Debate on the paper by Sichieri & Souza

The thorough and insightful review by Sichieri & Souza clearly describes the complexity of strate-gies used to prevent or reverse the trend of child-hood obesity. The most salient aspect of the re-view was the sheer variety of programs that have been attempted and the remarkably few that were successful, even in the short term. This ob-servation was remarked upon quite well by the authors and illustrates the problem with solving this dilemma once it has been underway. The authors make good use of their critical writing to emphasize that this global problem is multi-factorial and that most prevention or treatment programs address at most two to three factors as-sociated with obesity. The sheer number of fac-tors that are associated with childhood obesity is the underlying problem left unresolved by most programs and my response will focus on this is-sue by expanding on the observations of Sichieri & Souza.Obesity is the accumulation of excess body fat associated with the development of chronic metabolic diseases (e.g. type 2 diabetes, hyper-tension, cardiovascular disease, etc). The route to the development of this pathological state begins with a seemingly mild disruption of energy bal-ance normally maintained by the human body. It can be estimated that a difference of as little as 1-2% of total energy expenditure (estimated at an extra 50-100Kcal a day in combination of calories consumed or decreased energy expended) can promote a gain of 20-50 kilograms over a decade. Determining the origin of this positive energy balance is the 10 million dollar question as an extra cookie a day, parking closer to a store, using a car instead of walking, sitting versus standing, using an elevator versus stairs, an extra serving of ice cream, or a slightly larger portion of food, can each contribute to the 1-2% change in en-ergy balance. More importantly, exploring the vast socio-environmental factors that foster and support any of these changes in diet or activity is daunting for any investigator. Attempting to influence the correct combination or combina-tions within any one program or to statistically control for all confounding factors is impossible. Thus, the review presented rightly describes the “absence of positive results” to be found with ex-isting programs to prevent or reverse the current trend in childhood obesity. Specific programs that have studied various aspects of obesity, in-cluding promoting physical activity, consump-tion of nutrient and fiber rich foods, sugar-sweet-ened beverage consumption, portion sizes, fam-ily dynamics, and even industry-related aspects highlight factors that are associated with obesity, but are not easily controlled or have little influ-ence on maintaining body weight or promoting weight loss.First, school-based interventions and pro-grams will continue to fail if family dynamics are not integrated as a child spends approximately 30-40% of his/her day at school, the remainder being at home. Thus, opportunities to influence behavior are shared by schools and home and attempting to influence one without the other challenges only a portion of the status quo and leaves the child in essentially the original setting with limited tools to change the whole environ-ment that surrounds him/her.Second, the food environment that a child confronts each and everyday is moving more rapidly away from foods that promote health and prevent disease and towards foods that promote excess energy intake. Still, this is the dietary real-ity in which children are now forced to face be-ginning at early ages when the even the golden arches of fast food restaurants are recognized long before letters of the alphabet. The need to accept the fact that the opportunity for eating less than healthful foods is not going to diminish over the next several decades, if ever, sends a clear message to nutrition professionals and parents that children need to learn how to incorporate such foods into a healthful lifestyle. This can be accomplished by emphasizing that eating such foods is an occasional, rather than regular, event, helping them choose healthful meals (such as milk over soda), suggesting smaller portion sizes, exposing the marketing tricks companies use to encourage consumption of their products, and so on.Third, maintaining a moderate level of physi-cal activity is key and begins at home and con-tinues at school and during free time. Parents and schools are again essential for promoting physical activity by encouraging children to sim-ply move. This movement does not need to be organized sports or other activities, but simply moving by using stairs, taking short walks, not sitting at a computer or in front of a television, and performing activities together can result in an extra 20-30Kcal burned each day. Promoting physical activity early in life is key as it is far easier and better to prevent fat gain that to attempt to