If your child loves to eat unhealthy foods, and gets little or no exercise, he or she could be heading towards obesity, a growing problem among children in Singapore and around the world. Obesity and excess body fat are major risk factors for chronic illnesses such as diabetes, hypertension and obstructive sleep apnoea in children, just like in adults.

Doctors and dietitians from the Departments of General Paediatrics & Adolescent Medicine, Sports Medicine Service and Nutrition and Dietetics at KKH, give detailed answers to your questions.

Question by sieweng55

My boy is 10 years old but still has his baby fat. Isn’t it okay for kids to be a bit chubby when young? But recently he has expressed his concerns about his weight. I would like to find out how do recognize signs of obesity in a child? How can i help him or when should we seek medical care?

Answered by Dr. Oh Jean Yin Consultant Department of Paediatrics, General Paediatrics & Adolescent Medicine KK Women’s and Children’s Hospital

The body image and the weight measurement alone are definitely not accurate in determining if any child has a health risk such as obesity. Weight has to always be considered in context of the height. The BMI (Body Mass Index) is a simple formula that is used. In children, it is important to also note that the adult BMI cut offs are not applicable. The measurements are based on age and gender and these charts are available in the child’s health booklet. BMI for age and gender above the 90th and 97th percentile identify varying risk levels and it would help to see a healthcare practitioner to make an evaluation. Remember too that BMI measurements are a “screening” tool not a diagnostic one. The decision about whether a child truly has an overweight or obesity problem requires additional information such as medical history, dietary and physical activity habits, family history and screening for related illnesses. It is advisable to consult a doctor if you wish to get an opinion about your son in particular.

Question by mosmos

A child’s healthy growth and development needs food full of nutrition. If we restrict the fat intake, will it hinder the growth and development of the child?

Answered by Senior Dietitian from the Department of Nutrition and Dietetics at KK Women’s and Children’s Hospital

Both the American Academy of Pediatrics as well as Singapore’s Health Promotion Board (HPB) recommend limiting the overall fat intake for children above 2 years of age to safeguard against obesity and heart disease. Studies have shown that for the majority of children, there is no adverse effect of limiting fat intake on children’s growth, nutrient intake as well as psychological well-being. Apart from total fat intake, the type of dietary fat in the diet is also important. Saturated fat from animal fats (e.g. fatty meat, chicken skin) and trans fat from commercial processed foods (e.g. baked products, frozen fried foods, hard margarines) are especially hazardous for heart health, and should be avoided. Fat restriction is not recommended for children below 2 years of age as they are still growing rapidly, and fat is required in promoting brain and nervous system development.

Question by lamwkant

I'd like to know the various causes of overweight in adolescents and how to overcome this issue.

• What would you recommend for a day’s menu for weight reduction?
• Advise how can we work together to overcome the family weight problem.

Answered by Dr. Oh Jean Yin (profile) Consultant Department of Paediatrics, General Paediatrics & Adolescent Medicine KK Women’s and Children’s Hospital, Dietitian from the Department of Nutrition and Dietetics KK Women’s and Children’s Hospital and Mr Micheal Lim Senior Clinical Exercise Physiologist Sports Medicine Service KK Women’s and Children’s Hospital

It is a complex problem with interactions of environment, behaviour and genes. Subtle alterations in the interaction results in the imbalance between energy intake and energy expenditure which favours the net deposition of calories as fat. So, in other words, researchers believe that in some individuals there may be a genetic tendency for easy weight gain, and in an environment that promotes this, such as exposure to energy dense/ high caloric foods with sedentary activity, obesity may result.

Sit down together to identify a time and list the activities which the family can do together. Make sure that the activities are fun and engaging for the whole family. Go to the beach or parks on the weekends for cycling / b​risk walking. Check the community centres for sporting facilities and organise a badminton or basketball game.

Organise a game or challenge to encourage every family member to be physically active throughout the week. Some suggestions for challenges can include:

1. Stairs Challenge - be the first in the family to climb xx flight(s) of stairs in one week
2. FIND THIRTY – be the first in the family to accumulate up to 30 minutes of physical activity a day
3. Family pedometer marathon – a pedometer is a small device that can be used to measure step counts. This can be used as an estimate of an individual’s physical activity levels during the day or week. Be the first in the family to accumulate 42,195 steps in any week. This however does not meet the recommended step counts for adults and children, which are >10,000 steps and > 12,000 steps per day respectively. Work together as a family to progressively increase the step counts to meet these recommended targets.

There are many causes/factors that increase one’s risks of being overweight. First, if there is more energy taken in (from an excess intake in calories) than energy expended, it results in a greater risk of being overweight over time. Second, an inactive lifestyle can also predispose a person to being overweight. Other factors that also contribute to risks of being overweight include environmental factors such as oversized food portions and food advertising during television watching, all of which can result in excessive calories being ingested than what the body requires. Genes and family history can also be an influence - if one or both parents are overweight/obese, chances of being overweight are greater. Health conditions such as hormone-related conditions (hypothyroidism, Cushing’s syndrome and polycystic ovarian syndrome (PCOS) are also associated with greater risks of being overweight.

For growing children and adolescents, it is important to recognize that excessive caloric restriction is not recommended, as they still require these calories and proper nutrition to ensure continued growth and development. Rather, more importantly, foods of little nutritional value deemed “empty calories” such as sweet drinks, sweets or candies, fast foods and deep-fried foods should strongly be limited in frequency (e.g. limiting to once or at most twice a week) as part of a healthy diet. Depending on the age/age-group of your child/teenager, attached is a table (from the Health Promotion Board) that lists the servings from all the important food groups, ensuring your child gets all the essential nutrients he/she needs.

Below is a table that defines the serving size from each different food group (adapted from Health Promotion Board)

Support from family, friends and peers is pivotal to dealing with the issue of managing or reducing weight.

Some ways or tips towards setting healthier lifestyle as a family together include:

• Eating healthier together by choosing healthier food choices and limiting highcalorie foods can lessen the likelihood that one will over-consume excess calories.
• Being active together as a family by choosing a sport or activity that engages everyone
• Reduce overall screen time. Limit the use of TV, computer, video games etc. Health experts recommend limiting to 2 hours or less of overall screen time.

Question by esim

Hi Dr Oh, Like most children, my child loves to eat unhealthy food like fast food; burgers, fries, ice-cream, etc etc, his appetite has also increased as in he can now finish his meals and snack in between meal times, thing is he does some exercise, swims few laps, some push-ups, gym for short run twice a week, he weighs 26kg at age of 6+. He is not of small thin build, is he heading towards obesity? Should I limit his junk food intake to prevent obesity?

Answered by Dr. Oh Jean Yin Consultant Department of Paediatrics, General Paediatrics & Adolescent Medicine KK Women’s and Children’s Hospital, ​Senior Dietitian from the Department of Nutrition and Dietetics KK Women’s and Children’s Hospital, Dietitian from the Department of Nutrition and Dietetics KK Women’s and Children’s Hospital

Weight measurement must never be considered alone, as it is not accurate in determining if any child has a health risk such as obesity. Weight has to always be taken in context of the height. The BMI (Body Mass Index) is a simple formula that is used. It is important that serial measurements are taken over time. You can monitor these using the BMI for age and gender charts that are available in the child’s health booklet.

It is normal to have foods like burgers and fries and ice-cream sometimes; just not always. Children need to also learn to recognise their hunger cues and respond appropriately. And it sounds like he enjoys being active and exercising. This is great and you should encourage him to maintain his current exercise regime. Encourage him to be physically active throughout the week aiming to accumulate between 60-90 minutes of physical activities a day.

To determine if your son is overweight, you can plot his weight and his height on the growth charts found in his Health Booklet. If his weight percentile is within 1 percentile of his height percentile, he is within his acceptable weight for height. Occasional treats such as fast food are acceptable, as long as it is not eaten in large quantities and not on a daily basis. Snacking on unhealthy foods especially deep fried, oily or sweet foods add extra calories to the diet, which will lead to weight gain if the extra calories are not used up through physical activity. Fast food meals are also usually low in fruit and vegetables. Therefore it is recommended to limit high calorie foods to 1 – 2 times a week.

Question by gingwee

My child, 24 months, refuse to drink milk. I have change the milk powder but still failed. He get used to eat adult foods. He still cant talk well, only how to address mama & papa. Is it normal at this age. PLease advise.

Answered by Dr. Oh Jean Yin Consultant Department of Paediatrics, General Paediatrics & Adolescent Medicine KK Women’s and Children’s Hospital, Senior Dietitian from the Department of Nutrition and Dietetics KK Women’s and Children’s Hospital

At 24 months, children can be selective and picky about their food. However, if there are concerns about fulfilling growth and nutritional needs, then this issue should be addressed by his family doctor or paediatrician. With regards to his speech, it is best that he sees his family doctor or paediatrician to determine if there are any concerns. Most children are able to say more than 3 words apart from Mama/ Papa by the time they are 24 months.

Toddlers at your son’s age tend to have food refusal but these usually resolve over time. His milk refusal may be just a passing phase, and you can offer alternatives to milk like reduced sugar calcium-fortified soybean milk, cheese and yoghurt. At two years of age, you can also offer him the same milk that the rest of the family drinks. This may encourage him to drink milk as children are great imitators, so ensuring that the rest of your family consumes milk and dairy products will encourage your son to consume them as well.

Generally, children after one year of age should be successfully introduced to a complete family diet, while milk gradually becomes supplemental, especially if growth is adequate. However, milk and other dairy products remains an excellent source of calcium. Other good sources of calcium include small fish with edible bones (e.g. sardines and ikan bilis), green leafy vegetables (e.g. spinach, broccoli), beancurd, almonds, calcium-fortified cereals and biscuits. At his age, he needs 500mg calcium per day. You can be a ‘calcium-detective’ and look out for calcium fortified foods. You can also create your own milkshakes using milk, ice cream and fresh fruits in a blender.

Question by rajinair

My teenage daughter is overweight. due to her classes and extra activities she is not having much time for exercises. how to help her to maintain a healthy life style along with her studies ?

Answered by Dr. Oh Jean Yin Consultant Department of Paediatrics, General Paediatrics & Adolescent Medicine KK Women’s and Children’s Hospital, Mr Micheal Lim Senior Clinical Exercise Physiologist Sports Medicine Service KK Women’s and Children’s Hospital

It is very challenging for all of us to want to change and in this case to change our lifestyle. For a start parents need to be role models and help their teen children find a balance. Any suggestions or recommendations must be practical, realistic age appropriate and if possible enjoyable and fun. Instructions to “go jogging at 7am on Sunday morning” for many adults let alone teens, will not evoke any change.

Start by getting her to do more lifestyle activities first and these could include getting her to use the stairs or walk to and from school and/or MRT station. Small bouts of activities accumulated throughout the day works and its benefits should not be underestimated. Start by having her do 5-10 minutes of physical activity a day and progressively increase towards 60-90 minutes a day.

Use a pedometer, which is a small portable device that can be worn on the waist, to count steps that a person takes in a given day. This is a good estimate of her levels of physical activity. Start by doing a baseline step counts and aim to increase her step counts progressively by 10%-20% every two weeks. It is recommended that children should accumulate between 12000 – 14000 steps per day.

Be an active role model. When you have more time during weekday evenings or weekends, plan for someone in the family or the whole family to do some exercise together. Discuss the exercises that she may enjoy and lead with example. Exercising together is a fantastic opportunity for the family to bond together!

Question by octane

What sort of exercises are suitable for obese children? Can we impose the same adult exercise type and routine on the children to lose fats?

Answered by Mr Micheal Lim Senior Clinical Exercise Physiologist Sports Medicine Service KK Women’s and Children’s Hospital

To improve overall body composition or weight management, it is important to increase participation in cardiovascular or aerobics exercises, including brisk walking, jogging, cycling and swimming. The exercise type can be similar to those imposed in obese adults. However, it is important to understand that younger children may not enjoy these exercises especially when they have to do it for an extended duration.

Change the exercise routine by breaking up the exercises into smaller bouts and encourage them to accumulate them across a day. The smaller bouts will motivate them to start some activity. Even 5-10 minutes a day is a good start but you should progressively increase the activity levels towards 60-90 minutes a day.

Quite often, in children with weight problems, they spend an increased amount of time on sedentary activities. These include time spent watching TV, playing computer games etc. You should also aim to limit the amount of sedentary activities to less than 2 hours a day.

Use a ‘Displace and Replace’ concept to find more time for physical activity. Displace sedentary activities and replace them with health-changing physical activities!

Question by make8work

How to help my kids to lose midsection body fat in a healthy way? Is there any foods that can help to increase their metabolism rate?

Answered by Mr Micheal Lim Senior Clinical Exercise Physiologist Sports Medicine Service KK Women’s and Children’s Hospital, Senior Dietitian from the​ Department of Nutrition and Dietetics KK Women’s and Children’s Hospital

You should aim to focus on overall health benefits that can be attained through active participation in a wide range of physical activities. The concept of ‘spot reduction’, where an individual does only abdominal exercises to improve muscle tone in midsection is a myth. To improve overall body composition or weight management, it is important to increase participation in cardiovascular or aerobics exercises, including brisk walking, jogging, cycling and swimming. Regular whole-body resistance exercises such as abdominal crunches, pushups, squats, should be recommended to help maintain or improve overall muscle tone.

Metabolism is basically the process by which our body changes food and drink to energy. Even when one is at rest, our body still needs energy for normal functions such as breathing, digestion and blood circulation (this is known as the basal metabolic rate). Several factors determine one’s basal metabolic rate:

Body size and composition
If one has more muscle mass, the metabolic rate tends to be faster.

Gender
Men generally have less body fat and more muscle mass than women of the same age, so males will burn more calories.

​Age
​As one gets older, muscle mass decreases, which slows down the rate at which calories are burned. Infants, growing children and teenagers have higher metabolic rates than adults because of growth hormones.

Ref: O17​