Ask any parent to name the greatest health risk they fear for their children, and most likely the answer will be “cancer.” But in reality, a much more dangerous health risk faces our children today, one, in fact, for which we—as parents and as a community—are largely responsible: obesity.1
Obesity kills more Americans each year than AIDS, cancer and all home accidents combined. In fact, obesity is such an alarming danger that former US Surgeon General Dr. Richard Carmona called it the “greatest threat to public health today.”2
According to Chazal,3 the mitzvah “Venishmartem meod lenafshoteichem, Be very careful about your lives” imposes an obligation to preserve one’s health. As Orthodox Jews committed to the Torah, this mitzvah holds tremendous significance. Can you imagine any parent consciously endangering the health of his or her children?
Obesity—A Trend
In the early 1920s, the average lifespan for an American was fifty-four years. For most of the early twentieth century, physicians focused their energy on fighting infectious diseases such as polio, tuberculosis and diphtheria. But as antibiotics, vaccines, better hygiene and improved nutrition became part of the health habits of Americans, cases of infectious diseases decreased to such an extent that, by 2006, the life expectancy for an average American was well into the late seventies.4
Nevertheless, though infectious diseases no longer posed the same public health risk, as time went on, physicians began to see a rise in chronic diseases, particularly cardiovascular disease and cancer. The situation has become so dire that children today may actually have a shorter life expectancy than their parents.
In 2007, more than 15 percent of American teenagers were considered obese.5 Pediatricians in the Jewish community have seen firsthand the increase in cases of pediatric obesity among children and adolescents. The phenomenon is particularly disturbing because at times it seems that the Jewish community, its institutions and its communal frameworks, bear some responsibility for this epidemic. One need look no further than the lavish kiddushim and wedding spreads, as well as the proliferation of junk food with kosher certification, to see where this is heading. Twenty-five years ago, the kashrut industry was in its infancy and only a limited number of products were available to the kosher consumer. Today, however, it is quite easy to find kosher products at any supermarket; kosher restaurants have expanded exponentially; at weddings, Bar and Bat Mitzvahs and other semachot, guests are served an increasing number of delicacies and kosher junk food is practically a business of its own. In some ways, the blessings of prosperity are becoming curses.
Of course, it does little good to point fingers. Pediatric obesity is a trend that is prevalent beyond the Orthodox Jewish community. In fact, most Western countries face the same problem. In 2005, the US led pediatric obesity at 15 percent; countries such as Greece and Israel were not far behind, with a rate of 7 percent.6
Habits of Highly Healthy Families: For Tweens and Teens:
* Be a better role model. Just as we teach our children to wash their hands before eating bread and to recite Grace After Meals, we must also teach them to eat healthfully and in moderation.
* Control the speed at which your children eat. The brain needs time to record the satiety message from the stomach, so second portions should not be given unless fifteen to twenty minutes have passed since the first portion was completed.
* Teach children to read and understand food labels and nutrition facts.
* Provide healthy afterschool snacks everyday. Children love to dip, so serve cut fruits and vegetables with dips. It is somewhat hypocritical when parents complain about their children’s unwillingness to eat fruit and vegetables when they themselves do not eat these foods regularly.
* Advocate for healthy school lunch programs. Portion sizes should be monitored. If you prepare your children’s lunches, make sure they are nutritious.
* The shift toward artificial sugar or substitutes is not a healthy compromise. Although most scientists today feel that saccharin (Sweet’N Low), aspartame (Equal) and the recent sucralose (Splenda) are safe, they do not know the long-term effects these sugar substitutes might have.
* Drink water. Fruit juices, soda and power drinks are full of “empty calories.” Beverages containing high fructose corn syrup should be avoided, and offered only on special occasions.
* Limit eating out to once or twice a week, and teach your children food exchanges. For example, if your child will be eating dessert after dinner, he should cut back on French fries or soda that day.
* Limit screen time (TV, DVD, movies and Internet usage) to a maximum of two hours on a school night. Instead, encourage after-school physical activities, and allow children to “buy” extra screen time with additional physical activity. For example, suggest to your child that he walk on the treadmill while watching a movie.
* Make it a family rule not to eat in front of the TV. In addition, children should not have TVs in their bedrooms, and home computers should be kept in open areas to encourage less screen time.
I am not arguing that we should revert to pre-modern lifestyles and not enjoy the many advances in the kosher food industry. Rather, we must embrace the principles of moderation and rationality when eating and serving food, particularly when it comes to our children. This approach must be communal-centered; the various parts of our society—parents, schools and industry—must work together and cooperate in order to improve the health of our children.
Defining “Overweight”
Several methods exist for determining obesity, though currently the most accepted one used by pediatricians and obesity experts is the Body Mass Index (BMI). BMI is a calculation that uses a child’s height and weight to estimate how much body fat he or she has. Doctors then use BMI to determine how appropriate a child’s weight is for his or her height and age.7 BMI is calculated with the following formula:
BMI = [weight (lb)/height (in)2] x 703
BMI Basics
A child with a BMI below the 85th percentile does not have a weight problem. If his or her BMI is between the 85th and the 95th percentiles, the child is at risk for being overweight, and if the BMI is greater than 95 percent, he or she is overweight. Of course, this method is not error-proof. Muscular children or those who are “big boned” may have falsely elevated BMI percentiles for their age. As such, when determining whether a child is overweight, a physician should use the BMI as a guide but should also review the child’s nutritional intake and perform a physical exam before confirming a diagnosis.
Studies show a marked increase in the prevalence of pediatric obesity in the US over the past thirty years. A review of data from 1972 to 2000 shows that the rate of obesity increased almost twofold among two- to five-year-olds, fourfold among six- to eleven-year-olds, and threefold among twelve- to seventeen-year-olds. Today, the average incidence of pediatric obesity is rising.8
A “Weighty” Issue
Body weight is based on a combination of genetics (nature) and food environment (nurture). Since the obesity epidemic has evolved over a short period of time, genetics cannot be the sole factor responsible for causing it.
God created the human body as a complex organism, able to sustain itself under stressful conditions. One way the body does this is by storing fat so that it will have an energy source available in times of stress. Over the past millennia, being overweight was a genetic advantage for reproduction, lactation, growth and survival. In fact, many parents today grew up hearing stories from their parents and grandparents about towns where the people remarked that the sign of a successful businessman was whether or not he had a “pot belly.” Being slightly rotund meant you ate well, and led people to consider you ba’ale batish. Perhaps this is why nowadays so many of those from the older generation believe that a fat child is a healthy child.
Moreover, enduring harsh winters in places such as chilly Poland or even colder Russia with limited food sources meant that heavier children survived, while those who weighed less did not always make it through. In fact, medical evidence supports this: the “thrifty gene hypothesis” states that populations exposed to famine over many generations develop an efficient metabolism that runs on fewer calories. Yet if such a population is then exposed to “excess calories” when food is abundant, and the slowed metabolism is made even slower due to a sedentary lifestyle, the risk of obesity emerges. The “thrifty gene” has therefore lost its value, and in today’s American culture it has actually become a disadvantage.
The genetics of obesity are also quite disturbing. If both parents are overweight, there is a 75 percent chance that their children will be overweight. If one parent is overweight, there is a 25 to 50 percent chance of obesity. If both parents are of normal weight, there is only a 10 percent chance the children will be obese.9
Parents frequently ask pediatricians to assess their child for a hormonal deficiency or endocrine problem as a cause for obesity. But it is important to note that most overweight children are tall, which generally rules out a hormone etiology. Hormonal testing should be considered in a child with rapid weight gain who does not grow at least two inches per year.
Children today lead a sedentary lifestyle; they rely heavily on a fast-food diet, do not engage in adequate exercise and use screen devices (TV, DVDs, computers, et cetera) excessively. Even our own yeshivot have made physical education and recess low priorities. One hundred years ago, if one wanted to eat a piece of cake, he needed two hours to grind up the flour, add the necessary ingredients and bake it. Today, with the help of Duncan Hines, one can make a delicious microwave brownie in less than two minutes. Society might call this progress, but, unfortunately, in today’s world such “luxuries” have a detrimental effect on the health of our children.
The Jewish Way
Ironically, for Orthodox communities that stress the importance and value of a ruchani way of life, a tremendous emphasis is placed on gashmiut. Did we not learn from Kivrot Hata’avah, when Bnei Yisrael were wandering the desert and complained to God that they wanted meat because the manna was not good enough? They were jubilant when the slav (quail) arrived, and then overindulged. Ultimately, they were punished for their ta’avah for meat. How many times have you seen people at a simchah eating at a smorgasbord as if they had been fasting for an entire day? Have you ever wondered why children who bring “snacks” to shul must have a fruit roll, potato chips and candy?
Jeshurun became fat and kicked. You became fat, thick and corpulent; it thus deserted Hashem, its Maker, and was contemptuous of the Rock of its salvation (Devarim 32:15).
While the word “fat” in this passage can certainly be interpreted metaphorically, the simple peshat is equally true. Physical indulgence and overeating pull us away from Hashem and His Torah way of life.
Our rabbis have taught us the importance of avoiding gluttony. Rambam, writing in his famous Mishneh Torah, states that when eating a meal “one should eat one-third less the amount that brings satiety” (Deot 4:2).
King Solomon states in Mishlei (13:25), “Tzaddik ochel lesovah nafsho, A righteous person eats to satisfy his soul.” Proper eating means that one should eat only what is necessary to maintain good health. Often, we eat out of desire rather than to keep our bodies healthy so we can perform mitzvot. Of course, we’re not forbidden to eat delectable desserts and heavenly culinary creations; Chazal’s point, as is the principle for so much in our lives, is that God wants us to live our lives with balance and moderation.10
Long-term Effects: Diabesity
When discussing the complications of obesity, physicians often speak of co-morbidities. Most parents fuss more over poor body image than the long-term, life-threatening medical complications linked to obesity, which are far more important and a cause for concern. In children, the incidence of Type II diabetes mellitus is rising.11 The link between obesity and diabetes explains why pediatric endocrinologists often call the condition “diabesity.” Type II diabetes is a condition that results in the body needing higher doses of insulin to transport sugar from the blood into the cells of the body. This condition is also known as insulin resistance; it is unclear why obesity tends to create this resistance.
Habits of Highly Healthy Families: For Toddlers and Preschoolers:
* Educate children at a young age to eat to live, not to live to eat.
* Start teaching healthy eating habits when children are young. You’d be surprised how much healthy food your child will eat if you are creative. For toddlers who won’t eat raw vegetables, try adding vegetables to a quiche or mixing them with pasta.
* Do not give children frequent snacks. This gives them unnecessary calories and teaches them that one needs to eat constantly. Food should not be a substitute for boredom. (This does not apply to underweight children.)
* Ensure that snacks given at preschool or at “Mommy and Me” programs are nutritious. At birthday parties, junk food should be restricted.
* Limit processed and salty foods.
* Limit one-year-olds to a maximum of twenty-five ounces of milk per day. By age two, a child should no longer drink from a bottle.
* Cut out fruit juices from the start. They do not provide any health benefits.
Twenty-five years ago, less than 5 percent of all new onset childhood diabetics were Type II. Today, it’s more than 20 percent. Those with Type II diabetes must take medication to control their blood sugars in order to avoid later complications such as heart attacks and strokes. Long-term health issues may also include blindness (diabetic retinopathy), kidney failure (diabetic nephropathy) and limb amputation (diabetic neuropathy).
Another problem seen in children these days is metabolic syndrome, or syndrome X,12 [0]which is a constellation of conditions that may lead to heart disease in adults. This disease may begin in early puberty and can advance to insulin resistance, acanthosis nigricans (dark skin pigmentation in the neck and armpit areas), high blood pressure and high cholesterol.
Orthopedic disorders, like hip pain, in overweight children can occur and may even require surgical intervention. Being overweight can also cause one to sleep poorly at night and to fall asleep during the day. Most recently, medical research has found an increased risk of breast, uterine, colon, esophageal and kidney cancer in obese patients. Lastly, the development of a fatty liver called nonalcohol steatohepatitis (NASH) could lead to liver failure among overweight adults.
The Blame Game
Experts believe that to counter obesity, the individual himself must accept personal responsibility. But how does a five-year-old exhibiting dramatic weight gain accept personal responsibility?
In fact, everyone involved tends to blame everyone else. The food industry says the obesity epidemic is due to lack of exercise, and the TV industry blames it on poor nutrition. The Atkins advocates point to too many carbohydrates in one’s diet, and the Ornish followers point to too much fat. The fruit-juice makers accuse soda companies, while the soda people blame the excess juice intake. The schools condemn parents for not getting involved in their children’s diet, and the parents believe the schools do not provide a nutritious environment. How do we eradicate the obesity epidemic if no one will take responsibility and make necessary changes?
Taking Control
There is a well-known adage: “an ounce of prevention is worth a pound of cure.” In an effort to help their children remain at an ideal weight, parents should begin to educate them and to promote good nutrition and exercise at an early age. Once a child is already overweight, addressing the issue becomes far more difficult. As there is no safe medical treatment to suppress the appetite of a child, the only approach to tackling childhood obesity is a collective one, with parents, families and schools working in synergy.
For our community to take control of pediatric obesity, parents must make health and nutrition a priority. Both parents must be involved and on the same page. Additionally, siblings, grandparents, nannies, housekeepers and teachers should be on board. Parents often do not want to discuss weight issues in front of their child because they fear it might upset him. This is because oftentimes they approach the topic with negativity; using positive instead of negative reinforcement is much more effective. Rather than taking away privileges for unhealthy eating, parents should give rewards for eating healthfully.
An ideal time for using food as a reward is Shabbat, when our tables are bedecked with our finest dishes and we all together as a family. There’s nothing wrong with having special treats on Shabbat as long as they are offered in moderation and the children eat healthfully the rest of the week.
The emergence of pediatric obesity in the Orthodox Jewish community has reached critical proportions. That we live in times where food is plentiful is a tremendous blessing. But a Torah Jew knows that the bodies we inhabit are on loan from the Almighty, and we must take care and tend to them as such. Overindulgence and gluttony are not Jewish values.
We are meticulous about checking the kashrut of our children’s food, for we know that their spiritual wellbeing is at stake. But perhaps the kashrut symbol on a package should not only reflect the product’s adherence to the Torah laws but should also reflect its nutritional value. Just as we educate our children about shemirat hanefesh, protecting our spiritual health, we must also educate them about shemirat haguf, protecting our physical health.
Dr. Nagel is double boarded in pediatrics and pediatric endocrinology, and has been in clinical practice for over twenty years in Los Angeles. He is associate clinical professor of pediatrics at the David Geffen School of Medicine at UCLA. He wishes to thank Zev Nagel, his son, and Rabbi Daniel Korobkin for their insightful comments on this article.
Notes
1. In this article, the terms “obese” and “overweight” are used interchangeably.
2. Testimony before the Subcommittee on Education Reform on the obesity crisis for the US, House of Representatives, 16 July 2003.
3. Berachot 32b.
4. US Department of Commerce, Bureau of the Census, Historical Statistics of the United States, 2006.
5. Journal of the American Medical Association 288 (October 2002): 1728-1732.
6. “Prevalence and Trends in Overweight US Children and Adolescents 1999-2000,” Journal of Clinical Endocrinology and Metabolism 90, no. 3 (March 2005): 1871-1887.
7. “Body Mass Index Charts: Useful But Underused,” Journal of Pediatrics (April 2004): 455-460.
8. National Health and Nutritional Examination Surveys (NHANES I-IV).
9. “Predicting Obesity in Young Adulthood from Childhood and Parental Obesity,” New England Journal of Medicine 337 (1997): 869; The Journal of Nutrition 127, no. 9 (September 1997): 1884S-1886S.
10. Rambam, Hilchot Deot 1:4
11. “Prevalence of Impaired Glucose Tolerance among Children and Adolescents with Marked Obesity,” New England Journal of Medicine 346, no. 11 (March 2002): 802.
12. “The Metabolic Syndrome,” Journal of Pediatrics 145, no. 4 (2004): 427.