healthier eating and activity
habits, and share positive food-related family experiences
that reinforce eating high-nutrient dense foods, the parents
may reduce the risk of their child becoming obese as well as
modify their own body weight. Golan et al. (10,11) have

documented the effectiveness of programs that intervene
only with parents in the treatment of childhood obesity. In
addition, focusing on the parent has the potential to change
the familial environment of a normal-weight child who is at
risk for obesity, without identifying the normal-weight child
as a patient.
This study was designed to test a new parent-focused ap-
proach for modifying eating behavior in at-risk children and
their parents. Parents were instructed to modify their behavior
and the familial environment to reduce their obesity and were
taught parenting skills for promoting and reinforcing behavior
change in the at-risk children. The dietary changes suggested
for the parents would also result in a secondary goal of reduc-
ing weight in parents of at-risk children. Families with at least
one obese parent and a normal-weight child were randomized
to groups that targeted either a decrease in consumption of
high-fat, high-sugar foods or an increase in consumption of
fruits and vegetables and were followed for 1 year. The tar-
geted behavior was a change in the eating habits for parents
and children, leading to a decrease in weight for parents and to
stabilization of relative weight for children.
Research Methods and Procedures
Participants
Families with at least one obese parent and a 6- to
11-year-old non-obese child were recruited through physi-
cian referrals, posters, newspapers, and television advertise-
ments for the Childhood Weight Control and Prevention
Programs at the University of New York at Buffalo. A total
of 30 families were accepted into the program. All of these
families met the criteria: a child with a body mass index
(BMI) that was less than the 85th BMI percentile, at least
one parent with a BMI that was more than the 85th BMI
percentile (12,13), one parent willing to attend treatment

meetings, no family member on an alternative weight-
control program, no parent or child with current psychiatric
problems, and no dietary or activity restrictions on the
participating parent or child. In 28 of the 30 families, the
participating parent was the obese parent. A total of 15
families began in each of the two groups. Complete 1-year
data were available for 27 of the 30 families (90%).
Procedure
Families who met entrance criteria were randomly as-
signed to one of two groups for which the targeted behav-
iors varied: increase fruit and vegetable intake (Increase
Fruit and Vegetable) or decrease high-fat/high-sugar food
intake (Decrease Fat and Sugar).
Treatment
Common Components of Treatment.Weight-control treat-
ment was provided to the parents for eight weekly meetings,
followed by four biweekly and two monthly meetings dur-
ing the 6-month intensive treatment. Participating parents
and children attended the first meeting, at which they re-
ceived the first modules in their parent and child work-
books. The workbook included five main sections: intro-
duction to weight control and prevention, the Traffic-Light
Diet (14), developing a healthy eating and activity environ-
ment for children, behavior change techniques, and main-
tenance of behavior change. Child materials were sent home
with the parents each week and included new workbook
modules and program-related activities for the children to
do with their parents. At treatment meetings, participating
parents were weighed and their weight was graphed. The
participating parents also met with an individual therapist
for 30 minutes and attended a 30-minute group meeting.

During the individual meeting, therapists reviewed the pro-
gram-related child/parent activity, the weight change of the
parent, and the targeted dietary goal and parent-activity goal
of at least 30 minutes of moderately intense physical activ-
ity $6 days per week (15). Participating parents and chil-
dren were seen at for follow-up at 6 and 12 months.
The Traffic Light Diet (14) was used to promote a
balanced diet and to decrease energy intake in overweight
parents. Traffic Light Diet foods are categorized into the
colors of the stoplight: red, yellow, or green based on
their calorie and nutrient content. Green foods are very
high in nutrients and low in calories. Yellow foods are
higher in calories and include the dietary staples needed
for a balanced diet. Red foods are higher in calories with
low nutrient density. While they were attempting to lose
weight, overweight parents were instructed to consume
between 1200 and 1500 calories (kcal) per day and to
maintain nutrient balance by eating the recommended
servings based on the Food Guide Pyramid. When
participants got below the obesity criterion (,85th BMI
percentile) they were instructed on how to develop a
maintenance calorie level, which involved gradually
increasing caloric intake in 100-kcal/d increments until
weight gain occurred. Non-overweight parents had no
caloric restriction but were asked to meet their targeted
dietary goal. Families were provided additional nutritional
information regarding reading food labels and shopping.
Parents were taught positive reinforcement techniques that
included praise for targeted behaviors. Children were
reinforced for completing their program-related activities at
home by having a sticker placed on a tracking sheet. At the
6-month follow-up, children were given gift certificates
Fruit and Vegetable Intake, Epstein et al.

172 OBESITY RESEARCH Vol. 9 No. 3 March 2001
based on the number of activities completed during the
program. Parents were taught stimulus control to reduce
access to high-fat/high-sugar foods and to increase access to
fruits and vegetables, and to increase access to physical
activity and to reduce access to sedentary behaviors.
Preplanning and problem solving were taught to facilitate
decision-making and handling of difficult eating and activity
situations such as parties, holiday gatherings, school
functions, and work functions.
Targeted Dietary Goals.The between-group differences
focused on which dietary behaviors were targeted for
change. Both groups received the same basic information,
but the groups differed in the behaviors targeted for
change. In the Increase Fruit and Vegetable group, the
goal was to incrementally increase intake of fruits and
vegetables to reach at least two servings of fruits and
three servings of vegetables per day. Participants in the
Decrease Fat and Sugar group were provided incremental
goals to reach a goal of no more than 10 servings of
high-fat/high-sugar foods per week.
Measurement
All dependent measures were collected at baseline and
12 months.
Anthropometric Measures.Height was measured in
0.125-inch (0.32 cm) intervals using a stadiometer (Seca,
Columbia, MD), and weight was measured in 0.25-lb
(0.55 kg) intervals using a balance beam scale

(Healthometer, Bridgeview, IL); equipment was calibrated
daily. BMI (kg/m2) was calculated and compared with
population standards based on gender and age (12,13). All
children were under the 85th BMI percentile and were
considered non-obese. Parents who were greater than the
85th BMI percentile were considered obese. BMI changes
reliably with the age of the child, with a decrease from
ages 2 to 5 years and gradual increases through
development. Thus, the BMI value cannot be used to
establish obesity or assess change, because an older child
with a higher BMI value than a younger child may be
less obese. Percentage of overweight was established by
comparing the BMI of the subject with the 50th BMI
percentile based on the gender and age of the subject.
This provides a continuous value that determines the
extent to which the subject is overweight in comparison
with the population average.
Family History of Obesity and Related Diseases.
Parents were asked how many of the child’s parents or
grandparents were obese and had diagnosed hypertension,
hyperlipidemia, diabetes, or stroke. They were also asked
what their perception was of the probability of the
enrolled child becoming obese (from 0 [no risk] to 100
[will become obese]). Parents’ confidence in changing
their weight and their eating and exercise habits and in
helping their children change their eating and exercise
habits was assessed using a 1 to 5 scale (from 5 [very
confident] to 1 [not confident at all]).
Food Intake. Changes in eating habits over the past
month were assessed using the Food Habits Questionnaire
(16), which assesses changes in patterns of behavior
associated with avoiding meat, avoiding fat as a seasoning,
replacing high-fat foods with low-fat alternatives, sub-

stituting foods with manufactured substitutes, and using
fruits and vegetables. Participants rated how often they
engaged in specific patterns of eating habits on a four-point
scale, ranging from rarely or never to usually or always.
Daily intake of fruits and vegetables and high-fat/high-
sugar foods was assessed using the Food Intake
Questionnaire,1 a laboratory-constructed, self-administered
food frequency questionnaire. This questionnaire lists 15
fruits, 18 vegetables, and 33 high-fat/high-sugar foods
along with the serving size for each food. Serving sizes
for fruits and vegetables were similar to the serving sizes
defined by Domel et al. (6) and met the fruit and
vegetable definitions of the Food Guide Pyramid (17);
serving sizes for high-fat/high-sugar foods were defined
using standard serving sizes (18). Participants circled
“Yes” if they ate the food that day and circled “Less” if
they ate less than the serving listed, “Equal” if the
amount listed was the exact amount that they consumed,
or “More” if the amount eaten was greater than the
serving listed. The questionnaires were handed out to
parents and children at the first treatment meeting and
returned by the parents at the second treatment meeting.
Parents completed the food questionnaire for themselves
and assisted their child by prompting the child’s recall.
Parents were instructed on how to prompt recall without
introducing demand bias of healthy eating. The question-
naire was completed for 3 days: 2 weekdays and 1
weekend day. All families were given a one-half cup
measuring cup to help with portion size estimation.
The Food Intake Questionnaire was validated for fruits
and vegetables and high-fat/high-sugar foods for 48 adult
subjects and 32 child subjects against 24-hour dietary
recalls administered by trained research personnel (a
registered dietitian and a master’s level nutritionist). The

percentage of agreement between the questionnaire and
the dietary recall for parents was 91.4% (k 5 0.66) for
fruits and vegetables and 89.4% (k 5 0.60) for high-fat/
high-sugar foods. The percentage of agreement between
the questionnaire and the dietary recall for children was
94.8% (k 5 0.69) for fruits and vegetables and 88.8%
(k 5 0.64) for high-fat/high-sugar foods. The mean
number of servings for parents estimated by the 24-hour
recalls and the questionnaire was 1.75 vs. 1.83 for fruits,
3.30 vs. 3.17 for vegetables, and 10.52 vs. 10.10 for high-
1 This questionnaire is available from the authors.
fat/high-sugar foods. Measured and estimated servings for
children were 1.73 vs. 1.82 for fruits, 1.29 vs. 1.27 for
vegetables, and 12.07 vs. 11.16 for high-fat/high-sugar
foods. The high levels of agreement and similar outcomes
of total number of servings between the recall and
questionnaire indicate an acceptable level of agreement
between the methods.
Psychological Measures.Parental control over child
eating was assessed with the older, short version of the
Child Feeding Questionnaire, a well-validated instrument
(19) that measures concern about child overweight,
parental control over food, and perception of parent
overweight (20). The range of scores for the concern
about child overweight scale is 3 to 21, and the range of
scores for parental control is 7 to 49. Scores for
perception of parent overweight are based partly on

parent weight, so there is a very broad range of scores for
this scale.
Socioeconomic Status.Socioeconomic status was
assessed using Hollingshead’s Four-Factor Index of Social
Status (21).
Statistical Analysis
Between-group differences at baseline were assessed
using t tests. Changes in dependent variables were estab-
lished separately for parents and children using mixed
ANOVAs with the between-subject factors of group (In-
crease Fruit and Vegetable/Decrease Fat and Sugar) and
a repeated measures within-subjects (0, 12) factor. Re-
siduals were plotted, and outliers were examined for their
contribution to the model; outliers were removed if they
exerted an undue influence on the probability levels. One
obese parent was an outlier for weight loss and intake and
was removed from all analyses. Predictors of change in
child and parent intake and percentage of overweight
were established using Pearson product-moment correla-
tion coefficients.
Results
Characteristics of Participants
Baseline values for subjects are shown in Table 1. No
differences between groups for any of the baseline values
were observed, except for more hypertension in families in
the Decrease Fat and Sugar group (p , 0.01). The average
participating parent was 65.7% overweight, with a cluster-
ing of obesity-related risk factors in the family. Every
family had at least one parent or grandparent with an obe-
sity-related risk factor. The parents were quite confident that
they could lose weight (4.16 0.9, mean6 SD) but less

confident that they could make eating (2.16 1.0) or activity
(2.1 6 1.1) changes. The parents were less confident that
they could help their children change their eating (1.86
0.9) or their activity (1.76 1.3) habits.
Evaluation of Treatment Effects
There were no differences in the number of sessions
attended by each group. Families in the Increase Fruit and
Vegetable group attended 11.5 of 14 (82%) sessions,
whereas those in the Decrease Fat and Sugar group attended
12.2 of 14 (87%) sessions. Table 2 shows parent and child
changes in servings of fruits and vegetables and high-fat/
high-sugar foods and percentage of overweight change.
Significance levels are presented for main effects of time
and for between-group differences in change over time. As
shown in Table 2, parents showed significant differences in
fruit and vegetable intake over time by group (F(1,23) 5
6.56; p , 0.025). High-fat/high-sugar intake showed a
significant decrease across groups over time (F(1,23) 5
45.70; p , 0.001). Children also showed significant be-
tween-group differences in fruit and vegetable intake over
time (F(1,24) 5 7.20; p 5 0.025) and significant changes in
high-fat/high-sugar food intake for both groups over time
(F(1,24) 5 18.14;p , 0.001).
Significant decreases over time were observed for the
Food Habits Questionnaire, with an average decrease of
20.6 for use of fat as a seasoning (F(1,23) 5 14.84; p ,
0.001) and an average decrease of20.31 for substituting
low-fat versions of high-fat foods (F(1,23) 5 7.09; p ,
0.025), while use of fruits increased by10.47 (F(1,23) 5
4.45; p , 0.05). A significant interaction of group by time
was observed for parent perception of being overweight on
the Child Feeding Questionnaire (F(1,23) 5 6.52;p , 0.25),

with parents in the Increase Fruit and Vegetable group
showing greater decreases (215.9) than parents in the
Decrease Fat and Sugar group (22.4). Nonsignificant
decreases in parent control over child eating (21.6)
were observed.
Parents showed significant differences in percentage of
overweight change by group (F(1,23) 5 5.64; p , 0.05),
while children showed a stable percentage of overweight
over time.
Correlational Analyses
Baseline parent high-fat/high-sugar intake was related to
high-fat/high-sugar changes (r 5 20.82; p , 0.001), and
baseline parent fruit and vegetable intake was related to fruit
and vegetable changes (r 5 20.45; p , 0.025). Baseline
child high-fat/high-sugar intake was related to high-fat/
high-sugar changes (r 5 20.82;p , 0.001). Baseline parent
and child fruit and vegetable intake was related (r 5 0.38;
p , 0.05). Parent changes in fruit and vegetable intake over
the year were related to changes in habits of eating fruit
(r 5 0.50; p , 0.001). Age and gender were not related to
child changes.
Discussion
The goal of this study was to evaluate the effects of
targeting increased fruit and vegetable intake versus de-

creased high-fat/high-sugar intake in parents on eating and
percentage of overweight, as well as the associated effects
of parent-initiated changes on fruit and vegetable intake and
Table 1. Baseline values for parent and child (mean6 SD)
Groups
Increase Fruit and Vegetable Decrease Fat and Sugar
Parent
Gender (males/females) 1/12 1/11
Age 39.16 4.1 42.26 4.8
Height (cm) 166.56 6.5 167.86 5.0
Weight (kg) 101.46 19.7 102.16 25.8
Percentage of overweight 68.46 23.4 67.36 42.8
Family history (number of immediate family members with)
Obesity 3.26 1.7 3.16 1.4
Hypertension 0.96 1.0 1.86 0.8
Hypercholesterolemia 1.46 1.3 1.06 1.2
Stroke 0.66 0.9 0.56 0.7
Diabetes 0.56 0.7 0.46 0.7
Risk of child obesity 44.66 20.3 45.06 22.0
Servings per day of fruits and vegetables and high-fat/high-
sugar intake
Fruits and vegetables 3.86 1.8 4.26 2.6
High-fat/high-sugar 12.86 6.7 12.66 7.6
Food habits
Meat 2.16 0.8 1.96 0.8
Fat as a seasoning 2.76 0.9 2.56 0.8
Replace high-fat foods 3.26 0.6 3.16 0.5
Substitute for high-fat foods 2.56 0.7 2.36 0.7
Eat fruits and vegetables 1.96 1.2 1.26 1.0

Child feeding questionnaire
Perception of child obesity risk 11.16 2.3 11.36 1.6
Perception of parent control 26.96 6.7 22.66 5.3
Perception of parent obesity 251.76 44.6 250.76 60.7
Confidence in making choices
Losing weight 4.36 0.5 3.86 1.1
Parent eating changes 2.16 1.0 2.46 1.0
Parent activity changes 1.86 0.9 2.56 1.3
Child eating changes 1.96 0.6 1.86 1.1
Child activity changes 1.76 1.1 1.86 1.5
Child
Gender (males/females) 6/7 3/10
Age 8.86 1.8 8.66 1.9
Height 132.46 9.8 131.36 11.6
Weight 31.26 5.4 30.86 8.2
Percentage of overweight 7.26 6.0 6.56 8.0
Servings per day of fruits and vegetables and high-fat/high-
sugar intake
Fruits and vegetables 2.86 1.5 3.26 1.6
High-fat/high-sugar 12.96 8.3 14.16 7.6
high-fat/high-sugar intake and percentage of overweight in
non-obese offspring. Results showed that fruit and vegeta-
ble intake was greater for parents in the Increase Fruit and
Vegetable group, and the reduction in high-fat/high-sugar
foods was greater for parents in the Reduce Fat and Sugar

group. The Increase Fruit and Vegetable intervention also
reduced high-fat/high-sugar intake, whereas the interven-
tion to Decrease Fat and Sugar was associated with no
changes in fruit and vegetable intake. The Food Habits
Questionnaire, which deals with patterns of food use rather
than the more specific measures of daily intake, showed
significant improvement over time for both groups in re-
ducing use of fat as a seasoning and substituting for high-fat
foods, while at the same time increasing use of fruit.
Children showed trends toward greater increases in fruit and
vegetable intake for the Increase Fruit and Vegetable group
through the 1 year of observation. High-fat/high-sugar food
intake significantly decreased across all children, independent
of group. These data are consistent with parent results, sug-
gesting that targeting fruit and vegetable intake in children
increases intake of nutritionally dense healthy foods while
simultaneously decreasing intake of low nutrient dense foods.
Targeting fruit and vegetable intake in an environment in
which parents were working on weight control was associated
with a reduction in the consumption of high-fat/high-sugar
foods, whereas targeting a reduction in dietary fat and sugar
did not improve fruit and vegetable intake.
There are a number of ways in which targeting an in-
crease in fruit and vegetable intake may modify eating
behavior. Interventions targeting intake of healthier alterna-
tives for low-nutrient dense foods may increase preference
for healthier foods (22). Increasing carbohydrate and fiber
intake by eating more fruits and vegetables may enhance
satiation, reducing caloric and fat intake (23,24). Families
who are working on increasing fruit and vegetable intake in
the context of parental weight control may shift their buying
habits of food, and in the attempt to maintain total food cost,
reduce storage of lower nutrient dense foods as healthier

foods are bought and consumed. Reducing access to high-
fat/high-sugar foods did not have the side effect of increas-
ing intake of fruits and vegetables in parents or children.
This may be because there are many substitute foods that
are available that may not improve fruit and vegetable
intake as high-fat/high-sugar foods are reduced. Reducing
access to specific high-fat and/or high-sugar foods may
simply result in a substitute of other highly palatable, but
less calorically dense foods (25).
Changes in fruit and vegetable intake were greatest for
those parents with the lowest initial levels, and reductions in
high-fat/high-sugar intake were greatest for those parents
and children with the highest initial levels. Thus, the inter-
ventions generally benefited those with poorer baseline
eating habits.
Percentage of overweight change was greater for par-
ents who targeted increases in fruit and vegetable intake
than reductions in high-fat/high-sugar intake. The main
contribution to weight control is a reduction in caloric
intake, and dietary restriction is needed to lose weight.
These results suggest that a differential focus on what can
be eaten versus what cannot be eaten may make it easier
to adhere to the caloric reductions needed for weight
control. The interventions were designed to improve
child eating habits and to prevent increases in the per-
centage of overweight in these high-risk children. The
interventions were successful in meeting this goal, and if
continued over time, the interventions might be useful in
preventing the development of obesity.
Table 2. Changes in servings per day of fruits and vegetables
and high-fat/high-sugar foods, and changes in
percentage of overweight over 12 months for parents and
children in the increase fruit and vegetable or decrease

fat and sugar groups (mean6 SD)
Groups Significance levels
Increase Fruit and Vegetable Decrease Fat and Sugar Time
Group X Time
Parent
Fruits and vegetables 3.416 3.47 20.236 3.66 0.035 0.017
High-fat/high-sugar 26.476 4.63 28.226 6.19 ,0.001 NS
Percentage of overweight 212.016 11.05 23.946 4.17 ,0.001
0.026
Child
Fruits and vegetables 0.726 1.11 20.556 1.31 NS 0.12
High-fat/high-sugar 24.506 7.97 28.506 7.58 ,0.001 NS
Percentage of overweight 21.106 5.29 22.406 5.39 NS NS
NS,not significant.
The present study suggests that reductions in high-fat/
high-sugar intake in children can be achieved by focusing
on parent change and providing materials for parent– child
use at home. This approach is particularly well-suited for
obesity prevention when the child is normal weight and
does not require caloric restriction. In addition, this inter-
vention is cost-effective because it can influence multiple
family members by treating only one parent. The use of
parent-only intervention has been tested in the treatment of
childhood obesity, with initial results suggesting that better

results are observed when parents rather than children are
treated (10,11).
This study is limited by the small sample size for a
treatment study. Subjects were recruited over a 2-year
period with newspaper advertisements, letters to pediatri-
cians, community lectures, and direct mailings to families in
a large managed-care organization. It was challenging to
recruit an adequate number of families with obese parents
and normal-weight children who were interested in prevent-
ing obesity. The majority of successful prevention trials
have been implemented in schools (26,27), not in clinical
settings. Clinical settings may be better suited to family-
based interventions that directly involve the parents in pre-
vention, but parents must become better informed about the
importance of prevention and not wait until an at-risk child
becomes obese before deciding that changes in family
health habits are needed.
There are several issues to consider when evaluating the
clinical utility of this intervention. First, the sample in-
cluded families with obesity and related cardiovascular risk
factors in parents and grandparents, and parents who were
concerned enough about preventing obesity in their off-
spring to enter a behavioral-change program. Parents who
are obese but have not yet experienced obesity-related dis-
ease in family members may be less motivated to participate
in an obesity prevention program. Second, the percentage of
overweight change for parents was significant over time, but
less than we have observed in previous studies in which
both parents and children are provided treatment (28,29).
Motivation for behavior change may be very different in
families in which the targeted child is obese and needs to
lose weight compared with families in which the targeted
child is non-obese, where the goal would be to prevent the
probable but not definite outcome of obesity. Finally, the

intervention targets only one family member and thus may
not benefit from interactions between family members that
support behavior change or changes in the shared family
environment that may enhance the treatment effects of
the parent.
This study has implications for the prevention of obesity
in non-obese children and perhaps for family-based inter-
vention for obese adults. Further tests of programs to en-
hance healthy eating rather than decrease unhealthy eating
are warranted. Because obesity often runs in families (8,30),
cost-effectiveness may be enhanced when multiple family
members benefit. The family-based model has demon-
strated positive treatment effects in untreated siblings over a
5-year interval (31), but further research is needed to eval-
uate family-based interventions that target and provide
treatment for multiple family members that are at-risk or
prone to obesity. Prevention of obesity in the child using the
same program that also treated obesity in an obese parent
would represent a powerful and cost-benefit intervention.
Acknowledgments
This study was funded in part by National Institutes of
Health Grant HD34284 (to L.H.E.).
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Childhood Obesity: The Health Issue
Richard J. Deckelbaum and Christine L. Williams
Abstract
DECKELBAUM, RICHARD, AND CHRISTINE L.
WILLIAMS. Childhood obesity: the health issue.Obes Res.
2001;9:239S–243S.

Overweight and obesity in children is epidemic in North
America and internationally. Approximately 22 million
children under 5 years of age are overweight across the
world. In the United States, the number of overweight
children and adolescents has doubled in the last two to three
decades, and similar doubling rates are being observed
worldwide, including in developing countries and regions
where an increase in Westernization of behavioral and di-
etary lifestyles is evident. Comorbidities associated with
obesity and overweight are similar in children as in the adult
population. Elevated blood pressure, dyslipidemia, and a
higher prevalence of factors associated with insulin resis-
tance and type 2 diabetes appear as frequent comorbidities
in the overweight and obese pediatric population. In some
populations, type 2 diabetes is now the dominant form of
diabetes in children and adolescents. Disturbingly, obesity
in childhood, particularly in adolescence, is a key predictor
for obesity in adulthood. Moreover, morbidity and mortality
in the adult population is increased in individuals who were
overweight in adolescence, even if they lose the extra
weight during adulthood. Although the cause of obesity in
children is similar to that of adults (i.e., more energy in vs.
energy utilized), emerging data suggest associations be-
tween the influence of maternal and fetal factors during
intrauterine growth and growth during the first year of life,
on risk of later development of adult obesity and its comor-
bidities. In addition, recent data suggest that varying
biological responses in different racial/ethnic groups differ-
ently contribute to overweight, obesity, and their comor-
bidities. Although differences in gene–nutrient interactions
may contribute, the role of varying cultural and socioeco-
nomic variables still needs to be determined to understand
these disparities. Novel approaches in the prevention and
treatment of childhood overweight and obesity are urgently
required. With the strong evidence that a lifecycle perspec-

tive is important in obesity development and its conse-
quences, consideration must be focused on prevention of
obesity in women of child-bearing age, excessive weight
gain during pregnancy, and the role of breast-feeding in reduc-
ing later obesity in children and adults. Consideration must be
given to family behavior patterns, diet after weaning, and
the use of new methods of information dissemination to
help reduce the impact of childhood obesity worldwide.
Key words: pediatric obesity, adolescent obesity, obesity
comorbidity
Introduction
Overweight and obesity are independent risk factors for
increased morbidity and mortality throughout the lifecycle.
For example, overweight and obesity in women are predic-
tors of gestational diabetes during pregnancy and newborns
with excessive birth weight (1). High birth weight is a
predictor of overweight and obesity in adulthood and in
cofactors associated with insulin resistance (2). In parallel
with the worldwide increases in obesity prevalence, over-
weight and obesity in children are rising (3). Because obe-
sity in childhood frequently tracks into adulthood, increases
in childhood overweight and obesity clearly are major con-
tributors to the adult obesity epidemic (4). Children express
the same comorbidities that are associated with being over-
weight and obese as adults (4,5). Thus, being overweight
during childhood brings with it comorbidities that will in-
crease the duration of comorbidities in an individual by one
to two decades, a factor that can increase the impact of a
number of risk factors on adult diseases. In this article we
review the increasing prevalence of childhood overweight
and obesity, the impact of obesity in terms of a lifecycle
perspective, comorbidities expressed in childhood obesity,
and emerging evidence for different racial/ethnic responses

to biological contributors to obesity. Potential approaches to
fighting the obesity epidemic beginning in the childhood
years are discussed.
Department of Pediatrics and the Institute of Human Nutrition,
Columbia University, New
York, New York.
Address correspondence to Dr. Richard Deckelbaum, Institute
of Human Nutrition, PH
15-1512E, Columbia University, 630 West 168th Street, New
York, NY 10032.
E-mail: [email protected]
Copyright © 2001 NAASO
OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001 239S
Increasing Prevalence of Childhood Obesity
The increase in obesity prevalence has been observed in
the United States and internationally from pre-schoolchil-
dren to adolescence. These increases have been noted in all
racial and ethnic groups, but some groups are affected more
than others. In the United States, the National Health and
Nutrition Surveys (NHANES) databases offer alarming sta-
tistics showing substantial increases in the prevalences of
overweight [defined as the 85th to 95th percentiles of the
weight for length growth references; (5)]. At present, nearly
8% of children 4 to 5 years of age in the United States are
overweight. Whereas, in general, the increases in prevalence
cross the entire pediatric population, girls have been more
affected than boys. Between the NHANES I and NHANES
III surveys, a period of 20 years, prevalence for overweight
and obesity in young girls has increased more than 2-fold,
whereas that of boys increased less,;25%. However, in

children older than 6 years of age, and particularly in
adolescence, there has been an approximate doubling of
obesity prevalence in boys as well as in girls in the United
States in the same time (5).
Ethnicity differences are also apparent by varying rates of
increase. For boys and girls, overweight is highest in Mex-
ican American children, intermediate among non-Hispanic
black children, and lowest in non-Hispanic white children.
In examining what can be defined as the overweight group
in childhood (i.e., above the 85th percentile cutoff), nearly
22% of pre-schoolchildren in the United States can be
defined as overweight and 10% as obese. This compares
with 18.6% and 8.5%, respectively, in 1983. In the Bogalusa
Heart Study in Louisiana, the prevalence of overweight
among 5- to 24-year-olds from the biracial community
increased;2-fold between 1973 and 1994. Of particular
concern is that the yearly increases and relative weight and
obesity during the latter part of the study (1983 to 1994)
were;50% greater than those between 1973 and 1982 (6).
In addition, independent of racial/ethnic differences, lower
socioeconomic status is another important predictor for high
overweight and obesity prevalence in U.S. children (5).
Similar disturbing trends in increasing obesity prevalence
are being recorded in other industrialized settings. For ex-
ample, in Japan the frequency of obese schoolchildren be-
tween the ages of 6 and 14 years increased from 5% to 10%
and that of extremely obese children from 1% to 2% be-
tween 1974 and 1993 (3). Childhood obesity is not limited
to the industrialized countries. In a recent review, De Onis
and Blössner (7) reported rapidly increasing prevalence of
overweight and obesity among pre-schoolchildren in devel-
oping countries. Of interest, certain countries demonstrated
high percentages of overweight at the same time as high
frequencies of wasted (malnourished) children were also

measured. Specific examples include Northern Africa,
where the percentage of overweight children exceeded 8%
and wasted children were reported at over 7%. Similarly, in
Eastern Asia, 4.3% of pre-schoolchildren were overweight
and 3.4% wasted. In South America, where malnutrition
and underweight were once predominant, the percentage of
overweight pre-schoolchildren was close to 5%, but wasted
children were now only 1.8%. In a number of countries
(e.g., Egypt, Argentina, Malawi, Nigeria, Uzbekistan, Peru,
Qatar, South Africa, Jamaica), the percentage of overweight
children exceeds that of the United States. In 38 countries
where secular data are available, 16 showed a rising trend in
obesity prevalence over time, 14 were static, and only 8
showed falling rates in obesity prevalence. Rates of increase
seem most marked in countries of Northern Africa, such
as Morocco and Egypt, as well in some countries of the
Caribbean and South America (7). Thus, obesity in chil-
dren can no longer be classified as a Western problem
alone; it is now shared by nearly all industrialized areas
and many developing countries.
Overweight and Obesity in Children Predicts
Overweight Later in Life
Data from a number of studies provide strong evidence
that higher levels of body mass index (BMI) during child-
hood can predict overweight later in life. This was recently
summarized in a review by Goran (8). Data from four
longitudinal studies were reviewed and showed that the
probability of overweight at 35 years of age for children
with BMI in the 85th to 95th percentiles increased with
increasing age. The prediction for adult weight was most
accurate for BMI at 18 years of age with accuracy decreas-
ing for BMI below 13 years of age. Goran (8) concluded
that the “persistence of pediatric obesity into adulthood

increases according to the age at which obesity is initially
present.” Similar to what has been recorded in North Amer-
ica, obesity during childhood in Japan is associated with
increased likelihood of obesity during adulthood. In a Jap-
anese study, approximately one-third of obese children
grew into obese adults (9). Whitaker et al. (10) found that
the risk of adult obesity was greater in both obese and
non-obese children if at least one parent was overweight.
This effect was most pronounced in children that were,10
years old; over the age of 10 years, the child’s own over-
weight/obesity status was a better predictor than having an
obese parent. These studies show the importance of the
family environment in contributing to the increasing prev-
alence of obesity. Most likely these increases are associated
with changes (increases) in food supply and caloric intake
accompanied by diminishing levels of physical activity.
One might consider that these family studies provide strong
evidence for the genetic contribution to obesity. However, it
is very unlikely that changing gene pools can explain the
doubling or even tripling of obesity prevalence rates in
certain groups over 20 years; too short a period to affect the
genetic background in affected populations.
Childhood Obesity, Deckelbaum and Williams
240S OBESITY RESEARCH Vol. 9 Suppl. 4 November 2001
Must et al. (11) presented data relating to the outcomes of
overweight adolescents who were followed up to 50 years.
Both men and women who were overweight at adolescence
had increased age-specific morbidity and mortality relating
to cardiovascular and other chronic diseases. Increased risk
was also present even if adolescents who were obese had
lost the excess weight during the adult period (11), suggest-

ing that obesity during adolescence may set triggers that are
associated with adverse risk in the adult.
An emerging area of research is the potential role of
intrauterine growth and growth in the first year of life for
predicting the emergence of increased cardiovascular risk
and obesity during adulthood. These potential links were
critically commented on by Dietz and Gortmaker (4). In
reviewing the Dutch Famine Studies, they noted that indi-
viduals who were exposed in utero to famine in the first
trimester of pregnancy were more likely to be overweight at
18 years of age compared with those exposed to famine at
other periods during pregnancy. In contrast, individuals
exposed to famine late in pregnancy tended to be under-
weight at 18 years of age. Although low birth weight and
low weight gain in the first year of life may contribute to
increased risk of hypertension, dyslipidemia, and cardiovas-
cular risk in the adult population, Dietz and Gortmaker
conclude that it is unlikely that low birth weight contributes
significantly to obesity prevalence in the adult population.
In addition, although an individual who is born overweight
($4000 g) does have a higher risk of being an overweight
adult, these authors suggest that,5% of adult obesity is
attributable to individuals born with high birth weights.
Comorbidities of Childhood Obesity
Obesity-associated chronic disease risk factors are
present in adults and also manifest in overweight and obese
children. For example, data from the Bogalusa Heart Study
showed that;60% of overweight 5- to 10-year-old children
had one cardiovascular risk factor, such as high blood
pressure, hyperlipidemia, or elevated insulin levels (12).
From the same cohort of 5- to 10-year-olds,.20% of
overweight children had two or more cardiovascular risk
factors (12)—risk factors that would increase substantially

the risk of these individuals for earlier cardiovascular dis-
ease if they were tracked into adulthood.
Similar to adults, children who are moderately over-
weight showed that an elevation of low-density lipoprotein
(LDL) cholesterol levels and hypercholesterolemia does not
increase substantially with higher degrees of obesity. With
more marked degrees of obesity, rises in plasma triglyceride
levels and decreases of high-density lipoprotein cholesterol
are more common, and blood pressure elevations are more
common with significant obesity than with moderate over-
weight, similar to what occurs in adults.
With the rising prevalence of overweight and obesity in
children, noninsulin-dependent diabetes mellitus (type 2
diabetes) is increasingly a pediatrician’s problem. In one
report (13), 4% of new diagnoses of diabetes before 1992
were classified as type 2 diabetes. In 1994, 16% of new
diabetics were classified as type 2, a 4-fold increase. In
the Cincinnati area between 1982 and 1994, there was a
10-fold increase in type 2 diabetes in children and the
African American population was more severely affected
than the white population (13).
Alarming findings are now emerging from Asian coun-
tries that are rapidly Westernizing their lifestyle habits. For
example, in urban Japanese children, plasma total choles-
terol levels and LDL cholesterol now exceed those found in
U.S. children (14). A recent analysis examining differences
between the Japanese and American pediatric populations
suggests that dietary habits, exercise, and adiposity differ-
ences do not explain the varying lipid levels between U.S.
and Japanese children. The hypothesis was raised that the
populations not previously exposed to Western diets and
lifestyles may have more adverse effects on expression of

cardiovascular risk factors than long-exposed populations
(14). In Japanese children, overweight and obesity are also
associated with substantial elevations of plasma total and
LDL cholesterol levels and type 2 diabetes, and in some
areas of Japan, type 2 diabetes is more common in children
now than type 1 diabetes (15).
Other comorbidities are also associated with childhood
obesity. These include orthopedic problems, such as
Blount’s disease, skin fungal infections, and acanthosis
nigracans, hepatic steatosis and steato-hepatitis; pseudotu-
mor cerebri; and psychological and behavioral problems.
Psychological problems associated with childhood obesity
include negative self-esteem, withdrawal from interaction
with peers, depression, anxiety, and the feeling of chronic
rejection (5). Thus, a strong body of evidence suggests that
BMI in childhood is associated with various adverse bio-
chemical, physiological, and psychological effects, many of
which have the possibility of tracking into chronic disease
risk factors in adulthood.
There are different biological effects related to over-
weight and obesity in different racial/ethnic groups. Evi-
dence is available to suggest that aerobic capacity may be
lower in African American than in white children and may
be more significant than energy expenditure leading to
obesity (8). Goran (8) concluded that fasting insulin and
acute insulin response are significantly higher, and insu-
lin sensitivity is significantly lower in African American
than in white prepubertal children; these differences are
not explained by differences in body fat, body fat distri-
bution, diet, or physical activity. These findings are im-
portant because they suggest that prevention and treat-
ment strategies may require different approaches in
different racial/ethnic populations.

Although hereditability estimates of genetic population
studies suggest that 40% to 70% of adult obesity is due to
genetic factors, there is little information available yet in
pediatric populations. Nevertheless, statistics show that a
proportionate variance within adult populations is ac-
counted for by genetic factors, but this does not reflect the
interplay between genes and environment at the individual
level, and especially within the developing individual.
Prevention/Treatment of Childhood Obesity
Increase in energy intake and decrease in physical activ-
ity are the primary environmental influences on childhood
obesity, similar to adult obesity. In 45 minutes of exercise,
a 165-kg (75-lb) child may be expected to expend 90, 525,
135, and 180 calories during continuous bicycling, running,
walking, and dancing, respectively. These expenditures can
be contrasted to the difference of a regular size McDonald’s
meal, which provides;600 calories vs. a super-sized Mc-
Donald’s double cheeseburger meal, which provides.1800
calories. Note that the calories expended in the exercises
above do not nearly cover this difference. In approaching
childhood obesity, we can consider three levels of preven-
tion: primordial prevention, which aims toward maintaining
normal BMI throughout childhood and adolescence; pri-
mary prevention, directed toward preventing overweight
children (BMI: 85th to 95th percentiles) from becoming
obese; and secondary prevention, to treat obese children
(BMI . 95%) to reduce comorbidities and reverse over-

weight and obesity, if possible (5). Clearly, there is a need
to balance energy intake with energy output and to intro-
duce activity in place of inactivity. In obesity prevention,
an emphasis on plant-based foods and vegetable and fruit
consumption would be a major step forward in avoiding
energy-dense foods.
At different stages of development, we suggest the fol-
lowing components for obesity prevention:
● Perinatal: supply good prenatal nutrition and health care,
avoid excessive maternal weight increase, control diabe-
tes, help mothers lose weight postpartum, and offer
nutrition education.
● Infancy: encourage increased breast-feeding and contin-
uous breastfeeding to$6 months of age, delay introduc-
tion of solid foods until after 6 months of age, provide a
balanced diet and avoid excess high-calorie snacks, and
follow weight increase closely.
● Preschool: provide early experiences with foods and fla-
vors, help develop healthy food preferences, encourage
appropriate parental feeding practices, monitor rate of
weight increases to prevent early adiposity rebound, and
provide child and parent nutrition education.
● Childhood: monitor weight increase for height (slow
down if excessive), avoid excessive prepubertal adipos-
ity, supply nutrition education, and encourage daily
physical activity.
● Adolescence: prevent excess weight increase after growth
spurt, maintain healthy nutrition as the next generation of
parents, and continue daily physical activity.

For children who are significantly overweight, the goal
should be to reduce severity of obesity and to treat, reduce,
and eliminate comorbidities (e.g., hypertension, dyslipide-
mia, insulin resistance, and type 2 diabetes). For energy
balance, measures are needed for children to lose weight or
to slow down the rate of gain and to grow into their
expected heights. This requires some reduction in energy
intake and substantial increases in energy expenditure.
In summary, childhood obesity is increasing at epidemic
rates, even among pre-schoolchildren and is accompanied
by significant comorbidities and health problems. Preven-
tion should be the primary goal and, if successful, will help
reduce adult obesity. Accordingly, we will have the greatest
chance to successfully reverse the obesity epidemic if we
consider it a crisis, make it a funded government and public
health priority, and join forces across disciplines to mount
an effective public health campaign in the prevention and
early treatment.
Acknowledgments
This work was supported in part by NIH grant no.
HL50321.
References
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