Assessment of children was covered in the July 2008 issue of this newsletter and in detail in reference 1. The following briefly summarizes the recommended treatment of very young children ages 2 to 5. Treatment recommendations for older children will be covered in subsequent issues.

Obesity in very young children is becoming increasingly common, especially in families where one or both parents is obese.⁴ Correct assessment depends on the gender- and age-specific BMI percentile of the child, which will, with certain additional factors, determine the treatment strategy. There are three stages to the treatment strategy for overweight children 2 to 5 years old: 1.) Prevention Plus (healthy lifestyle changes), 2.) Structured Weight Management, 3.) Comprehensive Multidisciplinary Intervention.

This table summarizes the expert committee recommendations on treatment of overweight and obesity in children ages 2 to 5 years:

BMI Percentile	Category	Treatment Strategy or Path
5th Percentile or less	Underweight	Professional monitoring
5th to 84th Percentile	Normal	Prevention and at least yearly assessment
85th to 94th Percentile	Overweight	Prevention Plus; advance to Structured Weight Management after 3-6 months if BMI percentile increasing, is medically warranted and/or if parental obesity present. Goal is to maintain weight with growth of child until BMI is < 85th percentile
95th to 98th Percentile	Obese	Prevention Plus; advance to Structured Weight Management after 3-6 months if no improvement. Goal is to maintain weight with growth of child until BMI is < 85th percentile (See note)
99th Percentile or higher	Obese	Prevention Plus; advance to Structured Weight Management after 3-6 months if no improvement, then advance to Comprehensive Multidisciplinary Intervention after 3-6 months if medically warranted and/or if parental obesity present. (See note)

Note: The expert committee treatment recommendations ² for 2 to 5 year olds state that should weight loss occur as a consequence of treatment of obese children, it should not be greater than one pound per month. The author and Shape Up America! do NOT advocate weight loss per se in children so young. Our interpretation of what is intended here is that a change in diet that offers wholesome foods in amounts that provide calories appropriate for age and that are adequate for normal growth may prevent overeating and, hence, produce weight loss. Should that occur, the rate of loss should be monitored closely to ensure it does not exceed one pound per month.

Each of the weight categories in the table above points to a different treatment strategy. A brief overview of the basic components of each are provided below. The information is organized by the weight categories identified in the table.

Underweight: Children who are underweight should be evaluated by a qualified health care professional. Although it can be expected that some very thin children are perfectly normal, to be on the safe side, professional evaluation of children at the 5th percentile or below is needed to rule out the possibility of failure to thrive as a consequence of medical or developmental problems that should be addressed.

Normal weight: The growth pattern of normal weight children should be monitored by assessing them yearly and plotting BMI on the child's growth chart. Although BMI percentile will vary from year to year, annual updating of the child's growth charts permits detection of an unusually large change in BMI that may signal unhealthy weight gain (or loss). Prevention: Strategies to prevent unhealthy/excessive weight gain in normal weight children include playing and being physically active for 60 minutes or more per day; limiting TV and other sedentary recreation to no more than 2 hours per day; removing TV from the bedroom; eating 5 or more servings of fruits and vegetables per day plus other healthful foods needed for growth; limiting or eliminating soda, pop or other sugar-sweetened beverages and fruit drinks; limiting eating out; starting each day with a healthy breakfast; having regular meals and activities that involve the whole family.

Overweight (85th-94th percentile) and Obese (95th-98th percentile): More frequent professional monitoring of these children is needed, particularly if medical issues or parental obesity are present; this is referred to as Prevention Plus. To the basic Prevention strategies described above, Structured Weight Management (SWM) may be added that targets the entire family rather than the child. SWM involves structured daily meals and snacks that emphasize healthful foods that are low in calories yet high in nutritional quality. Further reductions in daily TV and sedentary recreation to no more than 1 hour per day may be needed. It is helpful to keep a diary of daily physical activity, and foods with amounts consumed at home and when eating out, including fast foods, snacks, candy, and sweetened drinks. These diaries should be monitored by a qualified health care professional, usually a registered dietitian (RD), but sometimes a physician or nurse practitioner with appropriate training. The emphasis is on healthy lifestyle change for the entire family.

Obese (99th percentile): For these children, in addition to the above treatment strategies, a Comprehensive Multidisciplinary Intervention (CMI) strategy may be warranted. The five components of CMI are: 1.) parent/caregiver involvement, 2.) assessment of family and child lifestyle and BMI (or body fat) at regular intervals, 3.) behavioral change plan that includes goal setting and training in anticipating challenges and problem solving, 4.) parent/caregiver and family training, 5.) specific diet and activity interventions that result in negative energy balance (i.e., calories expended exceed calories consumed) while safeguarding nutritional quality.

High risk interventions such as meal replacements, very-low-energy diet, medications or bariatric surgery are not warranted in children as young as 2 to 5 years old. More details are available in reference 2.

In closing, it should be noted that the scientific evidence on the various recommended components of treatment of children this young is scanty or nonexistent. The purpose of the treatment guidelines is "to offer practical guidance" including recommendations "that lack the best possible evidence."² Where evidence was lacking, the committee considered other factors such as clinical experience, the likelihood of harm and benefit, and the feasibility of implementation. In our judgment, this is a responsible and helpful step toward the effective treatment of childhood obesity and one that will, hopefully, be followed by annual or bi-annual refinements as the science advances.

New parents can get ideas for how to do this by reading Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years, a booklet by the National Association for Sport and Physical Education (NASPE). The document revolves around the notion that all children birth to age five should engage in daily physical activity that promotes health-related fitness and movement skills. Many parents view childhood activity as a given, rather than understanding the very important role they personally play in nurturing activity appropriately during key developmental stages in a child's life. Active Start is divided into recommendations for three key categories: infants, ages birth to 12 months of age; toddlers, ages 12 to 36 months old; and preschoolers, ages three to five years.

There are five guidelines for each of these age groups, with each guideline addressing the what, where and who of physical activity for infants, toddlers and preschoolers. Thus, the guidelines address the kind of physical activity most appropriate for infants and young children, the environment for the physical activity, and the individuals responsible for facilitating the physical activity.

Beginning with infants, parents and caregivers should take every opportunity to play a variety of baby games such as peek-a-boo and pat-a-cake. With increased opportunity for exploration and learning, toddlers will develop basic movement skills such as running, jumping, throwing and kicking. Parents and caregivers should encourage physical activities that foster creativity and imagination. As a child enters the preschool years, children should be encouraged to practice movement skills in a variety of activities and settings. Instruction and positive reinforcement is critical during this time in order to ensure that children develop most of these skills before entering school.

More structured play experiences for toddlers, which introduce a variety of movement skills, expose children to a wide variety of possibilities. Simple toys that encourage movement play, such as balls, FrisbeeŽ and hula hoops, are great staples that the whole family can play with together. Toddlers and preschoolers should engage in at least 60 minutes and up to several hours daily of unstructured play activity, and should not be sedentary for more than 60 minutes at a time except when sleeping. If a child is to value physical activity as s/he grows, it is important to explore all kinds of activities, so that your child finds several fun preferences that s/he will enjoy and incorporate into daily play.

The extent to which family members, parents and caregivers serve as role models, and are themselves physically active, can influence the child's urge to move and explore her/his surroundings. Interactive play with safe toys that encourage movement are a great start for infants. Toys that encourage toddlers to move, and promote unstructured, exploratory play go a long way to encourage physical activity, as they roll, push, ride, balance and climb their way into an active lifestyle.

To assist parents on a daily basis, NASPE publishes an early childhood physical activity calendar on its NASPE's Teacher Toolbox webpage. A new calendar is available each month for parents to download and use as a guide for active play with their toddler or pre-school child. Physical activity calendars are also available for elementary and secondary-aged children.

Active Start: A Statement of Physical Activity Guidelines for Children Birth to Five Years is available for purchase online. The next time you're selecting a gift for new parents, consider including a copy, to help get that child off to their own active start.

The Truman Award is presented by Independence, MO, the hometown of the former President, to an American with the qualities personified by Truman. As it happens, these two great men, both of whom dedicated their lives to their country and to public service, have a great deal in common. Here are a few vignettes illustrating why we owe them a tribute.

Truman was Vice President for only a few months when President Roosevelt died and Truman became President in 1945. He ran for re-election in 1948 and to the surprise of famous pollsters and the media, he won. As President, Truman faced one crisis after another, including the decision to drop the atomic bomb on Japan, the establishment of the Marshall Plan to rebuild post-war Europe, the precarious balance of power with the Soviets and the Berlin airlift, the establishment of NATO and the United Nations, and the start of the Korean War.

Truman was 60 when he became president, yet his youthful appearance, energy and vitality were legendary. He endured unrelenting stress and a grueling work schedule but took it all in stride. A non-smoker, Truman took a brisk two-mile walk "most every morning" and enjoyed an occasional swim. He was known to take an ounce or two of bourbon each day and his personal diary contained a description of his typical diet:

I eat no bread but one piece of toast at breakfast, no butter, no sugar, no sweets. Usually have fruit, one egg, a strip of bacon and half a glass of skimmed milk for breakfast; liver and bacon or sweet breads or ham or fish and spinach and another non-fattening vegetable for lunch with fruit for dessert. For dinner I have a fruit cup, steak, a couple of non-fattening vegetables and an ice, orange, pineapple or raspberry… So — I maintain my waist line and can wear suits bought in 1935.¹

During the Truman presidency, the White House literally started to collapse and the Truman family had to move out while an extensive renovation was undertaken. One day Truman visited General Glen E. Edgerton, the engineer in charge of the renovation, in his office in a "shack" on the White House lawn and noticed a framed poem written for Edgerton by a plumbing contractor named Reuben Anderson:

Every man's a would be sportsman, in the dreams of his intent,
A potential out-of-doors man when his thoughts are pleasure bent.
But he mostly puts the idea off, for the things that must be done,
And doesn't get his outing till his outing days are gone.
So in hurry, scurry, worry, work, his living days are spent,
And he does his final camping in a low green tent.²

Possibly influenced by this poem, it was around this period that Truman decided not to run again in the 1952 presidential election. Instead he enjoyed his "retirement" by working 12 hour days, traveling to Europe with his wife, writing his memoirs, and overseeing the design and building of the Truman Library and Museum in Independence, MO. He died in 1972 at the age of 88.

Dr. Koop never knew Harry Truman, but a copy of Dr. Koop's remarks upon receiving the Truman Award includes the following:

"…people used the same words to describe Truman and me when we first assumed office. One of the phrases that comes to mind is "uniquely unqualified." But I think we both proved our critics wrong. The people who yelled, "Give 'em hell, Harry!" said to me, "Sock it to 'em, Doc!"³

Like Truman, Dr. Koop has chosen to work long days in his "retirement" and he continues to play an active role promoting the health of our nation — speaking out on smoking, HIV-AIDS, obesity and other public health issues. On the occasion of Dr. Koop's upcoming birthday (October 14), this is an opportune moment to acknowledge his industry, eloquence and great spirit as a spokesman for the public health community, and to thank him for his many years of dedicated service. Keep sockin' it to 'em, Doc!

INGREDIENTS:

• 1/2 cup all-purpose flour
• 1/2 cup whole wheat flour
• 2 teaspoons baking powder
• 1 tablespoon sugar
• 1/4 teaspoon ground nutmeg
• 2/3 cup 1% milk
• 1 medium ripe banana, mashed
• 1 tablespoon vegetable oil
• 1 egg, lightly beaten

DIRECTIONS:

1. Combine all-purpose and whole wheat flours, baking powder, sugar, and nutmeg in a large bowl; stir well.
2. Whisk together milk, banana, oil and egg.
3. Add wet ingredients to dry and stir until smooth.
4. Heat non-stick griddle or skillet. Spoon about 1/4 cup of batter per pancake onto pan. Turn pancakes when tops are covered with bubbles and edges begin to look cooked.

Nutritional analysis per serving: 210 calories, 6 grams total fat, 1 gram saturated fat, 0 grams trans fat, 55 grams cholesterol, 35 grams carbohydrate, 7 grams protein, 3 grams dietary fiber, 230 milligrams sodium.

Source: Shape Up America!