Reducing Childhood Obesity

The challenge of childhood obesity is significantly different, some argue, from the challenge of adult obesity. Children don’t have the power over their lives, decisions, and lifestyles that adults have (parents and adults make many decisions for them and have the power to enforce certain behaviors).

Social institutions have more impact on kids than on adults (like church, YMCA, and especially school — including school lunch programs, mandatory gym classes, possible nutritional education, etc.).

Finally, there is the fact that kids are less set in their ways than adults, so it’s easier to change their behaviors and teach them new concepts. The number of obese children has just passed 17% and continues to grow. What is the full range of underlying causes for this trend and which combined causes are chiefly responsible?

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Meet the Challenge Team

The Challenge Team Members are leaders in their fields and reflect multi-disciplinary, passionate and thoughtful perspectives for the Challenge they represent.
Challenge Team members participate in the discussion held by the Great Challenges community, and will be creating responses to questions submitted by the community on the discussion tab.

  - look for this icon throughout the Great Challenges discussions. It is used to identify comments posted by the Challenge Team members.

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Larry Cohen, MSW
Founder & Executive Director, Prevention Institute
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Larry Cohen is founder and Executive Director of Prevention Institute, a national nonprofit center that has helped to shape the way that the country thinks about health and prevention: improving community conditions and taking action to build resilience and to prevent illness and injury before they occur. At Prevention Institute Larry has helped to advance a deeper understanding of how social and community factors and the design of communities shape health and equity outcomes. With an emphasis on health equity, Larry leads public health efforts at the local, state, and federal level on injury and violence prevention, mental health, transportation and health, and food and physical activity-related chronic disease prevention. He has developed resources, conceptual frameworks and tools and provides training nationally and internationally to build the capacity of communities to plan and implement comprehensive, collaborative efforts focused on policy and environmental change in order improve health and safety. Prevention Institute has also successfully lead state and national efforts to incorporate a focus on and investment in primary prevention as a significant part of health care reform and stimulus funding for communities.

As a public health advocate, I have learned that preventing illness and injury before it occurs is far better than trying to treat it later. I have worked for decades to help cities ban smoking, encourage healthy eating and exercise, and treat violence as a preventable public health issue. I believe that to have an impact in creating healthy communities, we need to work in partnership to develop comprehensive approaches that lead to policy change. I believe we need to reframe issues of diet and activity to focus on community change and corporate and government—not just personal—responsibility.

Larry Cohen, MSW
Founder & Executive Director, Prevention Institute
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Christina Economos, PhD
Vice-Chair and Director, ChildObesity180 
Associate Professor, Friedman School of Nutrition Science and Policy at Tufts University
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Christina Economos, Ph.D., is the Associate Director of the John Hancock Research Center on Physical Activity, Nutrition, and Obesity Prevention, the New Balance Chair in Childhood Nutrition, and an Associate Professor at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at the Tufts University School of Medicine. 

Dr. Economos is the Vice-Chair and Director of ChildObesity180, an organization which provides a politically neutral point of engagement; creates connections among leaders and organizations; and utilizes the best available evidence to power up a portfolio of key initiatives to deliver accelerated, amplified impact to improve the health of the nation’s children.

She is forging new research methods in the area of childhood obesity prevention, which has led to new public policy aimed at improving children’s health. Dr. Economos is the principal investigator of multiple large-scale studies at Tufts University examining childhood nutrition and physical activity with the goal of inspiring behavior, policy, and environmental change to improve the health of America’s children. She currently serves as an appointed member of the Institute of Medicine’s Standing Committee on Childhood Obesity, and previously served on the institute’s Committee on an Evidence Framework for Obesity Prevention Decision-Making (2008-2010) and Accelerating Progress on Obesity Prevention (2010-2012). Dr. Economos currently chairs the Public Policy committee for the American Society of Nutrition.

Public health efforts are often conducted in silos, with different sectors working in parallel and never fully harnessing the true potential of their collective work. As a researcher of childhood nutrition and director of a multi-sector organization dedicated to reversing the trend of childhood obesity, my work takes a systems approach to understand how we can improve children’s environments to support healthy eating and physical activity. Past successes have demonstrated that policy, programmatic, and environmental changes at all levels of society can help children to achieve and maintain a healthy weight, despite the environmental factors working against them. Working together across sectors, we can amplify the effect of our efforts and create real change for children, families, and communities. As a mother, my hope is to make the healthy environment the norm so I can witness the impact first hand.

Christina Economos, PhD
Vice-Chair and Director, ChildObesity180 
Associate Professor, Friedman School of Nutrition Science and Policy at Tufts University
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Melissa Halas-Liang, MA, RD, CDE
Founder, SuperKids Nutrition Inc.
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Melissa Halas-Liang is a nationally recognized nutrition educator, registered dietitian, certified diabetes educator, and wellness expert. She is a spokesperson for the California Dietetic Association and has over 15 years of experience in nutrition throughout the lifecycle, teaching, curriculum development, clinical/critical care, nutrition management, counseling, media and writing. Mrs. Halas-Liang holds an M.A. in Nutrition Education, Certificate of Training in Childhood and Adolescent Weight Management, and is a certified Wellness Coach.

In 2006, Mrs. Halas-Liang founded SuperKids Nutrition, Inc. (www.superkidsnutrition.com) to “save the world one healthy food at a timeTM” and help prevent and reduce childhood obesity. Through SuperKids Nutrition, she provides fun nutrition articles, resources, learning activities and newsletters to thousands of schools in over 40 states and motivates children, families and educators to actualize a healthy lifestyle. She is the creator of the Super Crew® characters, a cast of relatable superhero kids who acquire special powers through eating healthy, colorful foods. In her children’s books, SuperKids Nutrition websiteblogFacebook page and Twitter she offers innovative tips and tools for living healthfully. 

Mrs. Halas-Liang “practices what she preaches” by living a healthy lifestyle daily.” She believes good nutrition plays a vital role in spiritual, physical and mental health.

When I began working as a clinical dietitian, I saw patient after patient living with debilitating chronic diseases, often resulting from obesity. I witnessed the lack of knowledge these patients had about the etiology of their conditions. I often heard that they were “living and eating as they had since childhood” without understanding the ramifications of obesity, poor diet and lack of exercise. When I became a mother I saw how other mothers were unknowingly promoting these same disease-laden habits to their children. I was inspired to create SuperKids Nutrition, with a mission to end childhood obesity and promote a healthy lifestyle by making nutrition and exercise education exciting and engaging for children and families.

Melissa Halas-Liang, MA, RD, CDE
Founder, SuperKids Nutrition Inc.
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Elaine Kolish
Vice President and Director, Children's Food and Beverage Advertising Initiative, Better Business Bureau
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Ms. Kolish is Vice President & Director of the Children's Food and Beverage Advertising Initiative, Council of Better Business Bureaus (BBB) and is a nationally recognized expert on advertising and consumer-protection issues. 

Prior to joining BBB in 2006, Ms. Kolish was a partner at the national law firm now called SNR Denton, where she specialized in counseling national advertisers on advertising law compliance. From 1980 until 2005, Ms. Kolish was an attorney at the Federal Trade Commission. There, she was a member of the Senior Executive Service and head of the Division of Enforcement in the Bureau of Consumer Protection. She led numerous national advertising cases and rulemaking proceedings. She also oversaw the Bureau's regulatory review efforts, as well as a number of other key policy initiatives including the Class Action Fairness Monitoring Project and the Hispanic consumer-protection program. 

Ms. Kolish was an editor of the ABA’s Antitrust Section treatise on consumer protection law. She currently serves as a member of the Board of United Community Ministries, a secular non-profit that provides services to needy families in Northern Virginia.

She is a graduate of the University of Massachusetts, Amherst and graduated magna cum laude from Western New England College School of Law. 

I approach the childhood obesity challenge from the perspective that advertising self-regulation is an important  part of the solution. As a former  Federal Trade Commission  official and, now, the Director of BBB’s Children’s Beverage and Advertising Initiative, I’ve designed and enforced both regulatory and voluntary approaches to tackling complex issues. At the CFBAI, I work with  leading consumer packaged goods companies and quick-serve restaurants to  implement an Institute of Medicine (IOM) and FTC-inspired mission for self-regulation to help address childhood obesity by shifting child-directed advertising to healthier products.  Self-regulation both brings advantages and has challenges in addressing problems requiring multi-faceted solutions.

Elaine Kolish
Vice President and Director, Children's Food and Beverage Advertising Initiative, Better Business Bureau
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David Ludwig, MD, PhD
Director, New Balance Foundation Obesity Prevention Center Boston Children’s Hospital
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David S. Ludwig, M.D., Ph.D, is a practicing pediatrician and researcher at Boston Children’s Hospital. He is also Professor of Pediatrics at Harvard Medical School and Professor of Nutrition at Harvard School of Public Health, Director of the New Balance Foundation Obesity Prevention Center Boston Children’s Hospital (the Center), and Founding Director of the Optimal Weight for Life (OWL) program, one of the country’s oldest and largest multidisciplinary clinics for the care of overweight children and now part of the Center. His research focuses on the effects of diet on hormones, metabolism and body weight. In particular, he developed a novel “low glycemic” diet (i.e., one that decreases the surge in blood sugar after meals) for the treatment of obesity and prevention of type 2 diabetes and heart disease. This work has been cited as providing a scientific basis for numerous popular diets, including The South Beach Diet, The Zone, SugarBusters and The Glucose Revolution. Described as an “obesity warrior” by Time magazine, Dr. Ludwig has fought for fundamental policy changes to restrict food advertising directed at young children, improve quality of school nutrition programs, and increase insurance reimbursement for obesity prevention and treatment programs. Dr. Ludwig is a fellow of The Obesity Society and recipient of the E.V. McCollum Award (2008) of the American Society for Nutrition. He is Principal Investigator on numerous grants from the National Institutes of Health, has published over 100 scientific articles and presently serves as Contributing Writer for JAMA. Dr. Ludwig is the author of a book on childhood obesity for parents titled Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/Fake Food World (Houghton Mifflin, 2007). He appears frequently in national print and broadcast media.

With 20 years’ experience in obesity research and clinical care, the team at the New Balance Foundation Obesity Prevention Center Boston Children’s Hospital knows that the causes of the childhood obesity epidemic are many. For that reason, the solution will require a comprehensive, multi-disciplinary approach integrating research, patient care, education, community intervention and public policy. Ultimately, we must create a social environment that aligns biology and behavior, making maintenance of a healthful weight easier for everyone, and especially children. As home to the Optimal Weight for Life Program, one of the country’s oldest and largest pediatric obesity programs, the Center is committed to joining forces with partners throughout the country in the battle to protect childhood from obesity-related diseases.

David Ludwig, MD, PhD
Director, New Balance Foundation Obesity Prevention Center Boston Children’s Hospital
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Ernie Medina
Co-founder and CEO, MedPlay Technologies
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Co-founder and Chief Executive Officer of MedPlay Technologies, Dr. Medina first became interested in pediatric obesity working as a preventive care specialist at Beaver Medical Group, where he has been since 1993. Focusing on lifestyle medicine for all ages, he focuses on weight management, smoking cessation, and stress management. It is here where he put together his first pediatric obesity program called “Family Fit.”

Because of Dr. Medina’s interest in kids, he is always on the lookout for new and innovative ways to get kids moving. First introduced to the idea of “exergaming” or “active gaming” in 1998, Dr. Medina, through MedPlay Technologies, has been networking and researching in this new field in order to grow its use in healthcare. This has led to the belief that exergaming provides a unique intervention that overcomes many of the obstacles faced with promoting physical activity to kids.

Dr. Medina is a certified health and fitness instructor by the American College of Sports Medicine. He is also the former Executive Director of the American Preventive Care Association, is an Assistant Clinical Professor at Loma Linda University’s School of Public Health, and an intern preceptor for California State University of San Bernardino.

As a lifestyle medicine specialist working with both adults and children for the last 20 years, I’ve had the chance to experience what works and doesn’t work when it comes to dealing with the pediatric obesity challenge. Having a unique degree allows me to think outside-of-the-box in approaching obstacles. Being a parent myself gives me a personal perspective to what my patients and clients face on a daily basis. Finally, being described as a “big kid” who enjoys playing with them at their level provides another unique view that can be helpful in coming up with new solutions.

Ernie Medina
Co-founder and CEO, MedPlay Technologies
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Barbara Moore, PhD
President and CEO, Shape Up America!
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Dr. Barbara J. Moore is president and CEO of Shape Up America!, a national campaign founded by former U.S. Surgeon General C. Everett Koop in 1994. 

Dr. Moore served on the Institute of Medicine (IOM) Committee on Prevention of Obesity in Children and Youth, which produced the landmark 2005 report Preventing Childhood Obesity: Health in the Balance. She is a member of The Obesity Society and the American Society for Nutrition.

Before joining Shape Up America! in 1995, Dr. Moore served on the staff of the National Institutes of Health Division of Nutrition Research Coordination (DNRC). In 1993 and 1995, Dr. Moore served in the White House Office of Science and Technology Policy (OSTP). From 1989 to 1993, she was chief nutritionist and head of program development for Weight Watchers International. 

Receiving her M.S. and Ph.D. in nutritional science from Columbia University Institute of Human Nutrition (IHN), Dr. Moore has four years of postdoctoral training in nutrition and physiology at the University of California Davis. She was appointed a Henry Rutgers Fellow at Rutgers University (1987-1989) and holds a B.A. from Skidmore College.

My own struggle with obesity during my young adulthood stimulated an interest in nutrition and the desire to acquire my doctorate and post-doctoral training in the field. After more than 10 years in obesity research, I left academia to manage program development for Weight Watchers International. I acquired federal government policy experience at the NIH as well as the Office of Science and Technology Policy in Washington, DC. At the state level, I worked for the Montana Nutrition and Physical Activity Program to address the growing problem of obesity in rural America.

Barbara Moore, PhD
President and CEO, Shape Up America!

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Challenge Team Perspectives

We selected 10 questions out of the many submitted by our Great Challenges Community, to be addressed by each of our Team members.
See their responses and perspectives, below.

Question 1

What are the top 10 causes of obesity in children and which ones can be reduced or prevented?
Response from Barbara Moore, PhD

Throughout most of human history, corpulence has been viewed positively -- as a sign of prosperity or social status, good health, and a protective buffer against illness or injury. Current understanding that obesity is actually linked to increased risk for disease and premature death was developed relatively recently, over several decades in the 20th century. Research linking obesity -- a body mass index* or BMI of 30 kg/m2 or higher -- to illness and early mortality was conducted by the Metropolitan Life Insurance Company in the 1950s through the 1970s. But these studies focused on adults, not children. The growing prevalence of obesity among American children is a new and ominous development as it sets up these kids for social and economic underachievement and a lifetime of struggle with their weight. It also predisposes them to social ostracism and ill health.
There is no single factor responsible for the development of obesity in children or adults. Rather, many factors favor the accumulation of excess fat, but the contribution of each factor is small and difficult to measure. Consequently, it is the identification of all factors that favor positive energy balance (consumption of excess calories beyond physiological needs) and the accumulation of fat that is the appropriate focus of our efforts to stem obesity. A few of these factors will be discussed.
From a practical standpoint, there are only two avenues to weight control that an individual can influence-how much one consumes (i.e., food and drink) and how much physical activity one engages in. These are referred to as the "Big Two." The environment, broadly defined to include the family, the community, schools, the marketplace, the built environment, and the entire cultural and socioeconomic context in which a child lives, can profoundly influence the Big Two.

Taste, Food Palatability, Energy Density and Overconsumption
The food industry is well aware that the single most important driver of food selection and consumption is taste. The taste and palatability of a new food product will be carefully tested on members of the market segment for whom the food is intended - including children. The WHO has identified palatability as "one of the most powerful influences" on feeding behavior, which acts by increasing the rate of eating, as well as the sense of hunger during and between meals.1
A major contributor to the palatability of food is fat, which provides a pleasant "mouth feel" (as in ice cream) and is an excellent carrier for flavors. But fat contains more than twice as many calories per gram as either carbohydrate or protein, and fat is therefore a major contributor to the energy density of foods, even as it contributes to their enhanced palatability. This may be a factor favoring positive energy balance, because, if an energy-dense food is consumed quickly, a large number of calories can be consumed before satiety has a chance to develop and the meal is terminated.2 ,3
A particularly palatable combination is fat and sugar, such as found in cupcakes, butter cookies, fudge, and so on. Combinations of fat and sugar are highly appealing to humans.2 Savory snack foods are formulated as highly palatable combinations of fat and salt that interact with taste receptors on the tongue and stimulate neural signals to the brain that "feed forward" to encourage further consumption. This feed forward concept is succinctly captured in the advertising slogan for a popular snack chip: "Bet you can't eat just one!"

Fruit and Vegetable Consumption
Fruits and vegetables deliver a high concentration of nutrients and with few exceptions, they are quite low in calories. Fruits and vegetables are the opposite of energy dense foods such as cakes, cookies, etc. that are typically low in nutrients but high in calories. For this reason, considerable effort is now being invested in promoting fruit and vegetable consumption as an important strategy for insuring sound nutrition and combating obesity.

Sugar-Sweetened Soft Drinks and Soda
Few studies have been correctly designed to directly test whether reductions in soda consumption would lower body mass index or BMI of young people. Nonetheless, research is continuing and the evidence is mounting.4 ,5 ,6 ,7 As mentioned earlier, it is unrealistic to think that a single positive change in diet will solve the problem of obesity in children. Nonetheless, the evidence available today suggests that reduction or elimination of sugar-sweetened soda is not harmful and may well be helpful.
Supersizing and Portion Control
Researchers have documented the increasing portion sizes offered on a routine basis to American consumers, including children.8 Portion size is one of the many external cues that encourage overeating and favor a positive energy balance.9 Although infants are born with the ability to self-regulate their food intake, somewhere between the ages of 3 and 5 that ability can be over-ridden by the presentation of large portion sizes, which will encourage them to eat, even in the absence of hunger.10
Supersizing is a marketing strategy that offers a highly attractive "added value"-a larger quantity of a tasty and convenient food or meal-for little or no incremental cost. Supersizing of candy bars, lollipops, sodas and many other products intended for kids has occurred over the past 30 years - the same period that has witnessed a dramatic increase in childhood obesity. The same phenomenon has occurred in fast food restaurants frequented by children. The parent or teen sees the supersized portion of food as a "good value" because the cost increment is negligible. Hence, the supersized portion appeals on a rational economic basis-because it is a bargain-as well as from a taste perspective. Supersized menu choices appeal to consumers in many important ways: (1) the taste of the food is carefully crafted to appeal to children and adults alike through the strategic combinations of fat, salt, and sugar; (2) the economic value of supersized portions is appealing to those on a restricted food budget and to those who appreciate good value regardless of their budgetary constraints; and (3) the convenience of such restaurants, many of which have drive-up window service or a home delivery service that eliminates virtually all of the time and trouble associated with planning, shopping, preparing, and cleaning up after meals.

The Drive for Convenience
Eating out is considered more convenient than preparing home-cooked meals, yet the latter are typically lower in calories. Factors contributing to the drive for convenience are (1) the "parental time famine."11 that leaves little time for meal planning, shopping, preparation, and clean up; (2) marketing that casts cooking as a drudgery, and presents purchased meals as easier, cheaper and tastier than what can be made at home; (3) parental attitudes that each family member should be able to choose when and what to eat; and (4) cultural changes that have promoted TV time and TV dinners over family time and the family dinner.12

Physical Activity
Physical activity exerts a powerful influence on the physiological regulation of body weight. Physical activity boosts energy expenditure and favors weight loss by burning calories and, if sustained, it preferentially burns fat. This fat burning effect occurs as a training effect13 so it applies to young athletes who are vigorously active on a regular basis.
The lives of American children are more sedentary today than 20 years ago.14 ,15 To avoid excessive weight gain (note that because they are growing, weight gain in children is expected and healthy, but excessive weight gain is not) these reduced levels of physical activity represents a physiological challenge. To avoid obesity, children must regulate their body weight at a lower level of energy (calorie) intake - and this may not be possible at least for some children. Since the maintenance of a healthy body weight appears to be facilitated by high levels of vigorous, rather than moderate, activity in children,16 promoting vigorous physical activity in youth may be viewed as a critical refinement of public health messages and strategies targeting obesity in youth.

Breastfeeding
The American Academy of Pediatrics recommends exclusive breastfeeding -- that means feeding nothing but human breast milk for the first 6 months of life, followed by "continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant."17
Data collected on children born in 2005 show that the rates of exclusive breastfeeding at 6 months of age are very low.18 Across all racial and ethnic groups fewer than 14% of babies are breastfed exclusively for 6 months. Among blacks - it is only 6% -- and in American Indian/Alaska Natives - fewer than 8%.18 From the perspective of obesity, breastfeeding - especially exclusive breastfeeding - not only offers optimal nutrition for the child, but it also contributes to the goal of optimizing growth and preventing the accumulation of excess body fat in the infant. Milk production is energetically expensive so it mobilizes maternal body fat, helping the mother regain her prepregnancy body weight. It also helps to stem maternal weight gain between pregnancies. All of these factors help reduce the risk of childhood obesity in the offspring of these mothers in subsequent pregnancies. Thus, breastfeeding should be recognized as one strategy that operates in multiple ways to prevent childhood obesity.19

Monitoring the Growth of Children
The American Academy of Pediatrics is now calling for the routine measurement of height and weight of children in order to calculate the age- and sex-specific BMI percentile. This system is used to track the growth of children over time and to identify children who are failing to thrive (which is increasingly uncommon) and children whose growth trajectory suggests that obesity is developing. Accurate measurement of height and weight is imperative and should be undertaken only by properly trained health care professionals. Whether it is performed by the school nurse or in a clinic or doctor's office, monitoring the growth of children is a key strategy for identifying children who are at risk for obesity and offers an opportunity for intervention before the problem is too severe. Obesity that persists into the adolescent years is notoriously difficult to treat and is associated with adult obesity. So routine monitoring of the growth of infants, toddlers, preschoolers and pre-teens is of critical importance in any serious effort to stem and reverse the prevalence of childhood obesity.

Targets for Obesity Prevention Efforts
The Centers for Disease Control and Prevention (CDC) funds a number of states to address obesity. Montana, the state I live in, is one of the states funded by the CDC and I have worked with the Montana obesity program for several years. The priorities identified by the CDC can be summarized as follows:

  1. Reducing consumption of "energy dense" or high-calorie foods, especially foods of low nutritional value
  2. Reducing consumption of sugar-sweetened beverages
  3. Increasing consumption of fruits and vegetables
  4. Increasing the initiation and duration of breastfeeding, with exclusive breastfeeding for the first 6 months
  5. Reducing sedentary leisure-time pursuits such as television, movies, computers, and video games
  6. Increasing physical activity, and I would add, promoting vigorous physical activity in children

Conclusion
In addition to those identified above, researchers are studying a number of other factors that are likely to be very important for preventing childhood obesity. Examples include establishing regular routines at home such as insuring children get sufficient sleep (usually an average of 10.5 hours each night), family meals prepared and consumed at home, and authoritative rather than neglectful or authoritarian parenting styles. Evidence is emerging that the existence of parental obesity is associated with the development of obesity in their children, and this effect is stronger if parental obesity is more severe.
Reports in the media suggest that rates of childhood obesity are slowing in several states and cities throughout the United States.20 Although scientific verification of these reports is needed, these improvements are attributed to policy changes such as setting stricter nutritional standards for foods and beverages served and sold in schools, including those sold in school vending machines, and some states are adopting policies requiring more physical activity time in schools. But experts are quick to point out that significant declines in the prevalence of childhood obesity have yet to be reported and will undoubtedly require broader initiatives targeting the many factors discussed above. Reversing childhood obesity must involve concerted efforts on the part of all of us, including parents, children, educators, health care professionals, the media, political leaders and policymakers. As I have said in the past, it takes a nation to prevent childhood obesity.

 

* Obesity in adults is defined in terms of body mass index (referred to as BMI), which involves a calculation of weight (expressed in kilograms) divided by the square of height (expressed in meters), in other words, kg/m2. Using this system, adults with a BMI of 30 kg/m2 or higher would be classified as obese. This system works reasonably well in a sedentary population but will misclassify elite athletes such as football players and body builders whose weight is elevated because of a high muscle mass.

1World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation on Obesity. Geneva: World Health Organization Technical Report Series 2000;894:1-253.

2Drewnowski A. Human preference for sugar and fat. In: Fernstrom JD, Miller GD, eds. Appetite and body weight regulation: sugar, fat and macronutrient substitutes. Boca Raton, FL, CRC Press, 1994:137-147.

3Prentice AM, Jebb SA. Obesity in Britain: gluttony or sloth? BMJ 1995;311:437-9.

4James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328:1237. Internet: doi:10.1136/bmj.38077.458438.EE

5Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006;117:673-680

6Ebbeling CG, Feldman HA, Chomitz VR, Antonelli TA, Gortmaker SL, Osganian SK, Ludwig DS. A randomized trial of sugar-sweetened beverages and adolescent body weight. NEJM Sept 21, 2012 DOI:10.1056/NEJMoa1203388

7deRuyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. NEJM Sept 21, 2012; DOI:10.1056/NEJMoa1203034

8Nestle M. Increasing portion sizes in American diets: More calories, more obesity. J Am Diet Assoc 2003;103(1):39-40.

9Wansink B, Payne CR, Chandon P. Internal and external cues of meal cessation: the French paradox redux? Obesity 2007 Dec;15(12):2920-4.

10Rolls BJ, Engell D, Birch LL. Serving portion size influences 5-year old but not 3 year old children's food intakes. J Am Diet Assoc 2000;100(2):232-234.

11Hewlett SA,West C. The War Against Parents. Houghton Mifflin,1999.

12Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120:S193-S228.

13Hurley BF, Nemeth PM, Martin WH 3rd, Hagberg JM, Dalsky GP, Holloszy JO. Muscle triglyceride utilization during exercise: effect of training. J Appl Physiol 1986;60(2):562-7.

14Dietz WH Jr, Gortmaker SL. Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics 1985;75(5):807-812.

15Dietz WH. The role of lifestyle in health: the epidemiology and consequences of inactivity. Proc Nutr Soc 1996;55(3):829-840.

16Gutin B, Yin Z, Humphries M, Barbeau P. Relations of moderate and vigorous physical activity to fitness and fatness in adolescents. Am J Clin Nutr 2005;81:746-750.

17American Academy of Pediatrics. See: http://pediatrics.aappublications.org/content/129/3/e827.short

18U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Women's Health USA 2009. Rockville, Maryland: U.S. Department of Health and Human Services, 2009

19Kral J, Kava RA, Catalano P, Moore BJ. Severe Obesity: The Neglected Epidemic. Obes Facts 2012 Apr 25;5(2):254-269

20Hellmich N. Childhood obesity declines in several states, cities. USA Today Oct 24, 2012.


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