The war against childhood obesity
Fifteen-year-old Nick sits uncomfortably in David Ludwig's
examining room. He grins and throws his sweatshirt over his head
in embarrassment as his father, Gary, does most of the talking.
"The doctors kept saying he'll grow out of it," Gary
tells Ludwig. "But he grew into it. He eats what he wants,
whenever. At 2, 3, 4, 5 a.m."
Ludwig, who is the director
of Children's Hospital Boston's Optimal Weight for Life (OWL) program,
runs through a barrage of medical questions: How's your energy
and strength? Any changes in skin and hair? Do you have excessive
thirst or excessive urination? Shortness of breath?
Nick says no
to these, but yes, he has asthma, high blood pressure and constant
heartburn—a burning in his throat a few hours
after eating, especially at night.
"That's why he sleeps sitting
up," his sister,
Jessica, a certified nurse's aide, adds.
"That could be a serious medical problem," Ludwig says.
Nick also has sleep apnea—loud snoring. Does he stop breathing?
The family thinks possibly he does.
"Listen carefully for that," Ludwig
warns them. "If
you hear him gasping for air, that's another serious medical
problem, one that could be life-threatening."
Physical activity? "We try to get out on the basketball court," Gary
says. But on most days, Nick is inactive.
Now come the dietary questions.
"What's the first thing you
have to eat every day?" Ludwig
asks. At 9 a.m., Nick has a bag of chips from the vending machine
at school; for lunch, he has a Gatorade from the machine. In
fact, Nick's first real meal isn't until 2:30 p.m. when he
arrives home from school and eats leftovers from the lunch Gary
has prepared. Sometimes, if there's enough food, he'll
have a second meal.
"What happens at night?" The family
pauses. "I've
seen it all," Ludwig says. "Nothing you say can shock
me."
Gradually, it emerges that Nick binges at night, eating
hot dogs 10 at a time, a pound of cheese, chips, candy.
Ludwig
does a physical exam. "I want to show you something," he
tells the family. "Do you see this discolored skin here?" He
points out a patch of dark, velvety skin in the fold of Nick's
neck.
"He doesn't keep it clean," Gary says in exasperation. "We've
been after him to clean it."
"It doesn't come off," says
Donna, Nick's mother. "I've tried scrubbing it."
"This
is a skin condition called acanthosis nigricans," Ludwig
says. "It goes along with being obese."
He explains
that it signals high levels of insulin in the body—an
indication that Nick, at over 300 pounds, is at risk for diabetes. "Luckily,
it's just a warning sign," Ludwig tells the family. "It's
saying, ‘Keep an eye on the road and drive carefully.'"
The
road to Washington
Ludwig began his career in the laboratory,
studying the molecular basis of obesity. He is credited with helping
to find a gene in the brain that makes a compound that stimulates
hunger, called MCH (melanin concentrated hormone). In the 1990s,
Ludwig demonstrated that mice bred to make extra amounts of MCH
had a greater tendency to become obese. But he decided that wasn't
enough.
"There are hundreds
of genetic factors in obesity, and I came to feel that identifying
yet another gene wasn't going to end the obesity epidemic," he
says. "Our genes haven't
changed in the last 30 years—while obesity rates have
tripled."
| Nick binges at night, eating
hot dogs 10 at a time, a pound of cheese, chips, candy. |
Instead, Ludwig believed
that it was environmental factors—social
and cultural—that needed to be changed. This view led
him back to clinical work and eventually transformed him
into what Time magazine has termed an "Obesity
Warrior." He
has testified in Washington, D.C., and speaks publicly and
often about the need for government measures—including
restrictions on food industry and advertising practices—to
curb the obesity epidemic.
"Childhood obesity
really winds up being a political issue," Ludwig
says. "I came from a very politically active family,
and some of my earliest memories are of being taken to
civil rights demonstrations and anti-Vietnam war protests.
I've kind of returned to my roots."
Ludwig founded
the OWL program in 1996, and today it is the largest
pediatric obesity program in New England, caring for more than
500 obese children and adolescents each year. Services include
medical examinations, comprehensive nutritional counseling,
exercise training, behavior modification and group therapy.
But Ludwig believes that
much of the responsibility for obesity falls on society, and
he doesn't mind stepping on toes in saying so. He's irked by
the suggestion that curbing obesity is a matter of self-control
and personal responsibility.
"This argument is used
as a smokescreen to maintain the status quo," Ludwig contends. "Blaming
the mother for her child's obesity takes the onus off the food
industry for advertising junk food to young children, and politicians
for not taking actions against these practices. In any other
epidemic, we would seek to maximize both personal and societal
responsibility. No public health expert would try to solve
the AIDS epidemic just by telling people to act responsibly."
A
toxic environment
Ludwig feels parents want to do the right thing, but
that their efforts are drowned out by a food environment
that's "overwhelmingly
toxic." "If we were to reverse environmental
factors back to those of the 1960s, virtually the
entire obesity epidemic would disappear," he
asserts.
Changes in the past 40 years
have been enormous. Fast food, junk food, and soft drinks
have become a prominent part of the landscape,
and food advertising directed at children has
exploded. "Just
watch Saturday morning television," Ludwig
says. "The
food industry pays billions of dollars to convince
young children to eat the most unhealthful foods
imaginable. What's being marketed to kids is
a nutritonal nuclear bomb—no fiber,
no fruits, no vegetables, no vitamins, no minerals."
And
portion sizes have ballooned. Today, a single "supersize" fast
food meal can contain a child's total daily
calorie requirements, Ludwig says. "And
it's consumable in 15 minutes, before the body
recognizes that the calories have come in,
before the child feels full."
Social changes
are as much to blame for the obesity epidemic.
To help fund their programs, schools have
become purveyors of fast food and soft drinks through
contracts with the food and beverage industry—even
as they cut physical education classes from
their curricula to save money.
Lured by TV
and computers, and because of parents'
safety concerns, kids are spending less and less
time outside burning off calories. Cities
and suburbs increasingly lack parks and
sidewalks. And increased stress on families leaves parents
less time to supervise their children's
diet and exercise habits—"leaving
children increasingly vulnerable to the
marketing and advertising tactics of the food industry," Ludwig
says.
Low-fat diets: part of the
solution or part of the problem?
The solution society came up with to the obesity problem
was low-fat diets, but Ludwig believes they have actually
made matters worse.
"It would seem to make
sense that if you don't want fat on your body, you shouldn't
put fat in your body," he
says. "Unfortunately, that message
is much too simplistic. By reducing
fat and replacing it with carbohydrates,
we may have done more harm than good
in terms of hunger and ability to regulate
body weight."
Just as there are
good fats and bad fats, there are
good and bad carbohydrates. What's increased
dramatically in the American diet
are the "bad" carbs—foods
like white bread, refined breakfast
cereals and concentrated sugars—that
are rapidly digested and raise blood
glucose and insulin to high levels,
changes that eventually can lead
to diabetes. Such foods are said
to have a high glycemic index, or
GI. "Good" carbohydrates—foods
like whole grains, most fruits, vegetables,
nuts and legumes—have
a low GI, meaning they're low in
sugar or release sugar slowly.
The
first study Ludwig did outside
his basic-science lab found that a high-GI
meal can actually make kids more
hungry and cause them to overeat.
It seemed like a strange notion, and
Ludwig had no experience doing diet
studies, but he convinced Children's
to give him a $20,000 pilot grant.
With the money, Ludwig's team recruited
12 obese teenage boys, admitted them
to the hospital overnight, fed them
low-GI dinners, and provided them with
different test meals to eat for breakfast
and lunch the following day. The test
meals were formulated to have low,
medium, or high GIs. During the five
hours after lunch, the boys could request
and eat as much as they liked whenever
they felt hungry.
When food intakes were compared,
the total energy intake after the high-GI lunch was 53 percent
greater than after the medium-GI lunch, and 81 percent greater
than after the low-GI lunch. Compared with the low-GI meal, the
high-GI meal raised insulin levels. Basically, when the boys
ate high glycemic foods, their blood sugar went up and crashed
a few hours later, fueling hunger.
The study, published in
the journal Pediatrics in January 1999, received a flood
of publicity, and became Ludwig's calling card to get more research
funding. His subsequent studies have shown that reduced-GI diets
may produce more weight loss in obese adolescents than conventional
reduced-fat diets; that each additional serving of a sugar-sweetened
beverage increases a child's risk for obesity by
60 percent; that 30 percent of American children eat fast food
on a given day; and that children consume substantially more
total calories, with poorer nutritional quality, on days when
they eat fast food.
Ludwig theorizes that glycemic
index and related dietary factors can even affect a child's risk
for attention deficit hyperactivity disorder (ADHD). "When blood sugar
crashes, adrenaline skyrockets," Ludwig
says. (Some theorize that adrenaline
has a role in regulating attention and impulse control.) "Isn't it
interesting that the prevalence of ADHD has skyrocketed along with the
glycemic index of our diets and childhood obesity?" Ludwig's group
conducted a pilot study on
diet and ADHD, and is considering a larger study in the future.
The Atkins
alternative
In August 2004, Ludwig published
a study in The Lancet that provides
the clearest evidence yet that a
low-GI diet can lead to weight loss,
reduced body fat, and reduced risk
factors for diabetes and cardiovascular
disease. Previous studies have also
found benefits of low-GI diets, but
these benefits could have been due
to other dietary factors like fiber
intake. This study eliminated that
problem, feeding rats and mice tightly
controlled diets that were identical except
for the type of starch: one group ate a high-GI
starch and the other a low-GI starch.
At follow-up, rats eating
the high-GI starch had 71 percent more body fat than the low-GI
group. They also had significantly greater increases in blood
glucose and insulin levels on an oral glucose tolerance test,
and far more abnormalities in the pancreatic islet cells that
make insulin, all changes that occur in diabetes. Finally, their
blood levels of triglycerides—fatty
acids that, when elevated, have been linked to atherosclerosis
and heart disease—nearly
tripled compared with the
low-GI group. Rats that were switched from a low- to high-GI
diet showed greater increases in blood glucose and insulin
than rats that were switched from high- to low-GI diets.
Additional studies in mice
bore out these results: mice assigned to a high-GI diet
had 93 percent more body fat
than mice on a low-GI diet.
"This is the first
study that shows that glycemic index, as an independent factor,
can have dramatic effects on obesity, diabetes and heart disease," says
Ludwig.
Ludwig hopes
that his findings will prompt
major health agencies
and professional associations to
reference glycemic index in their
dietary guidelines. He sees the
low-GI diet as a more viable alternative
to low-carb diets like the popular
Atkins diet.
While Atkins dieters seek
to minimize carbohydrate intake, the low-GI diet makes distinctions
among carbs. "The Atkins diet
tries to get rid
of all carbohydrates, which we think is excessively restrictive," says
Ludwig. "You don't have to
go to this extreme
if you pay attention to the glycemic index and choose low-GI carbs."
Show
me the money
Ludwig's OWL program
struggles to stay afloat
financially. It receives
no government support
and "very marginal insurance
reimbursement," Ludwig
says. "Many
insurance companies
will not reimburse
at all, or limit
reimbursement
to three visits." As
a result, OWL's
staff members
spend a great
deal of time
writing letters
of appeal to
insurance companies
when they would
rather be treating
patients.
"Can
you imagine
an insurance company
saying to the
parents of
a child with leukemia, ‘Your
child has a
particularly high-risk version
that hasn't
been cured in three
visits, so
we're going to cut
off coverage
now'?" Ludwig
asked U.S.
senators at
a Congressional
hearing in
June. "That's
a routine statement
to parents
of children
with obesity."
With "adult" diabetes
and atherosclerosis
sharply rising
in children
and adolescents,
obesity treatment
and prevention
would seem
to be a smart
investment.
Yet nationally,
there is
as little as 10
percent average
reimbursement
for obesity
treatment,
Ludwig says. "Why
would we
want to pay
$60,000 or
more for
coronary
bypass surgery,
but not a
few hundred
dollars for
measures
that would
prevent the
need for
it in the
first place?" he
asks.
Nick's
parents
have struggled
to get his weight-loss
visits covered
by insurance. Gary
has been laid off,
and this year,
the family was
forced to move
from their 13-room
house to a two-bedroom
apartment. Financial
concerns have clearly put stress on the family,
and during Nick's visit, Ludwig offers the
family a consultation with a behavioral therapist
to address possible psychological issues
behind Nick's binge eating.
"Sometimes when people
are feeling sad or depressed or angry, they deal with that by
eating a tremendous amount of food," he
explains.
A therapist is available
that morning,
but Gary is
concerned the
session won't be
covered by the
family's insurance,
so it's put on
the back burner.
Preventing obesity
Dimitri Athanasiadis is also 15, an affable, outgoing kid whose
parents own
a pizzeria. Dimitri works there Friday nights and all day
Sunday, but in the summer he worked full time, waiting
on customers, working the register, answering the phone
and helping prepare food.
"I would say the summer
was a test of my willpower," he
says. "You
have everything
here for
you—fried
chicken, steak
and cheese,
pizza, wraps.
It's like
a multiple
choice test—which
are you
going to
pick?"
Dimitri
is in Children's
One Step Ahead
program. Developed
by the Children's
Hospital Primary
Care Center, One Step Ahead directs
children toward nutritional plans
and physical activity opportunities
both at home and in the community.
While the OWL program is for
people who are already obese,
One Step Ahead is designed to
prevent overweight children from
progressing to obesity.
Dimitri, about 200 pounds
and almost 5 feet 6 inches tall, receives his
primary care at Children's. His pediatrician recommended him for One Step
Ahead because he was gaining
weight at each visit. Dimitri sees four people in
the program:
a doctor, a nutritionist, a social worker and an exercise/physical activity
coach.
"They devised a plan
for me," Dimitri says. "You
have to eat in portions. A good portion is the size of your
fist. You can't just load up your plate and sit down. With
pasta especially, I used to load up my plate. Sometimes
I would even have seconds."
"Sometimes even more
than you were supposed to eat the first time," adds Georgia,
Dimitri's mother.
"Now I try to measure
portions with my fist. If it's too much I'll put some back. If
we have chicken parmesan, I'll try to find just the right size
piece—not
too large, but not too small. You want to eat enough to feel
satisfied."
Dimitri
also avoids
juices
now, drinking
mostly water to cut
down on sugar. "You think juices are good, but they're not," he
says. "I used to drink an amazing amount of Gatorade, and
I've cut down on that too.
"They show you how
much sugar is in a Coke—I
was just dumbfounded," Dimitri adds. "It's like eating
a can of sugar—that is absolutely gross. In the chicken
sandwich at Burger King, the mayo alone has the same amount of calories
as a medium order of fries. That makes you think twice before you eat
it."
In
addition
to dietary
counseling,
Dimitri received
a device that clips onto
his belt and measures how
many steps he's taken.
The goal is for him to
take at least 10,000 steps
every day. "You
think it's easy, but it's not at all," Dimitri
says. "You cannot sit down, you've got to stay moving.
You can't watch TV. I create ways to move around, because if you sit
down, you're not getting up! You can't be lazy."
In
the
beginning,
Dimitri had appointments
every three months, "but
I wanted monthly," he says. That way, there would always
be a visit coming up pretty soon where he'd be weighed—and
that's helped push him to stay with the program.
Like
Nick's
family, the
Athanasiadis
family has
difficulty
affording Dimitri's
sessions. As
small business
owners, the
family has
no insurance.
They receive some assistance
from the hospital.
After losing an initial
10 pounds, Dimitri's weight has stabilized,
despite him growing in height. His caregivers would now like to see more
weight loss. The possibility of weight-loss medication has been mentioned,
but neither Dimitri nor his mother believe in pills. "I believe
it's 100 percent better to do it naturally," Georgia says. "Because
I know he can do it. I don't care if it takes longer, as long as
he's taking that road."
Children's
Hospital Boston
is now recruiting
adults to join a large-scale,
18-month study of the
low-GI diet. Subjects
will receive comprehensive dietary
and behavioral counseling in
individual and group sessions
that will enable them to put
low-GI diets into effect. To
enroll, subjects must be overweight,
18 to 35 years old, and motivated
to attend weekly sessions for four months and
return for follow-up through 18 months. People
interested in enrolling should contact Erica
Garcia-Lago at (617) 355-2500.
