Who Are You Calling Fat?
Tuesday, July 18, 2006
Some doctors call it "the other f-word" -- a problem they see on a daily basis but many are reluctant to address: kids who are too fat.
The issue is not new, but experts say it has acquired greater urgency as obesity has ballooned in the past 25 years, accompanied by sharp increases in diabetes, hypertension and high cholesterol, conditions that used to be largely the province of those middle-aged or older. In 1980, according to the federal Centers for Disease Control and Prevention (CDC), 7 percent of children and 5 percent of teenagers were overweight; today the figures hover around 19 percent and 17 percent, respectively.
Doctors at Children's National Medical Center in Washington, where 38 percent of patients are obese, say that in recent years they have treated a 9-year-old who suffered a heart attack, a child with a body mass index of 52 (a 5-foot-6 adult with a BMI of 52 would weigh 322 pounds) and several others so dangerously fat that they underwent gastric bypass surgery.
So why are many doctors reluctant to mention an obvious problem?
The reasons are many, experts say: fear of alienating a family or hurting a child; uncertainty about what weight loss approaches have the best outcomes -- or work at all; accelerating time pressures coupled with the requirement that doctors cover an increasing number of topics in a visit; and an insurance system that often does not reimburse doctors for follow-up visits to treat obesity alone. Many pediatricians also say they have no place to refer children who need more intensive help managing their weight.
Locally, that will change in September when Children's is scheduled to open a multidisciplinary pediatric obesity clinic for children between 2 and 18. The clinic, which will feature individual and group treatments for children and their families, will include a nutritionist, a cardiologist, an endocrinologist and a personal trainer. "We're hoping to create a home for overweight and obese children," said Nazrat Mirza, the Children's obesity specialist who will direct the clinic.
"Many doctors don't feel comfortable or competent talking about obesity," Mirza said. Because pediatricians typically schedule patients every 10 to 15 minutes and are expected to cover a multitude of topics including immunizations and safety issues, "they think, 'Do I want to open that Pandora's box' " by mentioning a child's weight?
Often, she said, the decision is no -- particularly if a parent is overweight, as is often the case. Some who have broached the subject, Mirza said, have complained that "it doesn't seem to make a difference, kids just keep gaining weight, so why are we wasting our time?" And many doctors are unsure about which approaches are likely to work best with kids.
To help physicians address the problem, Children's has held classes designed to help doctors and nurses communicate with parents, advising them to open the discussion by showing them where a child falls on the growth charts and calculating the child's BMI.
Anything but 'Fat'
Even the terminology used to describe children's weight problems is prompting debate, as doctors draw up new guidelines for the diagnosis and treatment of obesity under the aegis of the American Medical Association and the American Academy of Pediatrics (AAP).
For several years the CDC has recommended that clinicians classify children who are overweight -- above the 85th percentile on growth charts that track height, weight and age -- as at "risk of overweight."
Those above the 95th percentile are called overweight -- rather than obese -- to avoid stigmatizing them.
Reginald Washington, a pediatric cardiologist in Denver who is co-chairman of the AAP's task force on obesity, said the CDC's "warm and fuzzy" labels obscure the health crisis personified by the children who are routinely referred to him for treatment of high blood pressure and high cholesterol.
"I think until people realize they have to change, they won't," Washington said, adding that one reason childhood obesity "is so out of control is that no one wants to talk about it."
Washington said he has been accused by parents of callousness or an inability to understand the problem when he tells them their children need to lose weight -- criticisms he rejects. Many parents, he added, are too fat themselves and are unwilling to make changes to help their children lose weight.
"There's a lot of denial," Washington said, adding that parents have told him they can't buy healthier foods because their children refuse to eat them, or they don't want to remove the TV set from a child's bedroom because he or she will get into trouble doing other things.
But other experts say that labeling kids overweight and obese may prove more harmful by making them feel there is little they can change. It is easy, they warn, to oversimplify a complex problem that may involve cultural differences, poverty and psychological factors.
"The issue is not as simple as telling people to eat more fresh fruits and vegetables and move more," said adolescent medicine specialist Adekemi Oguntala, who co-directs an obesity treatment program at Children's Hospital and Research Center in Oakland, Calif., that is grappling with problems similar to its District counterpart. In some cases, she said, families don't have access to fresh produce, are resistant to making changes that involve the entire family, or eat cheap, high-calorie foods because they are accessible or affordable.
And, Oguntala said, even someone who is highly motivated and has struggled with weight knows how difficult the problem can be.
In some cases, cultural differences in attitudes toward overweight can play an important role, said Children's Mirza. "The majority of parents don't know their child is overweight, and some parents get very upset" if they are told their child is too heavy.
"They say, 'I was big as a kid,' or that their child has a hormonal problem," she said. In some cultures, Mirza added, chubbiness is seen as a sign of health and people talk about "that poor skinny thing."
A recent study of 194 Latina mothers in California, presented at the Pediatric Academic Societies annual meeting, found that 44 percent had children who were overweight by age 3, but three-quarters thought their children were of normal weight.
Sometimes ignorance is a factor.
"Most people are not that knowledgeable," said Kelly Sinclair, a clinical nutritionist at Children's. "They think their diet is healthy -- that low-fat Pop Tarts are healthy or Goldfish crackers are because they're not potato chips. Some people count candy in the shape of fruit as a fruit."
Nathaniel Beers, medical director of Children's general pediatric clinic, said he takes a straightforward approach with families whose children are overweight or obese. First he calculates a child's BMI, then he asks parents and the child if "this is something they want to work on."
"Most people are willing to think about it," he said. Even those who haven't been successful controlling their own weight are often eager to help their child "because they don't want him or her going through what they've been through." It's important not to alienate parents by blaming them, he added.
"As pediatricians, we try to help get a dialogue going and to leave the door open," Beers said. Although he counts a few successes among his patients, Beers added, "it's a huge uphill battle." ·