Kelly is a pretty twelve year old girl who has an angelic face and a bubbly personality. She has been in very good health over the years. In fact, the reason for today's visit is because the school said she needed her Hepatitis B vaccines. Her mom figured that she needed a physical anyway, and her chart revealed that she hadn't had a physical for four years.
During the initial part of the visit, I plotted her growth parameters on her growth chart (her height and weight). I tried to hide my surprise when I saw the results. Her height was at the 80th percentile where it had been four years ago. This means that approximately 80% of all the girls her age would be shorter than her. Her weight which had been at the 75th percentile four years earlier, was now far beyond the 95th percentile...it was off the chart. This meant that Kelly was obese.
Obesity is an increasing problem in the United States that is reaching epidemic proportions. It is estimated that 35% of all adults in the U.S. are obese. Ten years ago this number was 25%. Around 22% of all 6-19 year olds are overweight whereas ten years ago it was only 15%.
The increased incidence of obesity in children is particularly distressing because it greatly impacts the Physical, emotional and social well-being of a child. If a child is obese at 6 years of age, there is a 25% chance of being obese in adulthood. If an adolescent at 12 years of age is obese, the chances of being an overweight adult climbs up to 75%. It seems clear that the risks of obesity increases with age and the main goal should be to recognize this at an early age and to intervene at as early an age as possible.
Genetics clearly plays a role in obesity. One study showed that if both parents are overweight, 2/3 of their offspring will be obese. If both parents are of normal size however, only 9% of the children will be obese. But genetics is only one piece of the puzzle as family dynamics also plays a major role in determining one's eating patterns and habits.
From a medical standpoint, childhood obesity needs to be addressed at an early age because these children are at risk for heart disease, diabetes, pulmonary insufficiency, high blood pressure and breast cancer when they become adults. The psychological impact on an obese child can be devastating. They are often teased and called names, lack self-esteem, and many are depressed.
As I started to discuss Kelly's growth curve with her mom, Kelly's whole demeanor changed. She became uncomfortable and anxious, interrupting me as if to change the subject. The conversation about her weight definitely struck a nerve with Kelly and she didn't want to discuss it. Sensing her anxiety, I had the nurse take Kelly to check her vision and collect a urine specimen. This was a convenient way to get Kelly out of the room so I could talk to mom alone. As we discussed childhood obesity, many things came to light. Mom too, is overweight, and I learned that dad is grossly overweight as is Kelly's older brother. In just a few moments of conversation it became apparent that most of the family activities centered around food...with very little physical activity.
Mom was deeply concerned about Kelly and let out with a frequently asked question, "Isn't there a pill or something we could give her?" As I was explaining why this was not possible it seemed to have really sunk in and hit mom. She stopped me in mid-sentence and said, "...Well, what are we going to do?"
The treatment of childhood obesity is formidable and not an easy task by any stretch of the imagination. The modalities that are used for adults such as appetite suppressants, strict low calorie diet, stomach balloons, stomach stapling and intestinal bypass are ALL contraindicated in children.
The goals for treating an overweight child include 1) diet modification 2) exercise 3) behavior modification and 4) family therapy. It is crucial that the child as well as the entire family are motivated and willing to undertake such a venture. They need encouragement and support because the process can seem so insurmountable and overwhelming. It entails changing the entire family dynamics. For these goals to be met correctly, the expertise of a nutritionist or a dietary counselor is often needed.
Diet modification in a child must be done carefully. Very low calorie diets in a young child can be dangerous and harmful. If not done properly it can impair normal growth and development at a critical time in their lives. In working out a diet for a child, the goal is to "maintain" weight while they grow in stature more than it is to lose weight. To determine the exact number of calories to attain this requires the input of someone who has been trained and experienced in doing so. Before a family meets with the nutritionist, it is important for them to keep a detailed diary of exactly what was eaten, and when it was eaten over a few typical days. This was done in Kelly's case and as it turned out, Kelly didn't eat large meals as much as she ate or snacked constantly. Most of her "scavenging" was done in front of the TV or computer when she got home from school. The dietary history also revealed that an incredibly large percentage of her meals were from fast food restaurants. In fact mom said that she was shocked...and embarrassed to realize that she only cooked dinner around two nights a week. The rest of the time it was pizza, hamburgers or Mexican food from their favorite "drive-throughs".
The meeting with the nutritionist was revealing to say the least, but it was also most instructive. The nutritionist was able to provide mom with a clear cut diet plan for Kelly that targeted exactly what calories she needed each day for proper growth. Both mom and Kelly were surprised to find that the suggested diet was very reasonable and "workable". It also allowed some leeway to allow for trips to the fast food places she enjoyed. Kelly's face lit up when she looked at the plan and said with confidence, "I can do that!". The only real change would be to eliminate her constant snacking.
This is where the second step of management comes into play. exercise. This is critical in the treatment of childhood obesity and there are so many fun activities that are available to children nowadays. Children can rollerblade, swim, bicycle, skateboard or just take family walks. There are organized sports such as soccer, water polo, karate, gymnastics, dance (ballet and tap), baseball and softball etc.. There is certainly something for every child, it's just a matter of getting them away from the TV or video games.
Luckily for Kelly her friends were going out for the school volleyball team which practiced every day after school from 3-4:30 PM. This is precisely when Kelly would come home from school and park on the floor in front of the TV to watch her favorite shows...and snack.
At first Kelly's eyes sparkled at the thought of playing volleyball with her friends, then her mood became somber. "I can't play volleyball, my friends are so much better than I am. They'll make fun of me," she said in a dejected voice. The low self-esteem reared it's ugly head. Over the years she had come to believe these things about herself. She truly believed that she couldn't do things...and stopped trying. With much coaxing and encouragement from her friends and the coach, she did go out for the team and had a wonderful experience. This gave her great confidence and marked a big turning point for her. The behavior modification just sort of fell into place afterwards and became infectious. The meeting with the nutritionist helped mom plan meals for the family. She now cooked all but 2 meals a week and the family ate together at home. Mom too, started to exercise. She walked every afternoon and would end her walks at Kelly's volleyball practice where she helped out with the team.
It has been 8 months now, and I have Kelly come by the office once a month to be measured and weighed. She has grown 11/4 inches, and has not gained any weight since we started this venture. This was our main goal. The real reward however, was to see a vibrant, happy, now 13 year old who was confident and who felt good about herself. A girl who could now say, "I CAN do that!"