Dr. Paula Gustafson, a Shelbyville pediatrician, employs a unique weapon in the fight against childhood obesity: sippy cups containing sugar cubes.
The cups convey how much sugar eight ounces of juice contains. Apple juice can have the equivalent of 12 to 13 sugar cubes, depending on the brand. A sweetened orange juice, 14 cubes. And Mountain Dew? A whopping 18 cubes, not that anyone would recommend the caffeine-laden drink for children.
The real enemy, Gustafson said, is juice and other sweet beverages.
If toddlers — yes, toddlers — stop guzzling juice, she thinks, doctors might curb the surge in childhood obesity.
Increasingly, experts such as Gustafson are recognizing that the fight against obesity may be lost by the time a child starts school. So they are looking for ways to change the eating habits of tots.
“Two to 5 is the ideal time to reset the button,” said Dr. Sandeep Gupta, director of a weight loss program at Riley Hospital for Children at Indiana University Health. “There’s increasing awareness that we need to evaluate for and address obesity at a younger age.”
Conventional wisdom used to hold that chunky toddlers would eventually thin out. But studies have shown that in many cases, a chunky toddler grows into a chunky adolescent. And that can lead to a host of health problems, such as high cholesterol and diabetes. Excess weight also can lead to fatty liver disease and heart problems.
So those on the front lines of the battle against childhood obesity emphasize that teaching healthy habits to smaller children will pay off later. Children who maintain healthy weights will not grow up to teeter on the verge of obesity.
“There has been a subtle shift in thinking,” said Julie Lumeng, an assistant professor of pediatrics at the University of Michigan. “It’s easier to prevent obesity than to treat it.”
Gustafson’s thinking underwent a similar shift.
She’s tried counseling her patients on obesity, she said, but “like the rest of the country, I’ve gotten nowhere.”
Almost 15 percent of children ages 10 to 17 in Indiana are obese. Add in those who are overweight and the percentage increases to 29 percent, according to the Indiana State Department of Health. About 65 percent of Hoosier adults are obese or overweight.
One in five children from 2 to 5 nationally is overweight or obese, an Institute of Medicine report published earlier this year found. And community pediatricians such as Gustafson are seeing more and more overweight youths. Two years ago, her practice, Major Pediatrics, implemented an electronic health record system, allowing her to take a more detailed look. About 15 percent of her patients were obese or overweight at 2 years old. By the time they reached school age, that had soared to 40 percent.
The Pediatric OverWeight Education and Research program at Riley welcomes patients as young as 2, said Gupta, the program director. And in recent years, more of those young patients have appeared.
Tackling the problem at a younger age, however, has its challenges.
Obesity prevention for older children takes place in schools and does not require parental participation. Reaching preschool-age children, however, means doctors have to enlist parents who may take offense at being told their child is at risk of being overweight or obese.
Gustafson decided to concentrate on all her young patients, not just those who had a weight problem. The transition from breast milk or formula to other beverages — such as juice and other sugary liquids — might be to blame, she suspected. Add the prepackaged snacks toddlers consume, and the calories flow.
Completely changing parents’ habits seemed daunting. But maybe, Gustafson thought, she could come up with an easy prescription to keep weight off.
To help parents, Gustafson has devised what she calls the Major Easy Three, three tips for parents: Drink milk with meals; offer water for refreshment; and eat only at the table.
“We decided we need to make it very simple,” she said. “A person can only remember three things.”
Since January, Gustafson has reinforced the Major Easy Three during patient appointments. Ideally, parents will never introduce juice to their toddlers, since once a child develops a taste for it, it’s harder to stick with milk or water.
Often her message comes as a surprise. Until her daughter’s 15-month checkup a few months ago, Erica Martin didn’t think twice about letting her drink three to four sippy cups of juice a day. Although she doesn’t worry about Emma Linton’s weight, Martin cut back on the sweet stuff.
“It surprised me how much sugar was in juice. . . . It was ridiculous,” the Shelbyville mother said. “I just assumed it was good for her, and it’s not.”
No one drinks juice with meals at the Stewart house. Beverage options for Eli, 2, and Macie, 5, are water and milk.
At 2, Eli Stewart has never had any juice, thanks to Gustafson. Weight isn’t a concern for him or his older sister, Macie, but their mother, Nicole, figured it couldn’t hurt to be careful.
“He’s a solid 2-year-old, so I figure he doesn’t need the unnecessary calories,” the St. Paul mother said. “Milk and water give them everything they need, so I have stuck with that belief.”
She’s passed it on to Macie. When her preschool served juice, Macie asked for water.
Gustafson thinks the Major Easy Three could serve as a foundation for combating obesity on a national scale. She has put together a website educating parents and her colleagues about the effort. She’s hoping the Indiana chapter of the American Academy of Pediatrics adopts her plan as its obesity initiative.
Experts do not contest that her proposals make sense. But some say they omit some other key prevention pieces.
Turning off the television must be included in a prescription for healthy weight, Lumeng said. Pediatricians recommend children younger than 2 see no television and those older than 2 watch less than two hours daily.
Exercise is also a key part of maintaining a healthy weight, said Debi Pillarella, a youth fitness spokeswoman for the American Council on Exercise.
Structured sports programs provide exercise, but parents should model a life filled with movement for their children and engage in activity as a family.
To broaden the Major Easy Three, Gupta proposes combining Gustafson’s first and second recommendations into one; extending eating meals at the table to include avoiding excess-calorie processed foods; and adding physical activity as the third tip. Still, the recommendations she makes are better than nothing, he said.
“They need to be modified a little bit,” Gupta said, “but it’s a great start.”
Shelbyville mother Sandy Morningstar, who has brought her 9- and 12-year-old boys to Gustafson since they were babies, wishes she had heard the tips years ago. During a well-child visit for her 12-year-old this summer, Gustafson brought up his weight.
Both her boys tend to stick with water, so drinking sugary beverages does not pose a problem, Morningstar said. Eating in front of the television, however, hit home. Between her job as a nurse and her husband’s as a fireman, family meals were erratic. The boys had a tendency to snack in front of the TV.
Now Morningstar asks the boys to take their food into the kitchen to eat. Often, they’ll stop eating rather than move.
“They’re not hungry sitting in front of the television,” she said. “They’re just bored.”
Had the doctor raised the issue earlier, Morningstar said, eating in front of the television would never have become a common practice in their home.
“Sure, I know better, but when the doctor looks at you in the face and says you need to do this, it’s a wake-up call,” Morningstar said. “I probably would have started it earlier and not gotten some of those bad habits.”
Call Star reporter Shari Rudavsky at (317) 444-6354.
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