Allison Lauretti, PhD, psychologist, Maryanne Lewis, CS, PNP, and Suzanne Rostler, MS, RD, LDN, clinical nutrition specialist, from Children’s Hospital Boston’s Optimal Weight for Life (OWL) program, share views on the obesity trend and ways pediatricians can help overweight patients.
Perhaps 60 percent of the cause is related to environmental factors, such as poor eating habits and too little exercise. Specific genetic disorders and other endocrinologic factors account for less than 5 percent of all cases of obesity.
The most important screening tool is plotting accurate height, weight and BMI at regular intervals, and watching for an increase in the velocity of the weight curve. New studies indicate a greater risk of obesity in babies who gain weight too rapidly in infancy. Identifying children early can improve the success of interventions. Each time he grows an inch, a child could be expected to gain approximately five pounds. With a slower weight gain, there’s a significant improvement in BMI over time.
Clues about individual risk may be present in the birth history. Studies point to factors, such as gestational diabetes and low birth weight, as increasing the risk for type II diabetes and obesity later in life. A family history of obesity, type II diabetes, hyperlipidemia, hypertension, sleep apnea and early heart attack may also increase risk.
Asking targeted questions to elicit a history of exercise intolerance, teasing by peers or sleep apnea give pediatricians insight into how a child’s obesity might be impacting his daily life. A careful dietary history should include questions about the quality of meals and snacks, the amount of juice or soda a patient drinks per day and the frequency of take-out meals or fast food.
The physical exam holds important information about the adverse effects of obesity on a particular child. Pointing out that a child is already suffering from hypertension, flat feet or acanthosis nigracans (a darkening and thickening of skin folds that signifies insulin resistance) should alert parents about the risk of increased obesity and allow for a discussion of how to prevent further problems. In most cases, acanthosis and hypertension should improve significantly as a child’s BMI improves.
Children who continue to gain weight despite a pediatrician’s efforts at counseling, and especially those with comorbidities, such as impaired fasting glucose, hypertension, acanthosis and elevated lipids, as well as those with suspected genetic syndromes (such as Prader Willi or Bardet-Biedl), should be referred to the OWL program. If a patient is pre-diabetic or diabetic, pediatricians should refer to an endocrinologist or to our OWL type II diabetes clinic.
The focus in OWL is not on calorie counting or fad diets, but rather on teaching children and teens to enjoy food in appropriately sized portions. Our approach is to encourage children to be strong and healthy—we don’t focus on weight loss or size. Pediatricians don’t have to stage an intervention in just one visit. There can be short 15-minute discussions every few months. Focusing on one food and one exercise goal at a session is realistic. Helpful messages include low-glycemic index dietary guidelines such as the following:
- eat slowly, stop when full
- eat three meals and one or two snacks a day
- eat whole grains, fruits, vegetable and legumes
- limit sweets and refined starch foods to occasional treats
- protect the home by only bringing healthy foods into the house
- choose lean protein and low-fat dairy
- avoid sweetened beverages and limit juice to a cup a day
- add healthful fats, such as those found in olive oil and nuts
- add protein and fruits or vegetables to meals and snacks
When it comes to talking about activities, it’s important to find out what motivates the child. Some kids want to lose weight in order to do better at sports or to fit into a bathing suit. Others prefer to do activities alone, like walking or biking.
A key part of a successful intervention is making it family-centered. Children model what their parents do. Family walks are inexpensive and work well with younger children. Along these lines, we’ve seen that when families eat together and keep a "food-safe environment" there’s a greater chance of success, regardless of the child’s age or the family’s income level.
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