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Albumin: This major protein constituent of blood is often given to individuals who need to retain more fluid in their bloodstream, such as burn victims or patients with liver failure or extremely heavy bleeding (hemorrhage). Albumin (along with clotting factors, growth factors, and immunoglobulins) is sometimes referred to as a minor blood fraction. If you are a Jehovah's Witness, whether or not you can accept treatment with a minor blood fraction may be considered an individual "matter of conscience."

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Allogeneic blood: Blood donated from another individual, which is typically stored and then provided through a transfusion. Jehovah's Witnesses do not accept allogenic blood.

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Anemia: A condition in which an individual's blood can't supply an appropriate amount of oxygen to their organs and tissues, either due to a low volume of blood, too few red blood cells in the blood, or too little hemoglobin or iron in the red blood cells. Patients who are suffering from severe anemia are sometimes more difficult to manage, unless they are treated by a team that is very experienced in transfusion-free medicine.

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Apheresis: A process used to obtain blood components (such as platelets) from a donor. The blood is removed from the donor, the necessary cells are harvested and retained, and the donor's plasma is returned to the donor. Donated platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses. However, "therapeutic apheresis" may be acceptable to some Jehovah's Witnesses because it is a treatment performed on the patient's own blood.

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Blood banking: This is when blood is donated by a person for their own use or a specific individual's use at a later time. It is usually done because of fear that donor blood will not be available or might have contaminants, or because the person has a rare blood type. This procedure is not "bloodless medicine" because it involves blood storage and blood transfusions.

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Blood salvage: Blood salvage procedures collect blood lost during or after surgery. A variety of methods may be used to collect blood, including suction and drainage devices. The devices that are used are sometimes called "cell savers." Those who object to blood transfusions may feel comfortable with "closed loop" blood salvage, where the blood is never stored and retains a semblance of connection to the patient at all times.

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Cautery: Deliberate surgical destruction of tissue, either because the tissue is abnormal or to seal off a bleeding area. Cautery is a method of reducing bleeding during transfusion-free surgery. It may be achieved through heat, freezing, chemical scarring, electricity, light, and ultrasonic or microwave energy.

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Cell savers: Devices that capture and hold blood during or after surgery, so that the blood can be returned to the patient.

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Clotting: The complex chain of chemical events that produces a plug (clot) at the site of bleeding. It is important for a patient undergoing transfusion-free surgery to have good clotting ability, in order to reduce bleeding/blood loss. Certain medications may interfere with clotting, such as aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs; anticoagulants (such as Coumadin); vitamin E; and herbal preparations containing garlic or ginkgo biloba.

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Clotting factors: Chemicals that circulate in the blood and interact together to help cause blood clotting at the site of an injury.

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Coagulation: The conversion of liquid (blood) into a somewhat solid plug that can prevent further bleeding from a particular site.

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Colloidal solutions: Intravenous fluid solutions that contain water, salts, sugars, and protein. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Some colloidal solutions contain albumin -- a protein whose use is a matter of personal conscience for Jehovah's Witnesses.

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Cryosurgery: A surgical technique that uses extreme cold to destroy abnormal tissues in the body. It is sometimes used as a bloodless medicine technique -- by freezing tissue, bleeding is minimized.

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Crystalloid solutions: Intravenous fluid solutions that contain water, salts, and sugars. They may be given to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery. Jehovah's Witnesses find cystalloid solutions such as Ringer's lactate and normal and hypertonic saline acceptable therapy.

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Donor: A person who gives blood. The donated blood may be stored and distributed to hospitals and medical centers to be given to a patient when needed (as a transfusion). When a patient receives whole blood in this way, this is considered traditional medicine -- NOT "bloodless medicine." However, donated blood may be used to harvest blood components that may be used during some bloodless procedures.

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Embolotherapy: Refers to various methods of blocking a bleeding blood vessel, preventing further blood loss. These include chemical agents that scar the inside of the blood vessel; mechanical agents that block a bleeding vessel, including metal coils and latex or silicone balloons; particles or microspheres, including gelatin foam; and injected liquid that quickly turns into a thicker gel-like or spongy mass to prevent bleeding from a vessel.

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Endoscopy: A scope that can be used to visualize the inside of the body, either through insertion into a tiny incision or by passing the scope through a body opening (such as the mouth or anus). Endoscopy is used to examine, biopsy, or surgically treat a variety of conditions. Types of endoscopy include arthroscopy (joints); bronchoscopy (bronchial tubes, lungs); colonoscopy/sigmoidoscopy (large intestine); colposcopy (vagina, cervix); gastroscopy (stomach, small intestine); laparoscopy (abdomen); and others. Endoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding. It is therefore a valuable bloodless medicine technique.

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Erythropoietin: Erythropoietin is the name of a chemical normally produced by your body, primarily by your kidneys. Erythropoietin stimulates the bone marrow to produce red blood cells. Laboratory-made synthetic erythropoietin (e.g., Procrit, Epoetin alfa, Epogen, or Aranesp) may be administered prior to a bloodless surgery procedure in order to maximize your bone marrow's production of red blood cells. Other synthetic chemicals that mimic the activity of erythropoietin are in development.

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Fibrin glue: A substance made from human clotting factors. These clotting factors can be harvested from donor blood plasma or from a patient's own blood plasma. Fibrin glue can be applied to a bleeding vessel. It both blocks the vessel from bleeding and activates normal clotting/coagulation activity. Because fibrin glue is made from blood products, each individual will need to examine their own conscience to decide if its use is personally acceptable.

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Fluid expanders: Intravenous fluid solutions that are used to increase the volume of fluid in the circulating blood. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Gamma knife: A high-tech surgical tool that can be used for brain surgery. This technique utilizes a powerful and precise form of radiation to destroy tumors or abnormal blood vessels with less blood loss than a traditional scalpel.

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Harmonic scalpel: A surgical tool that uses ultrasound waves to cut tissue and seal bleeding vessels at the same time -- a helpful characteristic in transfusion-free surgery, because it helps keep blood loss to a minimum.

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Hemodilution: The process of making blood more dilute than normal. The result is that when you bleed during surgery, your diluted blood contains a lower concentration of red blood cells.

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Hemoglobin: A chemical within red blood cells that allows oxygen to be carried throughout the body.

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Hemophilia: A disease in which the blood clotting system is defective, resulting in an increased likelihood of serious bleeding after even minor injury.

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Hemorrhage: Heavy bleeding.

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Hemostasis: To stop bleeding.

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Hyperbaric: To be at higher-than-normal atmospheric pressure. Hyperbaric oxygen therapy is used in some facilities to assist bloodless medicine in certain situations. You enter a chamber and breathe pressurized oxygen, which concentrates oxygen in your blood.

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Hyperoxic: Having higher-than-normal oxygen saturation.

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Hypotensive: Having low blood pressure. Hypotensive anesthesia is a technique that lowers a patient's blood pressure below normal during surgery. Blood loss tends to be slower when your blood pressure is low. However, blood pressure must be maintained at a particular threshold to ensure that all of your body's organs and tissues are receiving blood, so the practice of hypotensive anesthesia requires great skill and extraordinarily careful monitoring.

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Intraoperative: During the course of an operation.

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Iron: A nutrient that is required by your red blood cells for good oxygen-carrying capacity. Iron is important for bloodless surgery and can be obtained from dietary sources like red meat or through supplements, such as ferrous sulfate or ferrous gluconate.

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Kidney dialysis: A procedure in which the blood is cleansed of toxins through an outside machine, replacing work that the kidneys normally do.

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Laparoscopy: A surgical technique in which a lighted scope is inserted into a tiny incision in the abdomen. Laparoscopy can be used to visualize the inside of the abdomen for diagnosis, to retrieve tissue samples for biopsy, and to perform surgery using tiny instruments that are also passed into the abdomen through tiny "keyhole" incisions. Laparoscopy is considered a "minimally invasive" procedure, which results in reduced bleeding and may therefore be valuable for bloodless treatment of some conditions.

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Laser surgery: A surgical technique that uses the energy from light to cut through tissues. It can reduce bleeding compared to traditional scalpels and may therefore be valuable for bloodless treatment of some conditions.

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Major fractions: Blood products containing plasma, red blood cells, white blood cells, and platelets. Jehovah's Witnesses do not accept major blood fractions as part of any treatment.

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Mediastinal autotransfusion: A procedure performed most commonly after heart surgery, in which the fluids (including blood) that collect in the chest during and after surgery are collected and then given back to the patient through an IV.

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Minimally invasive surgery: Procedures that use small surgical cuts and holes, or no cuts at all. These methods can greatly reduce the amount of bleeding and are therefore of great importance to bloodless medicine. An example is endoscopy, which uses scopes inserted into small cuts or body openings. Another example is lithotripsy, which uses sound waves to break up a kidney or other stone into smaller bits, allowing it to pass out of the urinary system without having created any incision at all.

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Minor fractions: Blood products containing clotting factors, albumin, growth factors, and immunoglobulins. Some Jehovah's Witnesses accept minor blood fractions as an individual "matter of conscience."

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Normothermia: Normal body temperature.

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Normovolemia: All people maintain a particular volume of fluid circulating throughout their bodies; this is referred to as "normovolemia." During surgery, you will be given balanced intravenous solutions (volume expanders) to replace the fluids, salts, and sugars that you will invariably lose during the course of surgery.

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Oximeter: A device that monitors the amount of oxygen carried by the hemoglobin in red blood cells. In bloodless medicine, any blood a patient loses is not replaced by transfusion, so it is extremely important to monitor how much oxygen the patient's body is receiving from the remaining blood.

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Plasma: The fluid component of blood, in which the various types of blood cells are suspended. Jehovah's Witnesses consider plasma to be a major blood fraction and do not consider it to be an acceptable part of treatment.

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Plasmapheresis: A type of apheresis that is used to separate plasma from blood. Blood is removed from a donor, the plasma is harvested and retained, and the donor's blood cells are returned to him or her. Plasmapheresis may also be performed on a patient's own blood as a treatment for certain conditions.

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Platelet: A component of blood responsible for blood clotting at the point of an injury to a blood vessel. Without platelets, our blood would not be able to clot and hemorrhaging or uncontrolled bleeding would result. Platelets are considered a major blood fraction and are not acceptable to Jehovah's Witnesses as part of any treatment.

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Platelet gel: A concentrate made from a patient's own blood plasma, mixed with calcium and clotting compounds produced in cows. Platelet gel concentrates can be applied during the course of surgery to control bleeding. As with fibrin glue, platelet gel concentrates are produced from plasma, so their use by some individuals is a matter of conscience.

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Primary blood components: Red cells, white cells, plasma, and platelets (also called major fractions). Jehovah's Witnesses do not accept primary blood components (major fractions) as part of any treatment.

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Procuren solution: A solution made from an individual's own blood. The growth factors in the patient's own platelets are harvested, and reproduced in a laboratory to create the procuren solution. This solution is then applied to a wound to improve healing capacity and shorten duration of healing.

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RBC nuclear scan: A test in which the individual's own red blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of bleeding, because the tagged red blood cells will be seen leaking from these areas.

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Scalpel: Originally, a scalpel was a very sharp, small knife used to perform surgery. Now a scalpel can use a variety of energy sources to cut through tissue, including light (laser scalpel), microwaves (microwave-coagulating scalpel), ultrasonic energy (ultrasonic and harmonic scalpels), and radiation (gamma knife).

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Stereotactic/Stereotaxic: A technique for locating the exact area needing treatment by using advanced imaging techniques that verify the three-dimensional coordinates of the abnormal area. By pinpointing the exact area, the surgeon can minimize the amount of cutting (and hence bleeding) that occurs during surgery.

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Transfusion: The delivery of blood products to an individual to replace blood that is lost during surgery or from injury. The blood or blood products are usually donated anonymously or through blood banking, then stored until the time they are needed. At that point, the blood products are administered through an intravenous (IV) line into a patient's vein. A blood transfusion is what bloodless medicine seeks to avoid.

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Ventilation: To provide a patient with oxygen.

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WBC nuclear scan: A test in which an individual's own white blood cells are harvested, tagged with radioactive material, and then returned to the individual. Imaging scans are then performed that will highlight areas of infection, because the tagged white blood cells will migrate to these areas.

In the United States at least one child in three is overweight, and the number of overweight children continues to grow. Over the last 2 decades, this number has increased by more than 50 percent, and the number of "extremely" overweight children has more than doubled.

A doctor determines if children are overweight by measuring their height and weight. Although children have fewer weight-related health problems than adults, overweight children are at high risk of becoming overweight adolescents and adults. Overweight adults are at risk for a number of health problems, including heart disease, diabetes, high blood pressure stroke, and some forms of cancer.

Did You Know That...

  • Obese children and adolescents have shown an alarming increase in the incidence of type 2 diabetes, also known as adult-onset diabetes.
  • Many obese children have high cholesterol and blood pressure levels, which are risk factors for heart disease.
  • One of the most severe problems for obese children is sleep apnea (interrupted breathing while sleeping). In some cases this can lead to problems with learning and memory.
  • Obese children have a high incidence of orthopedic problems, liver disease, and asthma.
  • Overweight adolescents have a 70 percent chance of becoming overweight or obese adults.

Created by the National Institutes of Health, NIH Word on Health, June 2002

What causes children to become overweight?

Children become overweight for a variety of reasons. The most common causes are genetic factors, lack of physical activity, unhealthy eating patterns, or a combination of these factors. In rare cases, a medical problem, such as an endocrine disorder, may cause a child to become overweight. Your doctor can perform a careful physical exam and some blood tests, if necessary, to rule out this type of problem.

  • Genetic Factors: Children whose parents or brothers or sisters are overweight may be at an increased risk of becoming overweight themselves. Although weight problems run in families, not all children with a family history of obesity will be overweight. Genetic factors play a role in increasing the likelihood that a child will be overweight, but shared family behaviors such as eating and activity habits also influence body weight.
  • Lifestyle: A child's total diet and their activity level both play an important role in determining a child's weight. The increasing popularity of television and computer and video games contributes to children's inactive lifestyles. The average American child watches 4 hours of television each day, time that could be spent doing physical activity.

Is my child overweight?

If you think that your child is overweight, it is important to talk with your child's doctor. A doctor is the best person to determine whether your child has a weight problem. Physicians will measure your child's weight and height to determine if your child's weight is within a healthy range. A physician will also consider your child's age and growth patterns to determine whether your child is overweight.

For example, it is normal for boys to have a growth spurt in weight and catch up in height later. It is best to let your child's doctor determine whether your child will "grow into" a normal weight. If your doctor finds that your child is overweight, he or she may ask you to make some changes in your family's eating and activity habits.

Be supportive

One of the most important things you can do to help overweight children is to let them know that they are okay whatever their weight is. Children's feelings about themselves often are based on their parents' feelings about them. If you accept your children at any weight, they will be more likely to accept and feel good about themselves. It is also important to talk to your children about weight, allowing them to share their concerns with you. Your child probably knows better than anyone else that they have a weight problem. For this reason, overweight children need support, acceptance, and encouragement from their parents.

Focus on the family

Parents should try not to set children apart because of their weight, but focus on gradually changing their family's physical activity and eating habits. Family involvement helps to teach everyone healthful habits and does not single out the overweight child.

Increase your family's physical activity

Regular physical activity, combined with healthy eating habits, is the most efficient and healthful way to control your weight. It is also an important part of a healthy lifestyle. Some simple ways to increase your family's physical activity include the following:

  • Be a role model for your children. If your children see that you are physically active and have fun, they are more likely to be active and stay active for the rest of their lives.
  • Plan family activities that provide everyone with exercise and enjoyment, like walking, dancing, biking, or swimming. For example, schedule a walk with your family after dinner instead of watching TV. Make sure that you plan activities that can be done in a safe environment.
  • Be sensitive to your child's needs. Overweight children may feel uncomfortable about participating in certain activities. It is important to help your child find physical activities that they enjoy and that aren't embarrassing or too difficult.
  • Reduce the amount of time you and your family spend in sedentary activities, such as watching TV or playing video games.
  • Become more active throughout your day and encourage your family to do so as well. For example, walk up the stairs instead of taking the elevator, or do some activity during a work or school break-get up and stretch or walk around.

The point is not to make physical activity an unwelcome chore, but to make the most of the opportunities you and your family have to be active.

Teach your family healthy eating habits

Teaching healthy eating practices early will help children approach eating with the right attitude -- that food should be enjoyed and is necessary for growth, development, and energy to keep the body running. The best way to begin is to learn more about children's nutritional needs by reading or talking with a health professional and then to offer them some healthy options, allowing your children to choose what and how much they eat.

Don't place your child on a restrictive diet

Children should never be placed on a restrictive diet to lose weight, unless a doctor supervises one for medical reasons. Limiting what children eat may be harmful to their health and interfere with their growth and development.

To promote proper growth and development and prevent overweight, parents should offer the whole family a wide variety of foods from each of the food groups.

  • Most of the foods in your diet should come from the grain products group (6 - 11 servings), the vegetable group (3 - 5 servings), and the fruit group (2 - 4 servings). (See chart for suggested serving sizes.)
  • Your diet should include moderate amounts of foods from the milk group (2 - 3 servings) and the meat and beans group (2 - 3 servings).
  • Foods that provide few nutrients and are high in fat and sugars should be used sparingly. Fat should not be restricted in the diets of children younger than 2 years of age.
One Serving* Equals
BREAD, CEREAL, RICE, PASTA GROUP
  • 1 slice of bread
  • 1 ounce of ready to eat cereal
  • 1/2 cup of cooked cereal, rice, or pasta
MILK, YOGURT, CHEESE GROUP
  • 1 cup of milk or yogurt
  • 1 1/2 ounces of natural cheese
  • 2 ounces of processed cheese
VEGETABLE GROUP
  • 1 cup of raw vegetables or 1/2 cup of frozen leafy vegetables (cooked)
  • 1/2 cup of other vegetables -- cooked or chopped raw
  • 3/4 cup of vegetable juice
MEAT, POULTRY, FISH, DRY BEANS, NUTS GROUP
  • 2 - 3 ounces of cooked lean meat, poultry, or fish
  • 1/2 cup of cooked dry beans or 1 egg counts as 1 ounce of lean meat
  • 2 tablespoons of peanut butter or 1/3 cup of nuts count as 1 ounce of meat
FRUIT GROUP
  • 1 medium apple, banana, or orange
  • 1/2 cup of chopped, cooked, or canned fruit
  • 3/4 cup of fruit juice

*NOTE: Serving sizes are for children and adults ages 2 years and older. A range of servings is given for each food group. The smaller number is for children who consume about 1,300 calories a day, such as 2 - 4 years of age. The larger number is for those who consume about 3,000 calories a day, such as boys 15 - 18 years of age. For more information on healthy eating for children, visit the U.S. Department of Agriculture's food pyramid web site at www.mypyramid.gov.

If you are unsure about how to select and prepare a variety of foods for your family, consult a physician or registered dietitian for nutrition counseling. You may also want to refer to the readings and organizations listed at the end of this fact sheet for more information on healthy eating.

Carefully cut down on the amount of fat in your family's diet

Reducing fat is a good way to cut calories without depriving your child of nutrients. Simple ways to cut the fat in your family's diet include eating low-fat or nonfat dairy products, poultry without skin and lean meats, and low-fat or fat-free breads and cereals. Making small changes to the amount of fat in your family's diet is a good way to prevent excess weight gain in children. Major efforts to change your child's diet, however, should be supervised by a health professional. In addition, fat should not be restricted in the diets of children younger than 2 years of age. After that age, children should gradually adopt a diet that contains no more than 30% of calories from fat by the time the child is about 5 years old.

Don't overly restrict sweets or treats

While it is important to be aware of the fat, salt, and sugar content of the foods you serve, all foods-even those that are high in fat or sugar-have a place in the diet, in moderation.

Guide your family's choices rather than dictate foods

Make a wide variety of healthful foods available in the house. This practice will help your children learn how to make healthy food choices.

Encourage your child to eat slowly

A child can detect hunger and fullness better when eating slowly.

Eat meals together as a family as often as possible

Try to make mealtimes pleasant with conversation and sharing, not a time for scolding or arguing. If mealtimes are unpleasant, children may try to eat faster to leave the table as soon as possible. They then may learn to associate eating with stress.

Involve children in food shopping and preparing meals

These activities offer parents hints about children's food preferences, teach children about nutrition, and provide children with a feeling of accomplishment. In addition, children may be more willing to eat or try foods that they help prepare.

Plan for snacks

Continuous snacking may lead to overeating, but snacks that are planned at specific times during the day can be part of a nutritious diet, without spoiling a child's appetite at mealtimes. You should make snacks as nutritious as possible, without depriving your child of occasional chips or cookies, especially at parties or other social events. Below are some ideas for healthy snacks.

Healthy Snacks

Fresh, frozen, or canned vegetables and fruit served either plain or with low-fat or fat-free cheese or yogurt

Dried fruit, served with nuts or sunflower or pumpkin seeds

Breads and crackers made with enriched flour and whole grains, served with fruit spread or fat-free cheese

Frozen desserts, such as nonfat or low-fat ice cream, frozen yogurt, fruit sorbet, popsicles, water ice, and fruit juice bars

Warning: Children of preschool age can easily choke on foods that are hard to chew, small and round, or sticky, such as hard vegetables, whole grapes, hard chunks of cheese, raisins, nuts, and seeds, and popcorn. It is important to carefully select snacks for children in this age group.

Discourage eating meals or snacks while watching TV

Try to eat only in designated areas of your home, such as the dining room or kitchen. Eating in front of the TV may make it difficult to pay attention to feelings of fullness, and may lead to overeating.

Try not to use food to punish or reward your child

Withholding food as a punishment may lead children to worry that they will not get enough food. For example, sending children to bed without any dinner may cause them to worry that they will go hungry. As a result, children may try to eat whenever they get a chance. Similarly, when foods, such as sweets, are used as a reward, children may assume that these foods are better or more valuable than other foods. For example, telling children that they will get dessert if they eat all of their vegetables sends the wrong message about vegetables.

Make sure your child's meals outside the home are balanced

Find out more about your school lunch program, or pack your child's lunch to include a variety of foods. Also, select healthier items when dining at restaurants.

Set a good example

Children are good learners, and they learn best by example. Setting a good example for your kids by eating a variety of foods and being physically active will teach your children healthy lifestyle habits that they can follow for the rest of their lives.

Additional help

If you need to make changes to your family's eating and exercise habits, but are finding it difficult, a registered dietitian (RD) may be able to help. Your physician may be able to refer you to an RD, or you can visit the National Center for Nutrition and Dietetics of The American Dietetic Association (ADA) at the ADA's website: www.eatright.org.

If your efforts at home are unsuccessful in helping your child reach a healthy weight and your physician determines that your child's health is at risk unless the child loses weight steadily, you may want to consider a formal treatment program. To locate a weight-control program for your child, you may want to contact a local university-based medical center.

Look for the following characteristics when choosing a weight-control program for your child. The program should:

  • Be staffed with a variety of health professionals. The best programs may include RDs, exercise physiologists, pediatricians or family physicians, and psychiatrists or psychologists.
  • Perform a medical evaluation of the child. Before being enrolled in a program, your child's weight, growth, and health should be reviewed by a doctor. During enrollment, your child's weight, growth, and health should be monitored by a health professional at regular intervals.
  • Focus on the whole family, not just the overweight child.
  • Be adapted to the specific age and capabilities of the child. Programs for 4-year-olds are different from those developed for children 8 or 12 years of age in terms of degree of responsibility of the child and parents.
  • Focus on behavioral changes.
  • Teach the child how to select a variety of foods in appropriate portions.
  • Encourage daily activity and limit sedentary activity, such as watching TV.
  • Include a maintenance program and other support and referral resources to reinforce the new behaviors and to deal with underlying issues that contributed to overweight.

The overall goal of a successful treatment program should be to help the whole family focus on making healthy changes to their eating and activity habits that they will be able to maintain throughout life.

Created by the National Institute of Health, NIH Publication No. 97-4096

 

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Review Date: 4/17/2007

Reviewed By: Patrika Tsai, M.D., M.P.H., Assistant Clinical Professor, Pediatric Gastroenterology, Hepatology and Nutrition, University of California, San Francisco, San Francisco, CA. Review provided by VeriMed Healthcare Network.


The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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