Healthy Weight Toolkit

School and growth

The early school years are when children establish many routines and habits that guide their healthy eating as they age, including making smart food choices, getting enough sleep, and adopting regular exercise.

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PILLAR ONE: Physical Activity

Ongoing research supports that regular daily physical activity in early childhood improves crucial health factors, such as cardiovascular and muscular fitness, and greater bone mass and strength. It can also help children reduce their risk of obesity and maintain a healthy weight.

Research also suggests that the benefits gained from regular activity during youth carry forward into adulthood, and also can include improved memory and cognitive function, sharper attention, healthier sleep, better moods, and increased academic performance.

It’s essential to help parents understand the various benefits of keeping their children physically active. Also, point out that parents are the best role models when it comes to fitness. Children are more likely to be engaged if they see their parents doing the same.

For the best results, children ages 5 to 9 should get at least 60 minutes per day of moderate-to-vigorous physical activity. They also should do vigorous exercise and muscle- and bone-strengthening movements at least three days per week.

Keep in mind that exercise does not always have to be a structured activity. Running around and playing counts towards the recommended amount of exercise.

Here are some examples of the various activities children ages 5 to 9 can do:

ACTIVITY LEVEL

• Moderate-to-vigorous (You breathe hard, but can still maintain a conversation)
  • Brisk walking
  • Bicycle riding
  • Active recreation, such as hiking, riding a self-propelled scooter, and swimming
  • Playing games that require catching and throwing, such as baseball, softball, and Frisbee

ACTIVITY LEVEL

• Vigorous (You can only say a few words before taking another breath)
  • Running
  • Bicycle riding
  • Active games involving running and chasing like tag and flag football
  • Jumping rope
  • Organized sports such as soccer, basketball, swimming, and tennis
  • Martial arts
  • Vigorous dancing

ACTIVITY LEVEL

• Muscle-Strengthening (Anything that makes the muscles work harder)
  • Games like tug of war
  • Resistance exercises using body weight or bands (push-ups, squats, pull-ups, etc.)
  • Rope or tree climbing
  • Climbing and swinging on playground equipment like monkey bars
  • Some forms of yoga

ACTIVITY LEVEL

• Bone-Strengthening (High impact, dynamic, short-duration activities)
  • Gymnastics
  • Hopping, skipping, and jumping
  • Running
  • Tumbling
  • Sports that involve a rapid change in direction, such as flag football, soccer, basketball, and martial arts

PARENT EDUCATION

Physical activity strategies

The best activities are the ones that children enjoy, so ask them if they want to do more of a favorite one, or try something new. Keep in mind that anything is better than nothing, and small steps often lead to lasting changes. Here are some strategies that parents can try to encourage more daily activity for their children:

• Limit TV watching and screen time to two hours per day.
• Adopt low-cost or free activities, like playing at parks and recreation centers, community sports leagues, and after-school programs.
• Incorporate more child-friendly equipment and games that encourage activity into their daily life. For example:
  • Balance beams
  • Relay races
  • Bean bags
  • Hula hoops
  • Monkey bars
  • Climbing toys
  • Balls
  • Yoga mats
  • Obstacle courses

Wellness Tip

Do more family activities

Another way to help children be more active is to turn daily living experiences into fun family affairs. For example:

ACTIVITIES OF DAILY LIVING

• Walking the dog
• Helping with household chores
• Playing outside
• Taking the stairs instead of the elevator
• Gardening/yard work
• Flying a kite
• Helping wash the car
• Walking or biking to/from school

PILLAR TWO: Nutrition

As with preschool-age kids, the most common nutrition-related causes of obesity in early childhood (ages 5 to 9) are drinking too many sugar-sweetened beverages, choosing high energy, low nutrient “junk foods,” consuming large portion size, and snacking too often.

Children in this age group should eat three meals and up to two healthy snacks a day at structured times. Families should focus on age-appropriate portion sizes and no sugar-sweetened beverages, like soda and juice drinks. In terms of fruit juice, the American Academy of Pediatrics suggests 4 to 6 ounces per day for children ages 4 to 6. For kids ages 7 and older, the advice is no more than 8 ounces, or 1 cup of the recommended 2 to 2.5 cups of fruit servings per day. Here is a breakdown of the recommended daily intake and portion sizes for early childhood:

Intake

• 6 ounces protein
• 2 to 3 cups of dairy
• 3 cups non-starchy vegetables
• 2 cups fruit
• No more than 1½ cups whole grains

Portion Sizes

Proteins - 2 ounces

Fruit - ½ cup

Vegetable - ½ to 1 cup

Dairy - 1 cup

Grains - ½ cup

Wellness Tips

Encourage parents to adopt the following healthy eating habits for their children, which can help curb the risk of obesity:

• Make healthy foods easily accessible. Keep the kitchen well stocked with whole fruits and vegetables and healthy snacks like nuts. See the handout “25 Healthy Snacks” for suggestions.
• Allow children to help with meal planning and preparation. The practice can teach them what foods and ingredients are healthiest.
• Whenever possible, eat meals as a family. Avoid watching TV and do not allow any distracting electronic devices at the table.
• Fill half of their plates with colorful whole fruits and vegetables.
• Provide water and milk to drink throughout the day, which helps children from filling up on junk food and processed snack.
• Meals and snacks should center around healthy proteins, vegetables, and fruits with less emphasis on grains.
• Offer dessert only on special occasions.
• Review food labels and avoid products with high amounts of added sugars. The American Heart Association recommends children should limit daily sugar intake to 12 to 25 grams.
• Reduce fast food meals.
• Praise children for trying new healthy foods.
• Don’t tell children to “finish their plate,” which can cause overeating. Instead, let them say when they are full.

Watch the carbohydrates

When a child has a body mass index (BMI) greater than the 95th percentile, the child's diet should limit carbs and focus more on low glycemic index foods, such as oats, quinoa, 100 percent whole-wheat pasta, and low-fat dairy foods. Low glycemic index foods can help control blood sugar levels and manage cravings. See the “Go-Slow-Whoa Plan” handout for more details.

PILLAR THREE: Behavioral Health

As children enter the early school-age years, from kindergarten to fourth grade, it is vital to help parents monitor and improve their child's behavioral, emotional, and social functioning. Anxiety and fears often develop during this age range. Additionally, it is essential to maximize social support for school-age children to promote positive coping skills, resiliency, and healthy lifestyle habits. These changes can protect children from emotional or chaotic eating that can raise their risk for weight gain.

Anxiety and fear is a natural part of the body's fight-or-flight response and protects us from possible danger. In some children, these feelings can arise during non-dangerous situations, like when teased at school and having parents go through a divorce. They also can occur during stressful situations, such as test-taking and speaking in front of the class.

Anxiety and fear can appear in many forms. For example:

• Constant worry about specific people, places, or events
• Afraid that something terrible or embarrassing may occur
• Frequent stomach or headaches
• Series of ritualized behaviors, such as rechecking locks, washing hands excessively, and counting or reciting phrases.

Managing anxiety and fear

Parents often need help with managing their children’s anxiety and fears. Here are some strategies you can share with them.

• Never force your child to face a fearful situation all at once—throwing him or her into a swimming pool when afraid of water, for example—as this will often make the fear worse instead of better.
• Instead, encourage your child to approach fearful situations gradually. This tactic can help him or her breakdown the event into smaller, more manageable parts and help them progress at a less stressful pace. For example, if your child is afraid of a new family pet, suggest he or she first look at the animal from afar. When the child has less anxiety and feels more comfortable, he or she can slowly approach the animal. When the child feels more confident, they then can touch the animal.
• Help your child share his or her common fears and worries and offer solutions when those situations arise. For example, call a parent or seek help from a police officer or another adult if he or she is lost. If your child resists talking about their fears, ask him or her to write or draw about them.
• Do not provide false reassurance about your child’s realistic fears. For instance, never say, “You will never throw up again” when your child fears getting sick. Instead, be truthful and explain why and how specific measures can prevent the feared event in the future, such as "That’s why we take our vitamins to help keep our body healthy.”
• Teach your child relaxation techniques to calm the mind and body when he or she feels anxious or afraid. Examples include deep breathing (inhale for three to four seconds and then exhale for four to six seconds) and squeezing a small stress ball.
• Praise your child when he or she overcomes any fear or anxiety. For example, say, "Great job reading your project to the class!" if he or she resists standing in front of people.
• Create bravery statements to help instill confidence, such as "I can do this!" and "I am strong and brave!" and have your child repeat them whenever he or she feels anxious.

PARENT EDUCATION

Social Support

It's also essential for children in this age range to have adequate social support from family and friends. Positive social support helps with their emotional self-regulation. Parents can offer this kind of support in many ways. Examples include:

• Emotional support: Listen when your child shares their difficulties with you.
• Practical help: Help your child with basic daily chores, such as packing lunches and doing homework.
• Sharing information: Teach your child new facts and life skills.

Here are some other strategies parents can adopt to increase social support for their children.

• Enroll your children in extracurricular activities or sports. They do not need to be expensive activities either; for example, try school clubs, school sports, church youth groups, and volunteering.
• Keep your children active and engaged with their peers, like spending time with friends outside of school, attending birthday parties for friends and family, and going to school events.
• Practice social skills with children at home. For example, have them create a list of questions they may ask a new person (“Where are you from? How was your weekend?”).
• Teach your children to be kind, caring, and considerate when interacting with others. Coach them on proper communication and social skills, like replying to questions, using polite language, and complimenting others.
• Encourage your children to invite friends over for play days or sleepovers. This kind of interaction helps parents monitor how their children socially interact, so they can provide additional support and coaching, as needed.

PILLAR FOUR: SLEEP

Adequate sleep helps to reduce the risk of obesity for both adults and children.

The National Sleep Foundation recommends nine to 11 hours of sleep for children ages 6 to 9, although as few as seven hours and as much as 12 hours also may be appropriate. (Five-year-olds need 10 to 13 hours with as few as eight and as much as 14.)

Sleep disturbances often can keep this age group from getting their required rest. Two of the more common are sleepwalking and obstructive sleep apnea.

Sleepwalking. About 15 percent of children sleepwalk at some point. It is also more common among early school-age kids than any other age group as 6 percent have several sleepwalking events each week.

Sleepwalking is characterized by behaviors like sitting up in bed abruptly and navigating clumsily around the home. It typically occurs one to two hours after the onset of sleep during Sleep Stage IV when the deepest sleep occurs.

Safety is paramount in sleepwalking scenarios. Here is what parents should know if they experience their child sleepwalking:

• Secure windows and doors to the outside or any potentially hazardous areas. Installing safety alarms also may be necessary.
• A child is often unresponsive and difficult to arouse while sleepwalking. Do not force the child awake. Instead, redirect him or her to bed.
• Sleepwalking is sometimes associated with nocturnal enuresis (bed wetting).

Obstructive Sleep Apnea (OSA). OSA is a disorder in which a sleeping person experiences either partial upper airway obstruction for prolonged periods or complete upper airway obstruction intermittently.

OSA can occur in all age groups, but it is most common between the ages of 2 to 6. Children with OSA frequently snore with periodic pauses or gasps in their breathing. Snoring can disrupt their sleep and cause problems with attention, concentration, and daytime sleepiness.

Always screen children for snoring during wellness checks. Refer any child who snores three or more nights per week, and has any OSA symptoms, to a sleep medicine physician/sleep lab, or a pediatric ear, nose, and throat physician. A polysomnography—a test used to diagnose sleep disorders—can diagnose OSA.

School-age children who are overweight or obese are at higher risk for OSA, although this becomes more apparent in preadolescents and adolescents. OSA symptoms can improve with a healthier weight.

Children with OSA also may require an adenotonsillectomy as early childhood is when tonsils and adenoids are most massive relative to the size of the oropharynx.

Some children with OSA may need to use a Continuous Positive Airway Pressure (CPAP) machine at night. However, this is a second-line option for children who are not surgical candidates as it is often poorly tolerated.