Battling CHILDHOOD OBESITY

A Treatment Plan

By Naomi D. Neufeld, MD, FACE

Childhood obesity: the words have an ugly ring to them. If you are an overweight child, or know one, you know how painful those words actually are, how they can sting and how bad they can make you feel. Every day in my pediatric endocrinology practice in Los Angeles, I see and treat children who are overweight. More often than not, the parent first will pull me aside and say “I don’t want him/her to know why he/she is here.” The truth is, the child probably already does know. He/she has been teased in school, called names, left off of teams, left out of friendships, all because he/she is overweight.

While the emotional issues are real, childhood obesity has definite medical problems associated with it as well. If they are not treated early, these problems can affect a child for the rest of his or her life. The kinds of problems we see in overweight and obese children include:

  • Asthma
  • High blood pressure
  • Diabetes
  • High cholesterol
  • Abnormal, irregular or absent menstrual periods if they are girls
  • Girl-like breast development in boys
  • Bone malformation and hip fractures
  • Abnormally tall stature
  • Early development of puberty
  • Darkened skin around the neck and in the armpits, called acanthosis [ah-CAN-tho-sis] nigricans [NIGH-grih-cans]
  • Fatty liver

So once they are in my office, what do I do?

First we need to know the causes of the child’s overweight.

The reasons our kids are obese or overweight stem from three simple facts:

  • Too much junk food and too few fruits, vegetables and dairy products
  • Too little physical activity
  • Too much screen time: TV, computer time, video games

Too much junk food and too few fruits, vegetables and dairy products

Not only are junk food and fast food widely available, but the marketing of fast food products is aimed directly at children. And this marketing campaign is very sophisticated.

There are two other aspects of nutrition that have probably contributed to the obesity epidemic. The first is that people in general, and children in particular, are eating fewer fruits and vegetables, as well as inadequate amounts of whole grains. These foods are rich in nutrients and high in fiber, so they promote a sense of fullness and keep your digestive tract healthy.

The second food group missing from the meals of many overweight children is dairy products. I am continually surprised to see how many parents do not supervise their child in taking in three servings of milk or other dairy product per day. Milk is the best source of vitamin D, and we know from many research studies that high vitamin D levels are associated with lower rates of insulin resistance and diabetes.

Too Little Physical Activity

Children and adults are less physically active now than in previous generations. Children used to play outside of the home after school. Today many parents are fearful and say they are concerned about the lack of safe streets. There is also less physical education in schools due to financial constraints and to more (and, in many cases, misdirected) emphasis solely on academic subjects.

Too much screen time: TV, computer time, video games

Time in front of the TV contributes to the development of childhood obesity because it slows down a person’s metabolic rate, the rate at which you burn calories when you just sit. If you are burning calories at 50 cal/hour while you watch TV, as opposed to 100 cal/hr when you move around, and you watch TV for 5 hours every day, you will hold on to 250 calories per day or 3500 calories every 2 weeks. Since there are 3500 calories in a pound of fat, by spending 5-6 hours/day every day in front of the TV you will gain 1 pound every 2 weeks. In a year you will gain over 25 lbs.

So, what do I do in my office when I see an overweight child?

First, my staff weighs and measures the overweight children, and I calculate their body mass index or BMI. What is your BMI? It is your weight divided by a multiple of your height. The BMI provides a way of standardizing or comparing people of different heights. (You can find out more about BMIs and even calculate your own at the Power of Prevention Web site: www.powerofprevention.com/bmi/php). I plot my patient’s measurements on curves, which compare them to the rest of the population. I ask about their daily meals, physical activity, screen time, as well as any family history of diabetes, high blood pressure, early heat disease or stroke. On the physical exam I look at their blood pressure, teeth (how many baby teeth they have lost), skin for signs of acne or acanthosis nigricans, neck for signs of thyroid disease, lungs for signs of asthma, waist circumference, liver size and arm circumference. I often do blood tests to look for signs of insulin resistance, high cholesterol, high blood sugar (diabetes), liver disease or thyroid disease.

I base my treatment on how severely overweight the child is (how much their BMI differs from normal) and what other signs of disease they have.

In my practice I have access to a family-based weight management program called KidShape. This is a 9-week program involving families of children who are obese, as defined by BMI above the 95th percentile for age and sex. During these 9 weeks families meet in groups with a dietitian, a physical activity instructor, and a mental health professional to deal with topics related to eating healthier and being more physically fit, as well as feeling better about themselves. KidShape has been around since 1986 and is available throughout the country. More information can be found at the Web site www.Kidshape.com.

Treatment Plan

The table below lists the steps that I take with my patients above the age of 5 years and below 19 years, based on the severity of their weight.

BMI > 85th percentile but

  1. Lab tests
  2. Limit TV to 1 hour per day
  3. Add physical activity, as noted below
  4. Add fiber to the meal plan, using the USDA Table Fiber Content of foods. (Check their Web site: http://library.umsmed.edu/pe-db/pe-fiber-food.pdf). Fiber requirement is calculated as (age in years + 5 grams per day)
  5. Dietitian assessment
  6. Monthly office visits
  7. Physical activity: pedometer, to reach 6,000 to 10,000 steps per day

BMI > 95th percentile, but

  1. KidShape classes or comparable family-based pediatric weight management program
  2. Lab tests
  3. Low-calorie diet (1200-1500 kcal/day)
  4. Dietitian consultation
  5. Weekly office visits
  6. Physical activity: pedometer, to reach 6,000 to 10,000 steps per day; physical activity videos or classes
  7. Monthly laboratory tests
  8. If liver enzymes are abnormal, I add vitamin E 200 IU per day. Vitamin E has been shown to reverse liver damage, presumably by protecting the liver from oxidative damage
  9. If vitamin D Levels are below 30, I add 50,000 IU of vitamin D per week
  10. If insulin is high, I may consider the medication metformin

BMI >3 SD above the mean

  1. KidShape classes or comparable family-based pediatric weight management program, more than 1 series to reach goal weight
  2. Lab tests
  3. Repeat insulin, other labs in 1 month
  4. Restricted calorie meal plan: 1200, 1500 or 1800 kcal/day
  5. Dietitian consult
  6. Weekly office visits
  7. Physical activity: pedometer, to reach 6,000 to 10,000 steps per day; physical activity videos or classes
  8. Monthly laboratory tests
  9. If liver enzymes are abnormal, I add vitamin E 200 IU per day
  10. If vitamin D Levels are below 30 ng/ml, I add 50,000 IU of vitamin D per week
  11. May consider the medication metformin if insulin is high
  12. For patients above the age of 12, some physicians have recommended sibutramine, an appetite suppressant which has been approved by the FDA for use in children 13 years and older. Patients who take this medication require monitoring of blood pressure and heart rate.

Medications often used in the treatment of adults or teens have not been approved or found safe for younger children. Until these drugs have been approved for children, they cannot be recommended. There are no quick fixes in the treatment of obesity, and especially in the case of children. Our focus for children should be on their health, not so much their weight.

Naomi D. Neufeld, MD, FACE, is the President of Neufeld Medical Group (founded in 1996) in Los Angeles. Her practice focuses on the problems of growth, obesity, diabetes and the hormonal problems that can affect children and youth from birth to 21 years. Dr. Neufeld is Board Certified in both Pediatrics and Pediatric Endocrinology by the American Board of Pediatrics. She is the founder and President of KidShape®, Inc., a family-based pediatric weight management program, which has been in continuous operation since 1986 and now operates sites in Los Angeles, Ventura and Orange Counties.