The first step toward choosing the appropriate treatment strategy is assessment. This is based on precisely measured height and weight and calculation of body mass index (BMI). Next, determine the child's gender- and age-specific BMI percentile and mark it on the child's personal growth chart. Compare it to previous years to see if a trend is emerging. Although you can expect some variation, the child's growth should be tracking, or following a certain percentile, reasonably well over time. Then, use the gender- and age-specific BMI percentile to determine the child's current weight category and to choose the appropriate treatment strategy, as shown in the table below. An explanation of the treatment strategies for the different weight categories follows this table.

BMI Percentile	Category	Treatment Strategy
< 5th Percentile	Underweight	Professional monitoring (especially important if there is a downward trend)
5th to 84th Percentile	Normal weight	Prevention and at least yearly assessment of BMI percentile
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, then to Comprehensive Multidisciplinary Intervention after 3-6 months if no improvement. Goal is to maintain weight with growth of child until BMI is < 85th percentile. If weight loss occurs, it should be gradual, and no more than 1 pound per month. (See note)
99th Percentile or higher	Obese	Prevention Plus; advance to Structured Weight Management after 3-6 months if no improvement; advance to Comprehensive Multidisciplinary Intervention after 3-6 months if medically warranted and/or if parental obesity present. Advancement to Tertiary Care Interventions (TCI) may be warranted if medical conditions are present. Weight loss should be gradual; excessive weight loss should be evaluated further by health care provider. (See note)

Note: The treatment report ² states 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. The dietary goal should be provision of a balanced diet consisting of wholesome foods in amounts that provide calories appropriate for age and adequate for normal growth. If the child has a history of overeating, these dietary changes could produce weight loss. Should that occur, the rate of loss should be monitored closely to insure it does not exceed one pound per month. If weight loss exceeds 2 pounds/week, health care provider should evaluate further for causes of excessive weight loss.

Treatment strategies by weight category:

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 are discussed in detail in the prevention report.³ They 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 (lean meats, eggs, fish, poultry and low fat or fat free dairy) 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): More frequent professional monitoring of weight status and lifestyle of these children is needed (every 3-6 months), 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. Thus, family readiness to change must be assessed. If the family is ready, 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. (Note: A child who steadily tracks in this range, i.e., no upward trend in BMI percentile, and has no medical or family risks is likely to be at low risk for excess fat. This child can remain on the regular prevention strategy that applies to normal weight children.)

Obese (95th - 98th percentile): Treatment strategy is similar to that for overweight children described above, but monthly follow up with assessments is recommended. If progress is not made after 3-6 months, conduct family assessment of readiness to change (see prevention report³) and move to SWM if the family is ready. Greater support, increased structure of daily routine for both healthy eating and exercise, and greater oversight of eating and activity to insure compliance is recommended. Reinforcement for achieving behavioral goals is suggested. Lack of improvement may warrant advancement to Comprehensive Multidisciplinary Intervention (CMI).

Obese (99th percentile or higher): 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 to improve home environment, 5.) specific diet and activity interventions that result in negative energy balance (i.e., calories expended exceed calories consumed) while safeguarding nutritional quality.

Tertiary Care Intervention (TCI) is usually not warranted in this age group. These children are too young to understand the possible risks and lack the maturity to responsibly engage in treatment that involves meal replacements, very-low-energy diets, medications or bariatric surgery. The treatment report² provides more details. In closing, it should be noted that the scientific evidence on the recommended components of treatment of children in this age group is of variable quality. The schema presented in the treatment report is a responsible one that is based on the best evidence we currently have. It is likely that the guidelines for children in this age category will be refined and strengthened as the science advances.

Where It All Begins
For most children, physical activity begins with exploring movement in their home surroundings, involvement in a play group and, finally, in a school setting. In providing a quality physical education program, physical education professionals are guided by certain documents from the National Association for Sport and Physical Education (NASPE), including Appropriate Practices (NASPE 2000), Moving Into the Future: National Standards for Physical Education, 2nd edition (NASPE 2004) and NASPE's Report Card How Does Your Program Rate?

Here, we highlight some of the key components of these documents as they relate to children's involvement in physical activity. The ultimate purpose of any physical education program is to guide children toward being physically active for a lifetime. To do that, it should:

• Educate children through a variety of developmentally appropriate practices
• Build students' competency in fundamental motor skills and movement concepts
• Promote involvement in physical activity outside the school setting
• Provide children of all abilities and interests with a foundation of movement experiences
• Understand that children are not miniature adults and that they need age-appropriate, developmental experiences

Where It Can Run Off Course
Even the best-intentioned physical education or out-of-school programs can sometimes run off course. Teachers, parents, administrators, coaches and recreation specialists all have the potential to use poor practices that include:

• Approaching certain physical activities as gender-specific (e.g., girls with dance, boys with football)
• Limiting exposure to only mainstream-sport skills and activities (e.g., baseball, cheering, basketball, football)
• Failing to offer a well-rounded skill and activity set that covers all facets of an appropriate program: locomotor, non-locomotor, throwing, catching, striking, qualities of movement, manipulatives, educational gymnastics, dance and rhythms, etc.
• Failing to expose children to various cultural physical activities (e.g., cricket, folk dance)
• Failing to model a physically active lifestyle for children that is both diverse and varied in skills and activities
• Pigeon-holing children into one or two physical activities because of success at an early age
• Emphasizing one or two activities throughout the year and introducing adult skill sets (either in or out of school) that are not age-appropriate

Motivating Our Children to a Lifetime of Physical Activity
What motivates children to involve themselves in physical activity — and remain involved — is what motivates them to take up any activity, whether it's academics, arts, music or theater. Children want choices! They want the ability to select activities that make them feel good about themselves, can be implemented easily, and are appealing.

Kids want rhythms, dance, traditional activities, alternative activities, and activities that emulate their parents' activity options. They want recreational sports activities: kayaking, canoeing, karate, hiking, surfing, curling, fencing, cycling, winter sports, etc. Most important, they crave activities in which they feel competent, that contribute to their well-being, and are fun and enriching! Just ask them!

How Do We Accomplish That?
Here are some ways that parents, teachers and coaches can offer children the variety in physical activity that they crave:

• Take student-interest surveys at all levels (even youth sports)
• Take your children on a physical activity field trip in your community
• Include a variety of physical activities as a main component of every vacation
• Emphasize a family component to exercise and physical activity, to embed physical activity into their lives
• Take a seasonal approach to youth sports by switching sports from season to season and taking off at least one of the seasons. Devote the off-season to inquiry-based movement (playing games and backyard sports)
• Ask your child what physical activities s/he would like to explore, and provide a fun atmosphere for introducing those activities
• Explore the many avenues by which your children can remain active: recreation programs, family trips to state parks and recreation providers, a home environment that allows for safe physical activity, and involvement in youth sports

One of the main reasons that adults end their involvement with physical activity is lack of variety. Often, that stems from a limited skill set. Keep your children active by offering a multifaceted skill and activity experience that places the emphasis on fun.

The guidelines offer a roadmap to help Americans easily fit physical activity into their daily routine. There is clear evidence that regular physical activity yields long-term health benefits and reduces the risk of many diseases. It lowers the risk of early death in adults, and reduces the risk of heart disease, stroke, high blood pressure, type 2 diabetes, colon and breast cancer, and depression.

Physical activity can help older adults improve their ability to think and do activities needed for daily living. Children and adolescents also benefit from getting recommended amounts of physical activity, since it improves cardiorespiratory fitness, muscular fitness and bone health, and contributes to a healthy body composition.

The key guidelines by group are:

Children and Adolescents:

• One hour or more of moderate or vigorous aerobic physical activity daily, including vigorous intensity physical activity at least 3 days a week.
  Moderate intensity aerobic activities include hiking, skateboarding, bicycle riding and brisk walking. Vigorous intensity aerobic activities include jumping rope, running, and playing sports like soccer, basketball and ice or field hockey.
  
• Muscle-strengthening activities, such as rope climbing, sit-ups, and tug-of war 3 days a week.
• Bone-strengthening activities, such as jumping rope, running and skipping 3 days a week.

Adults:

• For health benefits, 2½ hours a week of moderate intensity aerobic activity, or 1¼ hours a week of vigorous physical activity.
  Moderate intensity aerobic activities include brisk walking, water aerobics, ballroom dancing and general gardening. Vigorous intensity aerobic activities include racewalking, jogging or running, swimming laps, jumping rope and hiking uphill or with a heavy backpack.
  
• Aerobic activity should be done in at least 10 minute segments.
• For greater health benefits, increase aerobic activity to 5 hours a week of moderate intensity or 2½ hours a week of vigorous intensity aerobic activity.
• Muscle strengthening activities, such as weight training, push-ups, sit-ups, carrying heavy loads or heavy gardening, at least two days a week.

Older adults:

• Follow guidelines for other adults if physically able. If a chronic condition prohibits following the guidelines as recommended, be as physically active as abilities and conditions allow.
• If at risk of falling, do exercises that maintain or improve balance.

Women during pregnancy:

• If healthy, at least 2½ hours moderate intensity aerobic activity a week during pregnancy and the time after delivery, preferably spread through the week.
• Those who regularly do vigorous aerobic activity or are highly active can continue during pregnancy and the time after delivery, provided they remain healthy and discuss with their health care provider how and when activity should be adjusted over time.

Adults with disabilities:

• At least 2½ hours of moderate aerobic activity a week, or 1¼ hours of vigorous aerobic activity a week, if able to do so.
• Muscle-strengthening activities involving all major muscle groups 2 or more days a week.
• If unable to meet the guidelines, do regular physical activity according to abilities and avoid inactivity.

People with chronic medical conditions:

• Regular physical activity yields important health benefits, so do it with the guidance of a health care provider.
  
  For more information, go to Physical Activity Guidelines for Americans.

In January 2008, we began a "Biggest Loser" contest at my job. We each put $5 into the pot twice a month and weighed each week. The person who lost the most by the first of June got the pot. I won by losing 25 pounds. My job has quite a bit of walking and in addition I went to the YMCA twice a week to the Strive room — a circle of strength building equipment. Since the first of June, I have continued my healthy eating and Strive and lost another 10 pounds. My blood pressure medication has been decreased by 2/3 and I am no longer taking any medication for my arthritis. I'm 64 years old and feeling great.

Shape Up America! wants to hear about you! If you would like to share your personal success story and be an inspiration to others who desire to lose weight, simply use our story submission system on the SUA Web site.

INGREDIENTS:

• 1/2 cup olive oil
• 1/4 cup red wine vinegar (Kids can experiment with other kinds of vinegar such as rice vinegar, cider vinegar or balsamic vinegar.)
• 1 heaping tsp. Dijon mustard
• 2 tsp. sugar (Kids can try other sweeteners such as jelly, honey or ketchup.)
• 1 peeled clove fresh garlic
• Salt and freshly ground pepper, to taste

DIRECTIONS:

1. In a clean jar, add oil, vinegar, mustard and sugar.
2. Mash garlic clove through a garlic press and add directly into the dressing. Add salt and pepper.
3. Put lid on jar. Shake jar for 1 minute or until all ingredients are thoroughly mixed. Serve over salad or vegetables and toss well so dressing coats vegetables.

Nutritional analysis per serving: 40 calories, 4.5 grams total fat, 0.5 gram saturated fat, 0 grams trans fat, 0 milligrams cholesterol, 0 grams carbohydrate, 0 grams protein, 54 milligrams sodium.