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Tour Elmwood Fitness Center in New Orleans and you'll find people pumping iron, sweating it out in a spinning class, and striking muscle-strengthening yoga poses. While this array of physical activity is not atypical at gyms, what stands out about Elmwood is its pint-sized members.
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The 160,000-square-foot family-centered facility, owned by New Orleans–based nonprofit health care provider Ochsner Health System, offers a range of structured fitness classes for children as young as 7 years. The center provides a more comprehensive weight management program called "I Can Do It" for children ages 7–17, which combines nutrition lectures, healthy cooking demonstrations, motivational speeches from pediatric specialists, and a physical fitness component that gradually increases in intensity over a 12-week period.
Determining how many gyms across the country cater to very young patrons is difficult, but the number seems to be expanding as quickly as children's waist and body mass index (BMI) measurements. Even McDonald's has gotten into the act, recently piloting "in-restaurant mini-gyms"—complete with stationary bicycles connected to video games, along with obstacle courses and designated aerobics exercises—in lieu of old-fashioned play areas. Children with chronic diseases have higher BMI and lower levels of customary activity, according to a recent study.1
Though children lifting weights or participating in an aerobics class may raise some eyebrows, others say it's never too early to start exercising. "By the time a child is 13 or 14, it's sometimes too late to change their habits," says Silva Arslanian, MD, chief of the Weight Management and Wellness Center at Children's Hospital of Pittsburgh.
Some physicians endorse the move toward structured physical activity programs for children. "Unfortunately, I refer a large number of patients to Elmwood Fitness," says Michael F. Wasserman, MD, a pediatrician with Ochsner. Using an age-adjusted BMI measurement, Wasserman recommends the gym to all patients who exceed the 95th percentile. He reports "tremendous success" with many of the patients he's referred to formal workout programs. But he and other pediatricians admit they don't work for everybody.
OBSTACLES TO FORMAL EXERCISE AND WEIGHT-LOSS PROGRAMS
Motivating kids to exercise can be challenging; getting them to attend an organized exercise program can be next-to-impossible. "It takes transportation from the parent or caregiver," says Wasserman. "The biggest issue is whether you can get the child there, and how often.",
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The cost of organized physical activity programs also presents a barrier for many. Some pediatricians do refer children to gym-based programs, particularly if the health system in which they work is affiliated with the gym. But health insurance typically does not cover the cost, which can run $30–$100 per month, depending on the scope of the program.
The absence of disease precludes children from receiving health care coverage for formal physical activity programs. "You have to remember that children who meet the definition of obesity don't have any real disease yet that's eating up health care dollars. Their complications are going to be 5 to 10 years down the road," Wasserman says.
Less formal, outdoor activities like bike riding and pick-up baseball and basketball games could provide a logical alternative to costly gym memberships, but such impromptu possibilities aren't available to many children. Those with dual-income parents generally head to after-school care instead of back to their neighborhoods after class. Safety issues prevent many kids from going outside. "We found in our studies that some children were afraid [to engage in activity outside] because of the neighborhood where they lived," says Julia Snethen, PhD, an assistant professor of nursing and obesity researcher at University of Wisconsin at Milwaukee. Weather presents another barrier to regular outdoor activity. "In places like Wisconsin, you've got a number of cold months," she notes.
HOSPITAL-BASED PROGRAMS
Some hospitals have begun treating childhood obesity as they would any other medical problem, that is, initiating an in-house program using a multidisciplinary approach. Such is the case at Children's Hospital of Pittsburgh, which opened its Weight Management and Wellness Center in November 2004. "The demand from referring physicians was growing, and we wanted to centralize the care of obese children," says Arslanian.
The program accepts any child with a BMI above the 95th percentile, with or without comorbidities. Arslanian says that 10–15% of children who enter the program have hypertension, and up to 30% have dyslipidemia. The program provides a comprehensive assessment of the patient's medical health; it also assesses nutritional know-how and physical activity, plus willingness and resources to create positive changes in these areas. Insurance covers all medical tests but not medical staff time.
The center has not yet conducted a formal study, but Arslanian estimates that after 6 months, 60% of the participants have maintained or reduced their current BMI. A database is being established to track health and weight-related outcomes data, notes Arslanian.
"The program is really to change lifestyle," Arslanian says. She and her staff emphasize small, manageable changes in nutrition and activity levels. "Historically, the attrition rate for formal exercise programs is very high," she says. Staff suggest joining fitness centers like the YMCA only if children and their parents are willing and can afford the cost. "Otherwise, we encourage school activities, particularly team sports, which tend to be more fun for children," explains Arslanian.
They also make practical suggestions about how to incorporate physical activity into children's daily lives, making sure the parents buy in to the recommendations. "I have told parents, `Let him do the vacuuming,'" adds Arslanian.
Another component of the program includes changing families' nutritional patterns, without requiring modifications that parents consider too demanding. For instance, families are asked to eliminate soda from their diet; this requires no drastic changes in food preparation but can make a big difference in calorie intake. This program also introduces other healthful concepts, such as the importance of eating fresh fruit and vegetables and drinking water. "There are children here who have never tasted vegetables or plain water in their lives," notes Arslanian.
COMMUNITY-BASED PROGRAMS
Some health care providers believe that by galvanizing more forces, community-based programs can better solve the problem of pediatric obesity. Pittsburgh's UPMC Health Plan, owned by the University of Pittsburgh Medical Center, recently awarded a $50,000 grant to Pennsylvania's Armstrong School District to develop a community-based weight loss and prevention program targeting school children in grades K–6. The program will consist of after-school and weekend health-related activities; it also will revamp the school district's physical education curriculum, require children to attend physical education classes more frequently, and make healthy changes in the cafeteria. "It is one of the first truly grassroots community programs of its kind," says Michael Culyba, MD, vice president of Medical Affairs for UPMC Health Plan, who oversees the program.
Only time will tell what works best to achieve long-lasting weight loss
among children. "The beauty of the formal program is the educational
component, for both children and parents," says Wasserman. "The
big question is: Can they keep the exercise going after the program is
over?" 
Reversing Obesity Among Children: Who Should Pay?
Childhood obesity is recognized as an epidemic with potentially far-reaching implications if left unchecked. In a recent nationwide survey of 800 adults, most respondents indicated that initiatives to resolve the problem should be a shared effort.
Q: Who should be at least partly responsible for addressing the obesity issue?
98% Parents
96% Individuals
87% Schools
84% Health care providers
81% Food industry
67% Government
Source: Research! America and The Endocrine Society
Footnotes
More information on Ochsner Health System's "I Can Do It" program can be accessed at www.elmwoodfitness.com/club/scripts/section/section.asp?grp=0&NS=KIDS.
To learn more about Children's Hospital of Pittsburgh's Weight Management and Wellness Center, go to www.chp.edu/clinical03a_weightmanage.php.
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