From her post behind the cafeteria lines at John Hopkins Middle School in St. Petersburg for the past three years, Willa Roberts was often struck by the fried and greasy foods students piled on their trays.
Pizza. Riblets. French fries. Chicken nuggets.
The staff made salads, but few picked them.
And each year, it seemed, the children got bigger.
Now, Mrs. Roberts is eyeing the foods her family eats. Her youngest boy, Antonio, is overweight, and she and her husband want to make sure he controls the problem before it becomes even harder to do so.
That has meant changing what they eat, at times reluctantly. It has meant taking extra care to be good role models, mom's Oreo cravings aside. It has meant pushing Antonio, 11, to eat less and play outside more.
It has not been easy. She and other parents helping their children battle fat say they could use more help from schools, government and organized programs.
"They advertise that a lot of Americans are overweight, but are they doing anything about it? I haven't seen anything," Mrs. Roberts said.
With up to 1 in 5 American children, and half of all adults, considered overweight or obese, fat now rivals smoking as the nation's top health scourge.
Public health officials and physicians recognize the problem, and several recent studies have measured its heft and pervasiveness, especially among black, Hispanic and poor children.
From a public health standpoint, however, little has been accomplished. Parents and pediatricians are frustrated. Consider:
Unlike other public health threats, such as AIDS, smoking and drugs, the federal government has offered little in the way of a cohesive message. Information is scattered among various health agencies.
Although top officials say obesity has become a top health risk, as yet there is no national strategy for reducing it.
Health insurance typically does not pay for weight-loss programs, nutrition counseling or obesity prevention, even though it does pay to treat diseases likely to arise from obesity.
The medical community has yet to reach consensus on the best ways to confront the issue, as it has with other pediatric health issues such as car seats, bike helmets and immunization.
Parents of overweight children say some physicians wait too long before talking action. Other doctors are more aggressive, suggesting counseling, strict diets and regimented exercise early on.
Parents also complain of a shortage of affordable programs for kids, especially when so many exist for adults. Denise Adams of St. Petersburg, whose 11-year-old son, Clayton, is 30 pounds overweight, recalled how his pediatrician recently suggested he join a swim team for regular exercise.
"I said, "You've got to understand that if Clayton joined a swim team, what would happen when all the other kids showed up in their little Speedos?' " Adams said. "There's nothing out there for him, and that understands him.
"He's not that bad overweight, but he struggles with it. He's going to spend his whole childhood on a diet."
Maintaining a healthy weight has always been the responsibility of the family or individual, and experts acknowledge turning weight into a public health issue may be challenging. And, unlike for children with other health problems, sympathy for heavy kids is lacking, parents say.
But the consequences of a nation of overweight children will far exceed their personal torment: Obesity is expected to lead to 300,000 deaths and cost more than $100-billion this year, the U.S. Centers for Disease Control and Prevention says.
Only smoking causes more preventable deaths.
"Unfortunately, I think for a lot of people the epidemic slipped up on us," U.S. Surgeon General David Satcher told the Times. "If we don't mount a very aggressive campaign now against overweight and obesity in children, we're going to pay a tremendous price."
At least 70 percent of overweight children will be overweight adults, studies show, putting them at greater risk for a variety of diseases. Type II diabetes, once solely the scourge of overweight adults, now accounts for up to one-third of new cases at many pediatric diabetes centers, the American Diabetes Association says.
Dr. Dennis M. Styne, an expert on childhood obesity at the University of California-Davis, warned his colleagues in the American Academy of Family Physicians that "a nationwide population-based approach to the prevention of childhood obesity is essential.
"Increasing physical activity and practical nutritional knowledge through education in schools or through extracurricular programs should be an obvious first step that may require legislative action."
That was in 1999, in a editorial accompanying a startling report in American Family Physician that found severe obesity among children had almost doubled in the past 20 years. But little has changed.
"The problem is, we haven't been able to give a consolidated, meaningful message," said Dr. Francine R. Kaufman, an obesity expert at Children's Hospital Los Angeles and president-elect of the American Diabetes Association, which has made obesity in youth a priority.
"Sure pediatricians say, "Lose weight, eat less,' but we don't have programs universally available to put these people into," Kaufman said.
"To ask the front-line doc to do something, verbally, is easy enough, but where's the follow through?"
It's not just about food
Experts can't explain why some children get fat and others don't, or why some kids eat more than others. It is common for obese children to have thin siblings, and Dr. Frank B. Diamond, who has treated overweight kids at All Children's Hospital for 25 years, believes most moms who say their slim and chubby kids eat the same foods and get the same amount of exercise.
Genetics plays a role. Other causes are being investigated, including mom's diet during pregnancy and metabolic imbalances, said Diamond, a pediatric endocrinologist.
But if the medical reasons aren't clear, the environmental ones are: more time spent in front of the television, computer or video games, less time playing outside. Food is everywhere.
Physical education has become an educational afterthought: Just half of all U.S. students are enrolled in P.E., and daily participation among high school students has dropped from 42 percent in 1991 to 29 percent in 1999, the CDC says.
Florida's requirements are minimal, though local districts can mandate more: High school students need just one year of P.E. to graduate. Younger students aren't required to take any.
In the past six years, about 250 U.S. school districts, including Pasco and Hernando, have signed marketing deals with soft drink companies that has made high-calorie "liquid candy" more accessible than ever. (Principals strike their own deals in Hillsborough, Pinellas and Citrus schools).
Many parents serve as barriers to their children's health, too. Several studies have found that parents, especially those who are overweight, often don't realize when their children are fat. Others avoid discussing weight because they fear damaging their child's self-esteem or worry it will lead to eating disorders.
That's a good reason to be gentle, doctors said, but not a reason to ignore it.
"If you know a kid's already psychologically stressed by their obesity, why not push it?" Diamond said. "I think that's an argument for saying look, we need to work on this, it's not going to be easy, but" we need to try.
"I hate to call it a disease, but it's a condition, like having high blood pressure," he added. "That's affected my approach to the parents and the kids."
Dr. Kelli Cross, a St. Petersburg pediatrician, said she is surprised by the number of parents who don't want to hear their children are too chubby, and pressing the point has cost her patients. They included an overweight boy whose mom insisted he needed to eat Doritos. "No one needs to eat Doritos," Cross said.
More often than not, a heavy child has at least one heavy parent, and children tend to adopt their parents' behavior. If mom and dad don't make healthy choices, neither will their children.
Likewise, they can't expect a child to lose weight unless the whole family changes its behavior.
"You can't make the child eat broiled chicken while everyone else has pizza," Cross said. "They may beg for McDonald's from the back seat of the car, but mom and dad actually decide where to go."
Parents play a big part
Even when parents recognize the problem, helping a child lose weight can be frustrating.
Antonio Roberts is 11 years old and weighs 184 pounds. He has been watching his weight for almost a year. Obesity, diabetes and heart disease run in the family, and his parents, Willa and Samuel Roberts Sr., say they just want Antonio to be healthy.
"We're not focusing on his weight, we're focusing on what we eat," said Mrs. Roberts, a food service specialist for Pinellas schools. "If we eat right and exercise, we figure we'll keep it at the same level."
Addressing his weight has meant monthly sessions with his doctor and a counselor at Bayfront Family Practice. His parents, three brothers and sister have had to change their diets, too, and his parents make sure Antonio spends more time playing outside and less time in front of the TV.
Sometimes it's a struggle, Mrs. Roberts said, but recent news was good: During the first five counseling sessions, Antonio gained weight. During the last three, his weight has stayed the same.
"I want to do it for myself. I don't want to grow up all big and sloppy-looking," Antonio said.
"You aren't going to be sloppy-looking, baby," his mom told him. "You can be big and handsome."
His father, a cook at Shell's restaurant on St. Pete Beach, added they try to make sure Antonio realizes they don't think less of him just because he needs to lose weight. His self-esteem is important.
"The thing we try to influence on him is you've got to love yourself, and health is part of loving yourself," Roberts said. "I tell him, "It's nice to love to eat, but you got to love yourself more.' "
Across town, the Adams family's latest attempt to help Clayton cut weight is marked by what's no longer in the kitchen. Macaroni and cheese. Frozen lasagna. Real mayonnaise.
Clayton, a rising sixth-grader, began his first diet between first and second grades. Last year, his doctor said he was heavy, but he didn't need to lose weight as long as he maintained it as he grew. He grew 2 inches, but gained 25 pounds.
Ten days ago he started diet No. 4.
"I didn't listen to her," his mom, Denise Adams, said of the pediatrician's warning last year. "I didn't count his calories, I wasn't 100 percent on it. If I had been, he wouldn't be 30 pounds overweight."
His goal is to lose 1 pound a week for 15 weeks, then maintain his weight as he grows.
Clayton is an active, popular boy who likes to play football with his friends, ride his bike and swim. But he also likes to eat too much. While his doctor helps, the Adamses say Clayton could benefit from an organized program, which they haven't found.
"The only thing being done is within the walls of your home," said Mrs. Adams, a floral designer at Publix.
The Tampa Bay area has a few programs. St. Joseph's-Baptist Health Care offers Why Weight?, a six-week course that shuns quick weight loss and instead encourages long-lasting changes in diet and exercise. At least one parent must attend, too.
But it costs $150, more than many families can afford.
Bayfront Medical Center in St. Petersburg plans to offer a similar class soon, a spokeswoman said. Jazzercise Inc. says it is expanding its children's programs in the area.
After Michael and Janine Schwartz set out to try to help their son, Austin, control his weight three years ago, they decided to fill the void themselves.
The Schwartzes, of Tampa, watched with alarm as Austin packed on pounds from the time he was 4, but their pediatrician said not to worry.
When he was 8, they took him to Dr. Diamond, who told them Austin indeed needed to lose weight. He suggested joining a gym or buying workout videos.
But they found kids weren't welcome at most fitness centers. He was too little to follow the Richard Simmons videos.
Frustrated, in 1999 Mrs. Schwartz found a production company to help her create two half-hour videos, called Movin' and Groovin' Fitness for Kids.
The tapes use original music and simple, dance-like steps to keep children moving. The Schwartzes sell them to parents over their Web site, www.exer-ciseforkids.com, and they're being used by a school system in Washington state and the diabetes clinic at Cincinnati Children's Hospital.
Austin, now 12, has lost 15 pounds using them.
"This is going to be a lifelong struggle," his dad said. "And we as parents are just trying to make sure he gets off to a good start."
Still forming a game plan
So what should be done?
The first step is convincing more parents that being overweight is not just an issue of looks, but also an issue of health, experts say. This is especially important among African-American girls and women, who are less concerned about their weight than other groups, studies show.
The second is establishing strategies for combating it. Some researchers suggest learning from the nation's anti-smoking campaign: publicize the health risks, then encourage behaviors that eventually make it unacceptable to eat poorly or not exercise.
A special report on youth and fitness, delivered to President Bill Clinton just before he left office in January, warned of the impending health disaster and recommended several steps, including a media campaign to counter the fast-food and soda industries. No action has been taken.
"Truly, we can have a massive campaign about nutrition. These kids are barraged with these images all day long about sugar-containing cereal and treats, and very little about how delicious an apple is, or where to exercise," said Kaufman of the diabetes association.
Some progress appears forthcoming.
Several states, including Florida, have received recent grants from the CDC to develop programs for obesity prevention. The National Institute of Diabetes and Digestive Diseases has formed a National Task Force on Prevention and Treatment of Obesity. And by late summer or early fall, the surgeon general plans to release a strategy for fighting obesity, similar to the office's strategies for smoking and teen pregnancy.
"What you want to target and change in terms of social norms is physical activity and good nutrition, so it would be unacceptable not to have children in physical education from K to 12," Satcher said. "So it would be unacceptable for schools to sell sweets and sodas."
Experts say prevention is key because once a child becomes seriously overweight, losing it is extremely difficult. And 95 percent of children will regain it, studies show.
But for now, with causes and treatments still being investigated, the CDC is prepared to advocate just three strategies for combatting weight problems in children:
Reduce time spent watching TV (30 percent of children watch at least five hours a day).
Increase physical activity.
"There hasn't been a public health message that focuses clearly on obesity, aside from the fact that the rise is a concern," agreed Dr. William H. Dietz, director of the division of nutrition and physical activity at the CDC, whom experts regard as the national leader in the field. "Those are legitimate public health strategies that we can employ."
Dietz said he understands the frustrations of advocacy groups, including the American Heart Association, the diabetes association and the American Cancer Society, who want a stronger stance, but more research is needed.
The CDC is looking at several behaviors, including more consumption of fast food, snacks and sugary beverages and a drop in how often families eat together, that appear to contribute, but their role in the epidemic has not been proven.
"You can't base a national campaign on intuition," Dietz said. "This awareness that (weight) constitutes a significant problem is a pretty recent awareness."
In the meantime, the bulk of American's war on obesity is being waged in fits and starts in the homes of people like the Adamses and the Robertses, often for years.
"It rocks your world. You have to change everything," Mrs. Adams said, her son Clayton at the kitchen table beside her. "And in the middle of the day, when he's hungry, you have to deny him. And you've been working all day, and you're tired, and it would be easier to say okay. But you have to stand firm."
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