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"Each year, more American children are killed by obesity than by gun violence." U.S. Surgeon General's Call to Action For the first time in history, there is a chance that new generations of Americans will live shorter and less healthy lives because of the debilitating effects of obesity

Almost everyone who cares for and about children in Maryland worries about an epidemic of obesity here. More than 200,000 of the 1.4 million Maryland children under the age of 17 are overweight, the U.S. Department of Health has estimated -- a rate triple that of 30 years ago.

Childhood obesity makes them easy targets for early onset diabetes, heart disease, sleep apnea and breathing problems, bone conditions. gastro-intestinal diseases and psychological problems. Obese children are at great risk of becoming obese adults, with an array of related problems that are already costing the nation more than $100 billion a year in added health care costs.

So when members of Maryland's General Assembly met this spring, it was not surprising that proposals to do something about this mounting problem were on the agenda. One bill suggested requiring 150 minutes a week of physical education for elementary school students. Another would have required schools toreveal the proportion of trans-fats on school lunch menus.

Both proposals failed. The fitness proposal was rejected because of concerns about the added costs to local districts of providing the space and extra teachers. The menu proposal went down because of concerns that the federal government, which provides much of the food on school lunch menus, lacked good information about the trans-fats in those surplus supplies.

For some educators, assuming greater responsibility for students' health was just another unfunded mandate.

In school districts elsewhere in the nation, reduced lunch and exercise programs have been aimed at children with high body-fat ratios, and some parents have lashed back, saying their children are being unfairly targeted publicly on an issue that the school should have nothing to do with.

The social pain of being overweight has led more than one in four teens who have been teased to consider suicide, a study by RAND researchers showed.

Children's health advocates say we all share responsibility for the obesity epidemic and will help pay the heavy costs if we fail to deal with it.

Causes of childhood obesity are complicated, tied to the busy lives of families in which both parents work and there's little time for shopping cooking or healthy exercise.

For starters, Americans eat an average of 4.2 commercially prepared meals each week. Processed foods are likely to be higher in calories, fat and salt and lower in fiber than natural meals prepared at home.

Consumption of fast food by children has increased five-fold since 1970. Each day, about one-third of American children eat fast food. On days that fast food is eaten, a child consumes on average about 187 more calories than a child not eating fast food. This equates to an extra six pounds of weight a year.

What's more, packaged food and restaurant serving sizes have greatly increased. For example, a small soda used to be two ounces. Now, 20-ounce soft drink portions are widely available at fast food restaurants. In fact in the last 20 years, children's consumption of soft drinks has doubled, while their milk consumption has decreased 40 percent.

Then there are irregular eating patterns. Recent studies show that family meals promote positive diets for children, yet many families report that they eat fewer meals together than past generations.

Inactivity is another important issue. Children now spend an average of 5 1/2 hours a day using electronic media, more time than they spend doing anything else besides sleeping. Even preschoolers spend as much time with screen media as they do playing outside.

Many schools in Maryland and elsewhere have drastically curtailed daily physical activity classes in recent years because of shortages of space and staff. Nationally, only 8 percent of elementary schools and 6 percent of middle schools have daily physical education.

And, after school, only two out of five children aged nine to 13 are participating in sports or other physical activities. About one in four children say they don't participate in any physical activity during their free time.

In Maryland's sprawling suburbs, many children are driven almost everywhere they go. Few kids walk or ride bikes to school or to other activities.

Fighting obesity is made more complicated because the health care profession has focused the largest portion of its time and resources to managing acute illnesses and relatively little on preventive care.

Many doctors face severe time constraints in assessing the health care needs of children who aren't seriously ill and they worry about how to address the issue of obesity sensitively. Many parents are ambivalent about getting involved in managing a child's weight problem, fearing they will do more psychological harm than good. In some families, extra weight is considered a sign of healthy prosperity.

Further complicating the problem, national studies show obesity is more prevalent among African-American and Hispanic children than among whites, and among children from economically disadvantaged neighborhoods, where access to healthy foods is more limited.

All of that said, there is a growing consensus that we have no choice, economically or socially, but to join efforts to fight the plague.

In California and elsewhere, health maintenance organizations like Kaiser Permanente have created programs aimed at training physicians how help families deal with the issue.

"We need to make this a priority in this country in the same way we dealt with the AIDS epidemic 20 years ago," said Dr. Melvin Heyman, chief of pediatric gastroenterology at University of California San Francisco Children's Hospital. "Otherwise there are going to be people who grow up with shorter life spans and the cost to society, both in resources and lost opportunities, is going to be enormous."

Medical leaders believe getting the healthy eating and exercise message across to kids in schools is a vital step. "The schools are critical," said Heyman, "because you have control over what these kids are exposed to for at least part of the day."

Some health care advocates have talked about possible government action to tax or even outlaw some unhealthy foods the way governments at every level ultimately acted on behalf of public health against smokers' self-interest and tobacco companies.

But Scott Gee, a Kaiser Permanente pediatrician and childhood obesity expert, notes, "Tobacco's not something that is necessary for life. Food is. You can't demonize the food industry. They have to be part of the solution."

In fact, a number of fast food companies like McDonald's have launched campaigns aimed at convincing the public that they are willing to provide healthier meals. Supermarkets are doing the same. With positive public pressure, such a trend could move beyond a PR effort and pick up significant momentum.

In Maryland and elsewhere, some local school boards have begun banning sugar-based soft drinks and unhealthy snacks from vending machines, replacing them in some instances with healthier foods.

As the expensive consequences of the obesity epidemic become more and more visible, public health advocates expect a growing effort at the state and local level to move against obesity in schools.

In 2005, 38 states considered or enacted legislation relating to nutritional quality of school foods and beverages, and at least 15 states enacted such laws, according to the National Conference of State Legislatures.

Bills to require or increase physical education and activity in schools were considered in 35 states and enacted in at least eight. Thirteen states acted on bills to require body mass screening of students and they were enacted in Tennessee and West Virginia.

One model program, in use at 11 Baltimore schools, has shown that fitness and play can be provided at a reasonable cost, with minimum equipment. Sports4Kids, a decade-old program that serves nearly 50,000 children in 114 elementary and middle schools nationwide -- including 3,000 kids in Baltimore -- uses 15 to 30 minutes of recess time to provide physical activity, including kickball and volleyball.

Other programs are encouraging families or individuals to walk more each day, to turn the television set off one or two nights a week or to organize easy-to-prepare healthy family meals.

"We need national leadership and courage to tackle the forces that are all too comfortable with the epidemic," said Dr. Linda Rosenstock, dean of the UCLA School of Public Health.

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