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									  Childhood Obesity Education For African-American Youth At A Neighborhood Health Fair

Background

       Obesity in children and adolescents has emerged as one of the most alarming health

concerns facing our country today. The proportion of children and adolescents that are

overweight or obese is now higher than ever before due to an accelerating obesity rate over the

past twenty-five years; specifically, the prevalence of obesity has quadrupled among children

aged 6-11 and more than doubled among adolescents during this period.1 In 2001, Surgeon

General David Satcher, M.D., Ph.D. expressed in his “Call to Action to Prevent and Decrease

Overweight and Obesity” that overweight and obesity had reached epidemic proportions among

all population groups with an estimated 61 percent of adults overweight and 15 percent of

children and adolescents considered overweight.1 These estimates are consistent with data

obtained from the 1999-2000 National Health and Nutrition Examination Survey (NHANES),

which reported that overweight and obesity affected 15.5% of 12- to 19- year olds, 15.3% of 6-

to 11- year olds, and 10.4% of 2- to 5- year olds.2 These population estimates of overweight and

obesity are even higher today.

       The etiology of the pediatric obesity epidemic remains multi-factorial. Obesity is

conventionally defined in terms of body mass index (BMI), with a sex- and age-specific BMI at

or above the 95th percentile considered overweight or obese. An individual’s weight is

determined by genetic, environmental, metabolic, behavioral, cultural, and socioeconomic

factors.1 Behavioral trends such as increased caloric intake, decreased physical activity, excess

intake of dietary fat, and increased consumption of carbohydrates have been widely implicated as

causative factors for childhood obesity. However, the overall contribution of each of these
                                                                                                  2


factors remains ambiguous. A review by Slyper3 argues against increased caloric intake as the

prime causative factor of obesity. The author cites the Bogalusa Heart Study, a long-term cohort

study of cardiovascular risk factors in both white and African-American youth, where the total

caloric intake of 10 year-olds remained virtually unchanged from 1973-1988 despite an increased

incidence of obesity.

       The pediatric obesity epidemic in the United States is most concerning for its resulting

morbidity among children and adolescents. Obesity-associated diseases in youth accounted for

hospital costs of $127 million from 1997 to 1999 while numerous studies have shown that obese

individuals have a 50-100 percent increased risk of premature death from all causes compared to

individuals with a normal BMI.4 The medical complications of childhood obesity include the

following: cardiovascular diseases such as dyslipidemia and hypertension; respiratory diseases

such as sleep apnea and Pickwickian syndrome; increased incidence of insulin resistance and

type 2 diabetes mellitus in youth; slipped capital femoral epiphysis and other musculoskeletal

pathology; and gastrointestinal diseases such as steatohepatitis and cholelithiasis. The

development of early-onset hypertension, dyslipidemia, and diabetes markedly increases the

likelihood of heart disease in adulthood. For example, the Bogalusa Heart Study discovered that

childhood obesity is a major predictor for the development of the metabolic syndrome (central

obesity, dyslipidemia, hypertension, insulin resistance) in adulthood.5 An increased rate of

development of type 2 diabetes mellitus has paralleled the rising number of overweight children

and adolescents. The early onset of type 2 diabetes results in an increased susceptibility to

complications such as diabetic retinopathy, neuropathy, nephropathy, and atherosclerotic heart

disease.6 The most significant morbidities affecting overweight youth, however, may be
                                                                                                    3


psychosocial with effects such as poor self-esteem, social isolation, and depression common

among these children and adolescents.

       Disparities within the pediatric obesity epidemic exist in the United States based on race

and ethnicity. African-American, Hispanic American, and Native American children and

adolescents suffer from proportionally high rates of obesity. Among 2- to 5- year-olds in the

NHANES study (1999-2000), the prevalence of overweight children by race was 8.6% in non-

Hispanic whites, 8.8% in non-Hispanic blacks, and 13.1% in Mexican-Americans.2 The findings

are more striking among 12- to 19- year-olds, where significantly more non-Hispanic black

(23.6%) and Mexican-American (23.4%) adolescents were overweight compared to non-

Hispanic white adolescents (12.7%). Moreover, the onset of obesity during childhood is

significantly earlier among the African-American population. A cohort analysis by Saha et al7

showed that 25% of blacks were overweight/at risk for overweight at or before the age of 7. In

comparison, 25% of white males and females became overweight/at risk for overweight not until

ages 10 and 11, respectively.

Background of Targeted Community

       The state of New York and Monroe County are not immune to the childhood obesity

epidemic. Approximately 28% of New York high school students are overweight or at risk of

becoming overweight while 33% of low-income children between 2 and 5 years of age are

overweight or at risk of becoming overweight.8 The 2003 Youth Risk Behavior Survey 9 found

that 36% of students did not participate in sufficient vigorous physical activity (>20 minutes on

>3 of the past 7 days) and 77% did not participate in sufficient moderate physical activity (>30

minutes on >5 of the past 7 days).
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       The Northeast Quadrant of the City of Rochester consists primarily of African-American

residents experiencing high rates of poverty, crime, violence, and unmet health care needs.

According to data obtained from the 2000 Census,10 the median income for a household in this

region is $31,909. The median family income is $36,231 and the per capita income was reported

to be $17,768. Approximately 10.5% and 8.7% of individuals and families living in this census

tract, respectively, are below the poverty line.10

       As a result of the high prevalence of poverty and limited access to health care in this

community, Preferred Care insurance sponsored a health and human services fair at the Frederick

Douglass Preparatory School on August 27, 2005 in cooperation with the University of

Rochester/Strong Health and many local organizations. The event featured a job fair, free health

screenings, booths dedicated to disseminating health information, prayer groups, and various

activities for children. With a large audience from a target population, this health fair was an

excellent means to educate parents and youth on childhood obesity.

Project Description / Methods / Partnerships

       My project involved the planning, designing, and staffing of a health fair booth

addressing childhood obesity education at the First Annual Preferred Care – Northeast Quadrant

Health and Human Services Fair. I was initially unsure of the best location to conduct such a

project and asked Gabrielle Kapsak, the clerkship coordinator, for any suggestions. She

informed me that CHIC had already reserved a booth at the Northeast Quadrant health fair, and I

believed this would be an excellent site in a target neighborhood to influence a large number of

people. I initially gathered background information on the scope and causes of the growing

epidemic of pediatric obesity by browsing the medical literature and many websites. In order to

ensure that the information was reliable, I directed my search at various governmental sites such
                                                                                                     5


as the Centers for Disease Control and Prevention (CDC). The most comprehensive background

resource was the US Surgeon General’s 2001 “Call to Action to Prevent and Decrease

Overweight and Obesity” (available at http://www.surgeongeneral.gov/topics/obesity). The

report outlines the epidemiology, disparities in prevalence, and health risks of pediatric obesity

and offers public health strategies designed to address the problem. Another excellent source

was the CDC’s resource on childhood obesity (available at

http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm), which provided useful information on

trends, contributing factors, and consequences. After acquiring knowledge of the problem, I

focused my efforts on planning and designing the health fair booth. While searching the Internet

for background information, I discovered a number of sites with both printable brochures and

online catalogs of publications. The US Department of Agriculture’s Team Nutrition program

(http://www.fns.usda.gov/tn) as well as the Weight-Control Information Network of the National

Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) (http://win.niddk.nih.gov)

provided many free resources. After contacting both organizations by phone and relaying my

task, I was able to order almost one hundred brochures as well as books, bookmarks, pens,

stickers, and activity sheets for children.

        My major partnership for this project was the Rochester office of the American Heart

Association. As the community affairs coordinator for the American Heart Association, Tamiko

Byrd was an excellent source for educational materials and project planning. I met with Tamiko

early on in the project and several times later to best ensure the ordering of materials and project

coordination. Overall, she was able to provide me with a tri-fold display board, numerous

posters and activity sheets for children, a scale to measure children’s BMIs, a model heart with

chambers that opened up, and American Heart Association brochures on topics such as “For
                                                                                                    6


Your Children”, “Six Steps to A Healthy Heart”, “Nutritious Nibbles”, and “Shop Smart With

Heart”. Tamiko is an enthusiastic and wonderful person, and I truly enjoyed partnering with her

on this project. She provided me with a lot of autonomy in designing the theme and actual health

fair presentation. As a result of my project, the American Heart Association decided not to

operate a separate booth on another health topic.

       Another valuable partnership was with the Cornell Cooperative Extension on Highland

Avenue in Rochester. Focused mainly on agriculture, the group also runs a campaign dedicated

to healthy eating and nutrition. I contacted Dora Christian, the head of the nutrition education

program, by phone. She was eager to assist and was an excellent source of activity sheets for

children, informational brochures, posters of the newly revised food pyramid, and healthy

recipes for parents. She also directed me to a number of useful websites dealing with nutrition.

       I also formed a partnership with the Golisano Children’s Hospital Outpatient Pediatric

Nutrition Services. I initially sought the advice of one of my former inpatient pediatrics

attendings, Dr. Peter Szilagyi, regarding the best individual that could assist me. He introduced

me to Bamini Pathmanathan, one of the outpatient pediatric clinical nutritionists, who provided

me with some educational materials on obesity that I was able to photocopy and distribute at the

health fair. Her materials on food portions and sample menus were particularly helpful. I also

contacted the Nutrition/Weight Management Center at Strong. Unfortunately, as all of their

materials were directed towards advertising their program, they were unable to assist me.

       Finally, as I was securing materials during the week before the health fair, I decided to

contact both the Tops Market in Brighton and Kinko’s on Jefferson Road to assess their

willingness to place a donation for my health fair booth. The manager of Tops, Adair McCarthy,

donated a $25 shopping card for use in her store. In order to better attract parents and children to
                                                                                                   7


my booth, I decided to purchase both bottled water and pretzel rods as an example of a healthy

snack. Kinko’s generously designed an 8’ x 2’ banner reading “Kids Eating Healthy” for use in

advertising my booth. I was truly impressed by the generosity exhibited by these local

businesses.

Implementation

       Upon arrival at the Frederick Douglass Preparatory School at 9:00 AM, I was assigned a

table under a tent containing all Strong-affiliated programs including dentistry, breast cancer

awareness, and poisoning prevention. Preparations for the event took place from 9:00-10:30 AM

with the health fair occurring from 11:00 AM to 4:00 PM. I utilized the tri-fold display board

provided by the American Heart Association to display a number of attractive, educational

posters such as the newly revised USDA food pyramid and another describing the amount of

exercise required to “burn off” a given food. The banner donated from Kinko’s prominently

displayed the theme of the booth, and free Aquafina bottled water and pretzel rods were

distributed. The free bottled water proved to be a great success in attracting individuals to my

booth. It was an extremely hot afternoon, and I gave away almost 100 bottles of water!

       A wide range of informational brochures from the American Heart Association, USDA,

and CDC were available for parents and kids. A number of parents were particularly interested

in the pamphlet called “Helping Your Overweight Child” that offered tips on how to encourage

your child to eat healthy and provided examples of healthy alternative snack foods. I was

initially concerned that the number of American Heart Association brochures would be

insufficient; however, the majority of patrons were interested in taking the USDA and CDC

materials plus kids’ activity sheets containing crossword puzzles, word searches, and other age-
                                                                                                   8


appropriate games. Each younger child was given a sticker, pen, and bookmark displaying the

healthy eating theme.

       Furthermore, I designed an interactive game in which kids (and parents!) were challenged

to match Ziplock bags containing measured teaspoons of sugar to their corresponding beverages

such as Coca-Cola, Snapple Iced Tea, Gatorade, Diet Pepsi, and bottled water. In addition, two

American Heart Association books entitled “No-Fad Diet: A Personal Plan for Healthy Weight

Loss” were raffled off by having individuals pick the winning ticket from a jar full of tickets.

Besides offering free bottled water and pretzels, I performed BMI measurements on interested

children and adolescents. After receiving their BMI, individuals received an informational sheet

describing how the BMI is used and their category of weight (see appendix).

Community Reaction / Feedback

       My booth at the First Annual Preferred Care – Northeast Quadrant Health and Human

Services Fair promoting awareness of pediatric obesity and healthy eating proved to be a great

success. The health fair served as an excellent forum to educate a large number of residents from

a target population – I gave away around 100 bottles of water and had almost 300 individuals

total stop by to look at my booth and materials! As a community struggling with poverty and

limited access to health care, the residents seemed extremely interested and grateful for the work

done by the volunteer vendors.

       In regards to my booth, I found both children and parents to be genuinely interested in

learning more about healthy eating and receptive to nutritional advice. For example, several

adults had never seen the newly revised food pyramid and listened as I instructed them on the

changes from the previous version. I was able to assist a mother with three young children under

the age of 5 who expressed frustration in interpreting nutritional content labels. Both children
                                                                                                    9


and adults enjoyed the challenge of matching the drink with its sugar content. Everyone was

astonished, for instance, that a 20-ounce bottle of soda contains 17 teaspoons of sugar and that

Gatorade contained any sugar at all! I am hopeful that viewing firsthand the amount of sugar in

popular beverages will lead to better selections in the future.

       One of the most rewarding experiences was observing the children’s enthusiasm and

interest in learning about the model heart. The majority of the kids had never seen a model such

as this and listened attentively as I showed them the various chambers and the path of blood

flow. One young boy even asked if he could take it home with him! Furthermore, I found the

poster detailing the amount of exercise required to burn off the calories in foods such as French

fries and jelly donuts to be highly effective for both children and adults. I also performed BMI

measurements as part of the booth; however, only a few children were interested in obtaining

their BMI. Many of the children, especially those overweight, were hesitant to have their weight

checked due to the large number of people around. The young children for the most part only

wanted to stand on the scale for fun. Due to the large number of booths, families did not tend to

spend much time at any single location. Nevertheless, some children did take advantage and

were given an informational sheet describing the uses of the BMI.

Sustainability

       Overall, I believe the First Annual Preferred Care – Northeast Quadrant Health and

Human Services Fair was an excellent vehicle to disseminate health information to a large

number of residents with unmet health care needs. After speaking with one of the health fair

organizers, I am confident that this venue will become a yearly occurrence.

       The concept of utilizing a health fair booth to disseminate information about pediatric

obesity and healthy eating is a sustainable and worthwhile CHIC project. Since this health fair
                                                                                                  10


could become an annual event in this community, another CHIC student could further the impact

that I made by conducting a similar project next year dealing with pediatric obesity education.

Through repetition, the community may come to realize the importance of this health problem.

As evidenced from a fourth year student last year, the model can also be used for smaller

audiences such as schools and the JOSANA area or expanded to meet the needs of a larger

audience such as this health and humans services fair.

Discussion

       My intensive four-week community health improvement project consisted of a health fair

booth addressing pediatric obesity education for African-American youth at the First Annual

Preferred Care – Northeast Partners Health & Human Services Fair. My project fulfilled nearly

all of the defined clerkship learning objectives. My health fair booth addressed a significant

community health issue affecting the Northeast Quadrant residents of the City of Rochester. As

addressed by the Surgeon General, pediatric obesity has accelerated to epidemic proportions in

the United States and has disproportionately affected the African-American community. My

goals were to distribute information about the pediatric obesity epidemic and to promote risk

behavior change in the form of healthy eating and physical activity for children and adolescents.

The stated objective to learn how to assess and control common community health problems was

addressed by reviewing public health strategies for pediatric obesity in the literature and by

developing approaches to educate individuals about this problem as part of my health fair booth.

Furthermore, I successfully developed a number of partnerships with prior CHIC-affiliated

organizations such as the American Heart Association and the Cornell Cooperative Extension

while also establishing new relationships with Outpatient Pediatric Nutrition at Strong, Tops

Markets, and FedEx-Kinko’s. As addressed previously, I believe that my health fair booth
                                                                                                   11


addressing pediatric obesity could prove to be an excellent and sustainable means of addressing

health education needs in this target community for years to come. Even by conducting just this

single event, I am hopeful that my educational efforts will have an impact on both children and

parents.

       As evident by the hundreds of people that visited and took materials from my booth, I am

optimistic that my project had a positive and sustainable impact on the Northeast Quadrant

community. I am convinced that the residents of this community, despite lacking access to

health care, are undoubtedly interested in health promotion and learning strategies to combat the

growing epidemic of pediatric obesity. By engaging in BMI measurements and other hands-on

activities, the community members may now realize the health implications of pediatric obesity

and incorporate simple interventions such as drinking diet sodas and low-fat cooking methods in

their daily lives. As seen from the enthusiasm of the young children in learning about the heart,

the challenge inherent in changing any health habit lies in making it fun.

       My community health improvement project had a large impact on myself as well. As I

am interested in pursuing a career in Cardiology, I enjoyed the opportunity to learn more about

the underlying etiologies, trends, and health impact of pediatric obesity. I witnessed the

generosity and community spirit exhibited by the local organizations that formed partnerships

with me. The opportunity to work with the Northeast Quadrant community was truly rewarding

for me. One of the most satisfying experiences was counseling a grandfather with two

overweight grandchildren on how to encourage them to eat healthy and be physically active. He

described how they were picky eaters and preferred unhealthy foods such as chocolate milk,

regular soda, and hamburgers. I appreciated his sincerity, and it was then that I understood the

difficulties inherent in behavioral change. Finally, the opportunity to interact and learn about
                                                                                            12


this community was truly worthwhile in helping me to grow both as a future physician and as a

person.
                                                                                         13


                                       References

1. U.S. Department of Health and Human Services. The Surgeon General’s Call To Action

   To Prevent and Decrease Overweight and Obesity. U.S. Department of Health and

   Human Services, Public Health Service, Office of the Surgeon General, 2001. Available

   at http://www.surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf

2. Ogden CL, Flegal DM, Carroll MD, Johnson CL. Prevalence and trends in overweight

   among US children and adolescents, 1999-2000. JAMA. 2002;288:1728-1732.

3. Slyper, AH. The pediatric obesity epidemic: causes and controversies. J Clin Endocrinol

   Metab 2004;89:2540-2547.

4. Schneider MB, Brill SR. Obesity in children and adolescents. Pediatrics in Review.

   2005;26(5):155-161.

5. Srinivasan SR, Myers L, Berenson GS. Predictability of childhood adiposity and insulin

   for developing insulin resistance syndrome (syndrome X) in young adulthood: The

   Bogalusa Heart Study. Diabetes. 2002;51:204-209.

6. Hannon TS, Rao G, Arslanian SA. Childhood obesity and Type 2 diabetes mellitus.

   Pediatrics. 2005;116(2):473-480.

7. Saha C, Eckert GJ, Pratt JH, Shankar RR. Onset of overweight during childhood and

   adolescence in relation to race and sex. J Clin Endocrinol Metab 2005;90:2648-2652.

8. Centers for Disease Control and Prevention. Overweight and Obesity: State-Based

   Programs – New York.

   http://ww.cdc.gov/nccdphp/dnpa/obesity/state_programs/new_york.htm. Accessed

   August 29, 2005.
                                                                                       14


9. Centers for Disease Control and Prevention. Surveillance Summaries, May 21, 2004.

   MMWR 2004;53:1-96. Available at.http://www.cdc.gov/HealthyYouth/yrbs/index.htm.

   Accessed August 29, 2005.

10. U.S. Census Bureau, Fact Sheet for Census Tract 83.01, Monroe County, New York.

   http://factfinder.census.gov. Accessed August 29, 2005.
                                                       15


                                        Appendix


1. Confirmation letter for attendance at health fair

2. Partnership contact information

3. Letter to Tops

4. BMI interpretation handout

5. Sample brochures
                                                                                      16




                             and Northeast Partners
                              “Family Fun Day”
                        Health / Human Service & Job Fair

                           Saturday, August 27, 2005
                                11:00am – 4:00 pm
                     at Frederick Douglass Preparatory School,
                 940 Fernwood Park     Rochester, New York 14609

Dear Community Partner:

Thank you for supporting the First Annual Northeast Quadrant Family Fun Day Health
& Human Service/Job Fair. Please note that this is a rain or shine event, which will be
held on Saturday August 27, 2005 11:00am to 4:00pm at
940 Fernwood Ave, Rochester NY 14609.

We have your agency confirmed with one 8’ table and 2 chairs. Additional tables will be
provided based on your sponsorship level, however your request must be made in
advance.

Since this is a Community Faith-Based Initiative Project, we are asking that you adhere
to the following:

      No Condoms at the display tables (abstinence related material is welcome)
      No Needle exchange materials
      No Campaign material
      No sales please
      Free give always are welcome
      Set-up times 9:00 am - 10:15 am. Volunteers will be available to help load and
       unload
      There will be one identified entrance for agency representatives who are setting
       up tables
      Free food and bathrooms will be available to vendors
      If possible please do not leave early. Be prepared to be in attendance at the
       event from 11am-4pm.

Please feel free to call Adonai at (585) 454-2640 with any further questions or concerns.

Once again, thanks for making a difference in our community!
                                                                   17


                              Partnership Contact Information

Tamiko Byrd
American Heart Association
2113 Chili Avenue
Rochester, NY 14624
(585) 697-6281
Tamiko.Byrd@heart.org

Dora Christian
Community Nutrition Supervisor
Cornell Cooperative Extension – Monroe County
249 Highland Avenue
Rochester, NY 14620
(585) 461-1000 ext. 257
dfc23@cornell.edu

Bamini Pathamanathan
Outpatient Pediatric Nutritionist – Golisano Children’s Hospital
(585) 275-3909

Tops Friendly Markets
c/o Adair McCarthy
1900 South Clinton Avenue
Rochester, NY 14618
(585) 442-2990

FedEx - Kinko’s
941 Jefferson Road
Rochester, NY 14623
(585) 240-2679
                                                                                               18


August 22, 2005


Ryan Anthony
4th Year Medical Student
University of Rochester School of Medicine
601 Elmwood Avenue, Box 215
Rochester, NY 14642

Tops Markets
1900 South Clinton Avenue
Rochester, NY 14618

Dear Ms. McCarthy:

I am a fourth year medical student at the University of Rochester currently working on a project
dealing with pediatric obesity and healthy eating for children. In partnership with the American
Heart Association, I will be staffing a booth at the upcoming “Preferred Care – Northeast
Quadrant Health Fair” being held on Saturday, August 27th at the Frederick Douglass
Preparatory School in northeast Rochester. The health fair is targeting an underserved
neighborhood, and my booth will be distributing a number of educational materials dealing with
healthy eating as well as measuring children’s heights and weights.

As I spoke with you this morning, I would like to see if you would be interested in providing
some healthy snacks for my health fair booth. The opportunity for children to try healthier foods
is an important step in changing eating habits in the long-term. I would be pleased to have any
trail mix, dried fruit, pretzels, or bottled water or perhaps a gift card that you could provide.

Please contact me with any questions. I can be reached at (585) 427-8043. I appreciate your
time and consideration.

Sincerely,



Ryan Anthony
                                                                                                19


                                 How To Interpret Your BMI

Your BMI today is _________
Your BMI percentile-for-age is _________

Body mass index (BMI) is a calculation that uses your height, weight, and age to estimate how
much body fat you have. Too much body fat is a problem because it can lead to illnesses and
other health problems. BMI, although not a perfect method for judging someone's weight, is
often a good way to check on how a kid is growing.

BMI is particularly helpful for identifying children and adolescents who are at risk for becoming
significantly overweight as they get older. In older children and teens, there is a strong
correlation between BMI and the amount of body fat. Therefore, those with high BMI readings -
and probably high levels of fat - are most likely to have weight problems when they are older. If
doctors can identify these at-risk children early on, they can monitor their body fat more
carefully and potentially prevent adult obesity through changes in eating and exercise habits.

Calculating BMI

The best way to determine your BMI is to have your doctor do it for you. That way, you'll know
the number is accurate and your doctor can discuss the result with you.

Once you have calculated your BMI, you'll learn that you are in one of 4 categories:

Underweight:                  Less than the 5th percentile
Healthy weight:               Between the 5th and the 85th percentiles
At risk for overweight:       Between the 85th and 95th percentiles
Overweight:                   Higher than the 95th percentile

Where BMI Can Fall Short

BMI is not the whole story when it comes to someone's weight. A more muscular kid may have a
higher weight and BMI but not have too much body fat. Also, a smaller kid could have an ideal
BMI, but might have less muscle and too much body fat. Because there are other considerations,
it's a good idea to rely on your doctor if you have questions about whether you are at your ideal
weight. If your doctor tells you your BMI is high, don't let it get you down. Instead, talk to your
doctor about what you should do to lower your BMI. Unlike adults, kids don't usually need to
diet. But by eating healthier and getting more exercise, a kid can improve his or her BMI.
Controlling a weight problem while you're still a kid can help you avoid becoming an overweight
adult and developing health problems like diabetes and heart disease.

								
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