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Part 2 book “Community nutrition” has contents: Nutrition in childhood and adolescence, promoting health and preventing disease in older persons, acquiring grantsmanship skills, ethics and nutrition practice, principles of nutrition education, private and government healthcare systems,… and other contents.
© Carlos Hernandez/Getty Images CHAPTER Nutrition in Childhood and Adolescence CHAPTER OUTLINE ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ Introduction Nutrition Status of Children and Adolescents in the United States Nutrition-Related Concerns During Childhood and Adolescence Malnutrition in Children Children and Adolescents with Special Healthcare Needs and Childhood Disability The Effect of Television on Children’s Eating Habits Nutrition During Childhood and Adolescence Food and Nutrition Programs for Children and Adolescents Challenges to Implementing Quality School Nutrition Programs Promoting Successful Programs in Schools LEARNING OBJECTIVES ■■ ■■ ■■ ■■ ■■ ■■ ■■ ▸▸ Identify the nutritional needs of adolescents and school-age children Discuss common nutrition problems during childhood and adolescence List the diagnostic criteria for eating disorders in adolescents Discuss the contributing factors to childhood overweight and obesity Explain the causes of malnutrition in children globally and in the United States Discuss the effect television has on children’s eating habits Outline different child nutrition programs Introduction Maintaining the proper physical, social, and cognitive development of children (ages to 11) and adolescents is essential and depends upon adequate energy and nutrient intake Children and adolescents who lack adequate energy and nutrient intake are at risk for a variety of nutrition-related health conditions, including growth retardation, malnutrition, iron-deficiency anemia, poor academic performance, protein–energy malnutrition, development of psychosocial difficulties, and an increased likelihood of developing chronic 281 282 Chapter Nutrition in Childhood and Adolescence diseases such as metabolic syndrome, diabetes, heart disease, and osteoporosis during adulthood.1 Children and adolescents who live below the national poverty level are more likely to experience nutrient deficiencies, food insecurity, and hunger.2,3 In the United States, child nutrition programs subsidize meals served to children and adolescents in schools and other organizations that may help prevent malnutrition The programs that make up the federal child nutrition programs are the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), National School Lunch Program (NSLP), School Breakfast Program (SBP), Summer Food Service Program (SFSP), and Special Milk Program (SMP) In addition, low-income families are eligible to enroll in the Supplemental Nutrition Assistance Program (SNAP) These programs will be discussed later in this chapter ▸▸ Nutrition Status of Children and Adolescents in the United States The diets of many children and adolescents in the United States are below the recommended dietary standards A small number of U.S children eat the recommended amounts of grains, fruits, vegetables, dairy products, and meat or meat alternatives from the MyPlate.4 The majority of them consume calorie-dense snacks and meals, with added sugars and larger portion sizes, which increase the overall amount of caloric intake.5-8 Children’s total fat, saturated fat, and sodium intake generally are above recommended levels.5,6 Children and adolescents also consume large amounts of beverages that are high in added sugars, such as soft drinks and fruit drinks.9 These habits can lead to inadequate intakes of essential vitamins and minerals Overconsumption of calories and inactivity are major factors contributing to the increased rate of childhood overweight and obesity in the United States.10 The prevalence of overweight and obesity in children ages to 17 years has doubled in the past 30 years Approximately 4.7 million children ages to 17 years are seriously overweight or obese.10,11 Overweight and obesity at any age increase the risk for type diabetes mellitus, cardiovascular disease, and severe social and psychological problems.11,12 Research shows that overweight and obese children with poor nutritional practices tend to have difficulty learning and concentrating and are more likely to be sick and miss school.13 TABLE 9-1 provides examples of fruits and vegetables that parents and caregivers can feed toddlers and preschoolers Healthy People 2010 Two goals of Healthy People 2010 are to increase the proportion of adolescents who participate in daily school physical education to 50 percent and increase the proportion of adolescents who engage in moderate physical activity (> 30 minutes on at least days of the previous days) and vigorous physical activity that promotes cardiorespiratory fitness on more than days per week for 20 minutes per occasion.14 Report shows slight progress toward these objectives.15 TABLE 9-2 presents a progress review for the Healthy People 2010 objectives for children and adolescents Growth and Physical Development and Assessment After the first year of rapid growth, children’s physical growth rate slows down during the preschool and school years until the pubertal growth spurt of adolescence.16 By age 2, children quadruple their birth weight They gain an average of 4.5 to 6.5 pounds (2 to kg) per year between the ages of and years.16 In addition, between these ages, children grow 2.5 to 3.5 inches (6 to cm) in height per year.17 The rate of growth during middle childhood is steady On average, a 7-year-old child grows approximately to 2.5 inches (5 to cm) per year in stature and about 4.5 pounds (2 kg) per year in weight By 10 years of age, the increase in weight is approximately pounds (4 kg) per year A 1-year-old child has several teeth, and his or her digestive and metabolic systems are functioning at or near adult capability.16,17 Also by year of age, most children are walking or beginning to walk With improved coordination over the next few years, their activity level increases noticeably The following are some eating behaviors of toddlers18,19: ■■ ■■ ■■ ■■ ■■ ■■ ■■ They can learn to feed themselves independently during the second year of life They can manage to use a cup, with some spilling, at 15 months Two-year-olds prefer foods that can be picked up with their fingers Toddlers tend to be apprehensive of new foods and may refuse to eat them (Continue to offer the new foods; it takes about 15 times before they will accept them.) They tend to play with food and refuse any help from the caregiver or mother Young children are curious about new foods, but may be reluctant to try them Childhood and adolescent eating behaviors are presented later in this chapter Nutrition Status of Children and Adolescents in the United States 283 TABLE 9-1 Food Guide for Toddlers and Preschoolers4 Food Group Servings Per Day Grains Vegetables 3–5 Fruits 2–4 Toddler Amounts Preschooler Amounts Bread, tortilla pieces, waffle squares, noodles, rice, pasta, etc Hot cereal (oatmeal, grits) Cold cereal (ready-to-eat cereal, any variety) ẳẵ slice ẳ cup ẳ cup ẳ cup ẵ slice 1/3 cup 1/3 cup 1/3 cup Carbohydrates, iron, fiber, and thiamin Cooked vegetables (broccoli, peas, sweet potatoes, squash, mushrooms, green beans, winter squash, spinach, etc.) Raw vegetables (carrot sticks, tomatoes, etc.) Tbsp ¼ cup Tbsp ¼ cup Carbohydrates, magnesium, fiber, carotenoids, vitamin A, and phytochemicals Fresh fruit (raisins, kiwi slices, berries, strawberries, melon, etc.) Fruit juice (apple, pineapple, orange, etc.) Canned fruit (any variety) Tbsp ¼ cup ¼ cup ẵ cup ẳ cup ẵ cup Foods Nutrients Supplied Carbohydrates, vitamin C, potassium, fiber, and phytochemicals Milk and dairy products 3–4 Milk or yogurt Cheese (cheese cubes, cheese sticks) ½ cup oz ¾ cup 1½ oz Carbohydrates, protein, vitamin D, calcium, and phosphorus Meat and poultry 2–3 Meat (beef cubes, turkey rollups) Chicken Turkey Fish (tuna and salmon without bones) Cooked beans Eggs Peanut butter Nuts oz 1½ oz Protein, vitamin B, iron, zinc, and phytochemicals oz 1½ oz Tbsp ½ an egg Tbsp ¼ cup egg Tbsp U.S Department of Agriculture Using Surveys to Monitor Nutrient Intake The U.S Department of Agriculture’s (USDA’s) Center for Nutrition Policy and Promotion (CNPP) developed the Healthy Eating Index (HEI) to evaluate and monitor the dietary status of the U.S population The HEI-2005 (see TABLE 9-4) represents different aspects of a healthful diet and provides an overall picture of the type and quality of foods people eat, their compliance with specific dietary recommendations, and the variety in their diets The CNPP used the 2005 Dietary Guidelines for Americans based on the recommendation found in MyPlate, and the recommendations of the Committee on Diet and Health of the National Research Council to formulate the current HEI-2005 The USDA and CNPP revised the HEI so that it conforms to the 2005 Dietary Guidelines for Americans, maximizes variation in individual scores, and standardizes dietary scores.20,21 The standards were created using a density approach that is expressed as the amount of food and nutrient intakes per 1,000 calories The total HEI-2005 score and standards are shown in Table 9-3 HEI-2005 consists of 12 components scores, Reduce the proportion of children and adolescents who are overweight or obese Reduce growth retardation among low-income children, years and younger Increase the proportion of persons age years or older who consume at least three daily servings of fruit Increase the proportion of persons age years or older who consume at least three daily servings of vegetables, with at least one-third being dark green or deep yellow vegetables Increase the proportion of persons age years and older who consume at least six daily servings of grain products, with at least three being whole grains Increase the proportion of persons age years or older who consume less than 10% of calories from saturated fat Increase the proportion of persons age years or older who consume no more than 30% of calories from fat Increase the proportion of persons age years or older who meet dietary recommendation for calcium Increase the number of adolescents who engage in moderate physical activity for at least 30 minutes on or more of the previous days Increase the proportion of the adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness or more days per week for 20 or more minutes per occasion Increase the number of adolescents who participate in daily school physical education 19.3 19.4 19.5 19.6 19.7 19.8 19.9 19.11 22.6 22.7 22.9 29% (1999) 65% (1999) 27% (1999) 46% 33% Females 2–11 years: 23% 12–19 years: 34% Males 2–11 years: 23%–25% 12–19 years: 27% (1994–1996) 7% 3% 28% (1994–1996) 8% (1997) 11% (1988–1994) 9% (1988–1994) 4% (1988–1994) Baseline (Year) Data from: National Center for Health Statistics Healthy People: Tracking the Nation’s Health http:// www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa16-mich.htm Accessed August 9, 2016 Decrease the occurrence of iron deficiency among children: a 1–2 years b 3–4 years Healthy People 2010 Objective 19.2 Healthy People 2010 Objectives Number TABLE 9-2 Healthy People 2010 Objectives Related to Children and Adolescents 32% 65% 26% Data statistically unavailable No change No change Little or no change No change Little or no change 8% 16% 7% Not available Progress Review (2002) 50% 85% 35% 75% 75% 75% 50% 50% 75% 5% 5% 7% Not available Healthy People 2010 Target 284 Chapter Nutrition in Childhood and Adolescence Reduce the proportion of children and adolescents who are considered obese Reduce the proportion of children aged 2–5 years who are considered obese Reduce the proportion of children ages 6–11 years who are considered obese Reduce the proportion of adolescents ages 12–19 years who are considered obese Reduce the proportion of children and adolescents ages 2–19 years who are considered obese (Developmental) Prevent inappropriate weight gain in youth and adults (Developmental) Prevent inappropriate weight gain in children ages 2–5 years (Developmental) Prevent inappropriate weight gain in children ages 6–11 years (Developmental) Prevent inappropriate weight gain in adolescents ages 12–19 years (Developmental) Prevent inappropriate weight gain in children and adolescents ages 2–19 years (Developmental) Prevent inappropriate weight gain in adults ages 20 years and older Reduce iron deficiency among children ages 1–2 years Reduce iron deficiency among children ages 3–4 years Reduce iron deficiency among females ages 12 to 49 years NWS–10 NWS–10.1 NWS–10.2 NWS–10.3 NWS–10.4 NWS–11 NWS–11.1 NWS–11.2 NWS–11.3 NWS–11.4 NWS-11.5 NWS-21.1 NWS-21.2 NWS-21.3 10.5% of females ages 12 to 49 years old were iron deficient in 2005–2008 5.3% of children ages 3–4 years were iron deficient in 2005–2008 15.9% of children ages 1–2 years were iron deficient in 2005-2008 N/A N/A N/A N/A N/A 16.1% 17.9% 17.4 % (2013–2014) 9.4 % (2013–2014) Baseline (Year) Target-setting method: 10 percent improvement Data from: National Center for Health Statistics Healthy People Tracking the Nation’s Health https://www.healthypeople.gov/2020/topics-objectives/topic/nutrition-and-weight-status/objectives Accessed August 9, 2016 * Healthy People 2020 Objective Healthy People 2020 Objectives Number TABLE 9-3 Healthy People 2020 Objectives Related to Children and Adolescents N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Progress Review (2020) 9.4%* 4.3% 14.3%* N/A N/A N/A N/A N/A 14.5%* 16.1%* 15.7%* 10.4%* Healthy People 2020 Target Nutrition Status of Children and Adolescents in the United States 285 286 Chapter Nutrition in Childhood and Adolescence TABLE 9-4 Healthy Eating Index—2005: Components and Standards for Scoring* Component Maximum Points Standard for Maximum Scoring Standard for Minimum Score of Zero Total fruit (includes 100% juice) 5 ≥ 0.8 cup equivalent per 1,000 kcal No fruit Whole fruit (not juice) 5 ≥ 0.4 cup equivalent per 1,000 kcal No whole fruit Total vegetables 5 ≥ 1.1 cup equivalent per 1,000 kcal No vegetables Dark green and orange vegetables and legumes† 5 ≥ 0.4 cup equivalent per 1,000 kcal No dark green or orange vegetables or legumes Total grains 5 ≥ 3.0 oz equivalent per 1,000 kcal No grains Whole grains 5 ≥ 1.5 oz equivalent per 1,000 kcal No whole grains Milk‡ 10 ≥ 1.3 cup equivalent per 1,000 kcal No milk Meat and beans 10 ≥ 2.5 oz equivalent per 1,000 kcal No meat or beans Oils§ 10 ≥ 12 g per 1,000 kcal No oil Saturated fat 10 ≤ 7% of energy5 ≥ 15% of energy Sodium 10 ≤ 0.7 g per 1,000 kcal ≥ 2.0 g per 1,000 kcal Calories from solid fats, alcoholic beverages, and added sugars 20 ≤ 20% of energy ≥ 50% of energy * Intakes between the minimum and maximum levels are scored proportionately, except for saturated fat and sodium (see note 5) Legumes counted as vegetables only after Meat and Beans standard is met ‡ Includes all milk products, such as fluid milk, yogurt, and cheese, and soy beverages § Includes nonhydrogenated vegetable oils and oils in fish, nuts, and seeds Saturated fat and sodium get a score of for the intake levels that reflect the 2005 Dietary Guidelines, less than 10 percent of calories from saturated fat and 1.1 g of sodium/1,000 kcal, respectively Reproduced from: Guenther PM, Krebs-Smith SM, Reedy J, et al USDA Center for Nutrition Policy and Promotion and National Cancer Institute Available at: http://www.cnpp.usda.gov /HealthyEatingIndex.htm Accessed October 21, 2016 † each representing a different aspect of diet quality with a minimum score of 0; the highest possible overall HEI-2005 score is 100 An HEI-2005 score over 80 is interpreted as a “good” diet, a score between 51 and 80 is interpreted as a diet that “needs improvement,” and a score of less than 51 is interpreted as a “poor” diet.21 Moderation is recommended for saturated fat (< 10 percent of total energy intake), sodium, and extra/ discretionary calories for solid fat, including fat from milk and sugar.22,23 The data from the 2003 to 2004 National Health and Nutrition Examination Survey (NHANES) show that children ages to had the highest mean HEI-2005 score over children to 11 and 12 to 17 years old in total fruits, whole fruits, milk, and extra calories The overall HEI-2005 scores for children were 54.7 (6 to 17 years old) and 59.6 (2 to years old) of a possible 100 points The likely reasons for the poor-quality diet of older children are a diminished parental role in providing nutritious foods, peer pressure, and increased consumption of fast foods.23 The consumption of dark green vegetables and legumes ranged from 0.5 to 0.6 of maximum points of Whole grains score ranged between 0.6 and 0.9 of points The consumption of saturated fat, sodium, and extra calories was approximately 50 percent lower than the maximum Nutrition-Related Concerns During Childhood and Adolescence scores for all age groups, suggesting that intake levels should be reduced.21,22 In the United States, national surveys of dietary intakes are used to determine the types and amounts of food people consume Wilkinson et al.23 compared nationally representative USDA surveys of dietary intakes of 6- to 11-year-old boys and girls using the Nationwide Food Consumption Survey (NFCS) 1977 to 1978, the Continuing Survey of Food Intakes by Individuals (CSFII) 1989 to 1991, and the CSFII 1994, 1996, and 1998 to assess whether the trends in children’s food intake changed over time.24-26 (The CSFII and NHANES merged into an integrated survey that acts as the primary source of nationally representative data on dietary intake of foods and nutrients and nutritional status.27) Results showed increases in intakes of soft drinks as well as decreases in intakes of total fluid milk due to decreases in whole milk intake Higher intakes of crackers, popcorn, pretzels, corn chips, and potato chips and higher intakes of noncitrus juices, candy, and fruit drinks were observed Results also showed lower intakes of yeast breads, rolls, green beans, corn, green peas, lima beans, beef, pork, and eggs.23 These findings imply that these children were not consuming important nutrients such as vitamins and minerals that can promote growth and development In addition, this trend of poor-quality diet may be one of the reasons for the high incidence of childhood obesity Children should consume a daily total of cups of milk or the equivalent from other dairy products daily ▸▸ 287 Nutrition-Related Concerns During Childhood and Adolescence Concern has been raised regarding poor dietary habits during childhood and adolescence Appropriate food selection is essential because children of this age are still growing Appropriate food selection also can reduce some of the negative consequences of inadequate food intake Hence, it is important to monitor children’s food and nutrient intakes to reduce nutrition-related health conditions, which include but are not limited to iron-deficiency anemia, lead poisoning, dental caries, overweight and obesity, and high blood cholesterol Iron-Deficiency Anemia Iron-deficiency anemia is a problem for all ages, but especially for children Many iron-deficient children come from low-income families with poor diets.28 Cultural traditions and lack of nutrition knowledge about iron requirements are also factors that contribute to iron deficiencies.29 Iron deficiency is defined as absent bone marrow iron stores, an increase in hemoglobin concentration of less than g/dl after treatment with iron, or other abnormal laboratory values, such as serum ferritin concentration.30 Age- and sex-specific cutoff values for anemia are derived from NHANES III data For children to years of age, the diagnosis of anemia would be made if the hemoglobin concentrations were less than 11 g/dl and hematocrit was less than 32.9 percent For children ages to years, a hemoglobin value of 11.1 g/dl or a hematocrit of 33 percent signifies iron-deficiency anemia.31 One of the Healthy People 2010 objectives was to reduce iron deficiency in children ages to years from percent to percent and in children ages to years from percent to percent.32 Healthy People 2020 objectives were to reduce iron deficiency by 10 percent A 2010 progress report showed no progress in to and to year olds (see Table 9-2).40 Reaching this goal will require reducing or eliminating disparities in iron deficiency by race and family income level The prevalence of iron deficiency is higher in African American than in European American children (10 percent vs percent for children ages to years) and is highest in Mexican American children (17 percent of children ages to years).33 Also, children of families with incomes less than 130 percent of the poverty threshold have higher incidences of iron deficiency than those with a higher income (12 percent vs percent) Low blood iron levels affect a child’s resistance to disease, attention span, behavior, and intellectual performance.34,35 It is reported that excessive consumption of milk could contribute to low iron intake Milk or 288 Chapter Nutrition in Childhood and Adolescence soymilk intake should be limited to to cups per day or no more than 24 ounces; this will permit inclusion of iron-rich foods, such as lean meats, legumes, fish, poultry, and iron-enriched breads and cereals.30 Larger intakes of milk or soymilk may replace foods that are high in iron Cultural and religious practices also may affect children’s iron status For example, it was reported that East Indian mothers living in Great Britain not feed their children beef if they are Hindu; if they are Muslim, they not feed children pork or meats that are not “halal” (permitted, or lawful, foods are called halal.) They often not replace the nutrients in those items with equivalent foods, consequently causing anemia.36 In contrast, it was reported that in Spain, preschool children showed better iron status when meat was included in their diets during their eighth month or earlier, compared to those who were given meat later.37 There are no reports on the effect of kosher meat on iron status Iron-deficiency anemia is not common in schoolage children The NHANES III data from 1988 to 1994 and other studies have shown that more than percent of older children were iron deficient, however For adolescents, it was reported that iron deficiency was found in 2.8 to 3.5 percent of 11- to 14-year-old females, 4.1 percent of 11- to 14-year-old males, 6.0 to 7.2 percent of 15- to 19-year-old females, and 0.6 percent of 15- to 19-year-old males.38,39 Dietary intake of iron ranges from 10.0 to 12.5 mg per day in females (ages 14 to 18 years old).39 The Dietary Reference Intakes (DRIs) are 15 mg per day for girls and 11 mg per day for boys Donovan et al.39 reported that 32 percent of male and 83 percent of female adolescents consume less than the DRI for iron.1,40 Lead Poisoning Approximately 4.4 percent of children ages to years have high blood lead levels—higher than 10 µg/dl Lead poisoning is common among children under age and can cause learning disabilities and behavior problems, slow growth, brain damage, and central nervous system damage Lead poisoning also can cause iron deficiency, and, in turn, iron deficiency can impair the body’s ability to prevent lead absorption.32,41 Satisfactory calcium intake may slow lead’s absorption or interfere with its toxicity The U.S Environmental Protection Agency’s (EPA’s) “Keep It Clean” public health campaigns to prevent lead poisoning have significantly reduced the amount of lead in the environment Also, the U.S ban on the use of leaded gasoline, leaded house paint, and lead-soldered food cans have helped reduce lead poisoning.42 Other strategies for preventing lead poisoning include providing nutritious foods, screening children for lead poisoning, preventing children from eating nonfood items, avoiding water containing lead, and preventing children from putting dirty or old painted objects in their mouths In addition, food providers must wash their hands before handling foods and require children to also wash their hands before eating.14,17,43 The prevalence of elevated blood lead levels above 10 µg/dl in U.S children to years old has decreased.44 Results show a decrease of 84 percent Low-income children, especially African American children, are still at higher risk for lead poisoning than other U.S children.45 Among the different ethnic groups, the prevalence of lead poisoning decreased 84 percent in Mexican American children, 82 percent in African American, and 78 percent in European American A study conducted in California identified Mexican-born children as being at a higher risk than Hispanic children born in the United States.46 The Centers for Disease Control and Prevention (CDC) recommends universal lead screening for children living in neighborhoods where the risk for lead exposure is widespread, and the federal Medicaid program requires that all eligible children be screened for elevated blood lead levels Children who live in housing built before 1950 are at high risk for lead poisoning because of the presence of lead-based paints.47 Children who live in inner cities are also at risk for lead poisoning because of the lead in dirt Also improper drinking water treatment that happened in the city of Flint Michigan in Detroit can expose children to high levels of lead Successful Community Strategies Lead Poisoning Prevention in Hartford, Connecticut40 The Hartford Health Department, the Hartford Regional Lead Treatment Center, and the Hartford Lead Safe House established a Lead Poisoning Prevention and Education Program (LPPEP) in 1999 The program was a citywide effort to increase lead poisoning awareness and promote behaviors leading to lead poisoning prevention among the residents within the city of Hartford, Connecticut They implemented a multifaceted public health campaign that involved several partnerships The program was funded by the Centers for Disease Control and Prevention, (continues) Nutrition Status of Children and Adolescents in the United States Successful Community Strategies 289 (continued) the U.S Department of Housing and Urban Development, the Connecticut Department of Public Health, and the U.S Environmental Protection Agency The campaign used 10 different strategies to carry out the intervention program, including an educational video that aired on public access television and was made available to 10 of the city’s public libraries; drawings showing the hazards of lead poisoning that were chosen from a poster contest were displayed at the capitol building; and an educational table was displayed in front of a local Hartford hardware store for almost year to reach patrons and pedestrians with messages about lead poisoning and leadsafe work practices In addition, four educational notices highlighting lead poisoning prevention were placed for two consecutive months, from April to June 30, 2000, in Connecticut’s major newspaper and two smaller, local Hartford newspapers, to reach different segments of the population One of the notices featured two African American boys encouraging readers to test their children and homes for lead The notices included phone numbers for both the Hartford Health Department and the Connecticut Children’s Medical Center From April 2000 through April 2001, the Hartford Health Department posted an educational awareness message in English and in Spanish on 16 Hartford billboards These messages featured a woman playing with a child; underneath was the phrase, “He got his eyes from grandma, his laugh from Daddy, and his lead poisoning from home.” The billboards have continued to be posted throughout the city In addition, the Hartford Health Department partnered with a local dairy to place lead awareness messages on almost million milk cartons and 300,000 orange juice cartons that were distributed throughout Connecticut, Rhode Island, Westchester County in New York, and western Massachusetts These notices featured drawings of children, along with the phrase “One good reason to prevent lead poisoning.” Additionally, the Hartford Health Department partnered with the Connecticut Transit Authority to place educational signs on the interiors of 120 city buses, on the exterior bus tails of 20 additional buses, and on the walls of five of the city’s bus shelters Plus, a series of 4- by 8-foot lead poisoning awareness signs were placed on the sides of Hartford’s 13 municipal sanitation trucks The signs posted messages in English and in Spanish about the hazards of lead poisoning and the importance of having children tested for lead In addition, the city of Hartford collaborated with the U.S Postal Service and the U.S Department of Housing and Urban Development to implement, for the first time in the United States, postmarks aimed at the prevention of lead poisoning This postmark was applied to almost every stamped, first-class card and letter mailed in Connecticut in October 2001 The postmark featured an illustration of a house accompanied by the phrase “Let’s give every child a lead safe home.” At the end of the campaign, the Hartford Health Department conducted a survey to evaluate its effectiveness Approximately 45 percent of the respondents said that they took specific steps to learn more about lead poisoning because of the campaigns just described The survey also showed that: Approximately 73.3 percent of the respondents said that they asked their doctor about blood tests for lead poisoning ■■ 21.3 percent said that they called a phone number to learn more about lead poisoning ■■ 76 percent said that they changed the way they cooked or cleaned ■■ 42.7 percent said that they changed the kinds of foods they fed their families ■■ 41.3 percent said that they spoke to their landlord ■■ 60 percent said that they took other steps to prevent lead poisoning Among those reporting that they took specific steps to learn more about how to prevent lead poisoning, approximately 51 percent specified that they took steps because of the newspaper notices Consequently, the newspaper notices were the most effective campaign strategy in terms of self-reported lead poisoning prevention behavior ■■ Dental Caries Dental caries is a widespread problem for all age groups Approximately one in five children ages to years has decay in their primary or permanent teeth.48 Foods containing carbohydrates that stick to the surface of the teeth—for example, sticky candy such as caramel—can interact with the bacteria Streptococcus mutans and cause tooth decay.49 The following suggestions may help reduce dental caries in children17,31,50: ■■ ■■ ■■ ■■ Brush the child’s teeth to remove carbohydrates Rinse the child’s mouth with water Use fluoridated water Provide crunchy foods such as carrot sticks and apple slices for a snack These are less likely to promote tooth decay than sticky candies or raisins 290 Chapter Nutrition in Childhood and Adolescence Tooth decay occurs when sugar in liquids is in contact with teeth for a prolonged time Milk, formula, juice, Kool-Aid, and soft drinks contain sugar Courtesy of Dr Hisham Yehia El Batawi Overweight and Obesity There has been a significant increase in the United States in the prevalence of overweight and obesity in children and adolescents A body mass index (BMI) between the 85th and 95th percentiles for age and sex is considered at risk for overweight, and a BMI at or above the 95th percentile is considered overweight or obese.51 According to the 2003 to 2004 NHANES data, approximately 18.8 percent of children to 11 years old and 17.4 percent of adolescents 12 to 19 years are overweight A research study conducted by Krebs et al.50 showed that about 15.3 percent of 6- to 11-year-olds and 15.5 percent of 12- to 19-year-olds were at or above the 95th percentile for BMI on standard growth charts developed by the CDC One of the Healthy People 2010 objectives is to reduce the prevalence of overweight from the baseline of 11 percent to percent However, the data show an increase of almost 45 percent from estimates of 11 percent obtained from NHANES III (1988 to 1994) and a threefold increase from the 1960s.51 Overweight and obesity occur at a higher rate in African American girls than Hispanic and European American girls For example, the prevalence of overweight in girls ages 12 to 19 years for African Americans was 25.4 percent, for Mexican Americans was 14.1 percent, and for European Americans was 15.4 percent.52 But for a boy of the same age group, there was a slight difference: for African Americans, 18.5 percent; for Mexican Americans, 18.3 percent; and for European Americans, 19.1 percent In addition, Hedley et al.51 reported that 42.8 percent of Mexican American boys ages to 19 years were at risk for overweight compared with 31 percent of African American boys and 29.2 percent of European American boys.53 Among girls, 40.1 percent of African American girls were at risk for overweight compared to 36.6 percent of Mexican American girls and 27.0 percent of European American girls.53 In addition, results from the 2007 to 2008 NHANES, using measured heights and weights, showed that about 16.9 percent of children and adolescents ages to 19 years are obese The mechanism of obesity development is not well understood, but it is confirmed that obesity develops when energy intake exceeds energy expenditure Many factors contribute to obesity in children and adolescents worldwide, including the amount of television viewing, an inactive and sedentary lifestyle, genetic factors, environmental factors, and cultural environment.54,55 In a small number of cases, childhood obesity is due to medical causes such as hypothyroidism and growth hormone deficiency.56 Other causes may be that low-income families lack safe places for physical activity and lack consistent access to healthful food choices, mainly fruits and vegetables The situations that encourage overweight or obesity evolved over a period of years; therefore, no single change will reverse the trend Multicomponent, family-based, community-based, and school-based approaches, including diet, physical activity, and behavior modification for reducing overweight in children and adolescents, may be the best strategy Obesity is associated with major health problems in children and is an early risk factor for morbidity and mortality in adults.57 Studies show that approximately one third of overweight preschool children, half of overweight school-age children, and three quarters of overweight teenagers grow up to be obese adults.58 Medical Problems Related to Childhood Obesity Obese children and adolescents commonly have problems that affect cardiovascular health (hypercholesterolemia, dyslipidemia, and hypertension),57 the endocrine system (hyperinsulinism, insulin resistance, impaired glucose tolerance, type diabetes mellitus, and menstrual irregularity),59 and mental health (depression and low self-esteem).60-62 Other major problems that can be caused by overweight and obesity include osteoporosis and some cancers (such as ovarian and breast cancer).63 In addition, some children may develop sleep apnea and liver and gallbladder diseases.64 ... June 30, 20 17 684 922 1,160 1,398 1,636 1,874 2, 1 12 2,351 23 9 7 42 1,001 1 ,26 0 1,519 1,778 2, 037 2, 296 2, 556 26 0 594 801 1,008 1 ,21 5 1, 422 1, 629 1,837 2, 045 20 8 Every Two Weeks 3 42 461 580... 36,335 42, 523 48,711 54,899 61,113 6 ,21 4 19 ,29 2 26 , 028 32, 760 39,494 46 ,22 8 52, 9 62 59,696 66,458 6,760 15,444 20 , 826 26 ,20 8 31,590 36,9 72 42, 354 47,749 53,157 5,408 Annual 1,481 1,997 2, 513 3, 028 ... Weekly 25 ,29 0 34,096 42, 9 02 51,708 60.514 69, 320 78, 126 86,969 8,843 27 ,454 37,037 46, 620 56 ,20 3 65,786 75,389 84,9 52 94,5 72 9, 620 21 ,978 29 ,637 37 ,29 6 44,955 52, 614 60 ,27 3 67,951 75,647 7,696 2, 108