By Brigid Schulte
Washington Post staff writer
Thursday, May 22, 2008
Marisol Quiroz watched in alarm as her overweight son ballooned 50 pounds in a year. She had taken him to doctors and nutritionists who told her to make him stop eating so much but never told her how.
David Quiroz, 12, weighed 215 pounds last fall. Half his body mass was fat. His cholesterol was elevated, his blood pressure was too high and the sugar in his blood was hitting dangerous levels. He was well on his way to diabetes and heart disease before reaching high school. His mother made an appointment to see David's pediatrician alone. In tears, she told him she had no idea what to do.
She found out that the medical community does not really know, either. Doctors are great once a child becomes so obese that he or she develops diabetes or heart disease, critics said. But they have yet to figure out how to keep children from becoming obese or how to help them lose weight.
"We pediatricians do a fantastic job talking about food during a child's first year of life. We know precisely how much formula a 6-month-old needs because we've been concerned about failure to thrive. But we're not terribly good about what happens after that," said Nazrat M. Mirza, a pediatric endocrinologist at Children's National Medical Center in the District. "We pediatricians don't even talk about obesity."
Most in the medical community said they did not begin to recognize childhood obesity was a problem until it had become an epidemic. Now, researchers are predicting that one of every two children will develop Type 2 diabetes because of excess weight, which raises the probability that they will die as much as 20 years younger than their parents. And doctors are scrambling to catch up. The American Academy of Pediatrics only recently issued guidelines about what to do for an overweight child.
"There's been a delayed response in the medical and health-care community because, in many ways, we weren't prepared for it," said Thomas N. Robinson, director of the Lucile Packard Children's Hospital at Stanford University's children's hospital. The conventional wisdom was that children would outgrow the excess weight.
With so many young lives at stake, about the only thing the medical community knows for sure is that traditional weight-loss programs do not work. A success rate of 1 percent is the best medical professionals have seen.
"We know how to change people's behavior, but we don't know how to sustain those changes," said Terry Huang, program director for pediatric obesity at the National Institute of Child Health and Human Development. It sounds so easy, he said. Eat less. Exercise more. If it were so easy, though, the majority of Americans would not be overweight.
Even when it comes to bariatric surgery, the most radical method of weight loss that physically shrinks the stomach, only 5 percent of patients return to what doctors consider a normal weight . In all weight-loss programs designed for adults and children, almost everyone initially loses, but within two years, patients have put the weight back on. "We have to change course," Huang said.
That change is complicated by money. Obesity is not classified as a medical disease, which means few insurance companies will pay for weight-loss treatment. What they will pay for, however, are all the illnesses that arise from obesity.
Researchers are finding genes that contribute to obesity, and they are studying how foods affect hormones that contribute to appetite. Some researchers have found that people metabolize food differently, so no one diet will work for all types of people.
They are finding that the body is, evolutionally, still programmed to hunt for food and survive famine. If the body is not moving, as most aren't in these sedentary times, the brain thinks the body is starving. So the body begins to cannibalize protein-rich muscle to feed the brain and conserve fat stores.
"We are living not as our genes intended. It's not normal to play video games all day," said Eric Hoffman, director of the Center for Genetic Medical Research at Children's Hospital. "We have taught our children how to kill themselves. We have to reverse that."
Mirza is one of the few pioneering pediatricians who is trying. Shocked at the rates of childhood obesity when she came to the United States from Kenya, Mirza has been working on a new kind of weight-loss program, one that involves changing the behavior of the whole family by reteaching everyone how to shop, cook, think about food. She is starting with the Latino community, where diabetes runs high. And, following up on genetic research, she is testing whether low-fat or low-glycemic diets work better for Latinos.
The need is acute, she said. In her practice, she has seen a 9-month-old weighing 30 pounds -- twice the average size for a child that age. She works with an 11-year-old who weighs 420 pounds. And her associate, a psychologist who studies sleep apnea, is considering a tracheotomy for a 16-year-old so dangerously obese that he stops breathing 75 times an hour during the night.
It was to Mirza's program that David Quiroz's pediatrician told the boy's mother to go.
David, a good-natured honor student at Julius West Middle School in Montgomery County, can matter-of-factly recite what he used to eat. School lunches of cheeseburgers, pizza, two or three servings of french fries or tater tots every day. A trip to the snack line for ice cream or cookies. Candy and soda from vending machines after school. Chips and soda at home while watching television or playing Halo on Xbox. "I think I overdid it," he said.
He also can describe all the diets he has tried. He wanted to be healthy. He did not like that he got winded walking to class. He was not happy when he signed up for wrestling, but had to spend the semester on the bench because teachers could not find anyone in his weight class.
It's just that he loves food. And he has always felt hungry, even after a big meal. "We'd go out to dinner at the Cheesecake Factory or Red Lobster and I'd eat all my dinner, then my brother's, then everybody's leftovers in the car on the way home," he said.
His mother thought she was cooking healthy meals, but they were heavy on the white rice she liked from her childhood in the Dominican Republic. And she tried to help him. "I wanted him to join a soccer team or sports teams, but they have practices after school and I could never get him there," she said. She works as a dental assistant in Bethesda and does not return home until late. His father works two jobs as a nursing assistant to pay for their house in Potomac. So she bought him a treadmill, an exercise bike and a punching bag. He never used them. She couldn't get him interested in the equipment.
At his first weigh-in with Mirza's Cool Kids program, David's body mass index, which is the relationship between his height and weight, was 36 -- more than twice the BMI for the average 12-year-old. His glucose tolerance was 177. Normal tolerance is 140; a diabetic's is 200. And his insulin resistance was 13.2. Because insulin resistance has never been a problem for children before, doctors are not sure what a normal range is. Normal for adults is 2. "He really had the metabolic syndrome," Mirza said, a new condition marked by a cluster of risk factors that lead to heart disease and diabetes.
That scared David. The summer before, he had found his father collapsed in the driveway, in the early stages of a heart attack.
For 13 weeks, David, his younger brother, William, and their parents went to Mirza's clinic in Adams Morgan every week. They set goals and talked about overcoming barriers to healthy eating. They met with a psychologist to talk about self-image. The boys exercised, then learned about nutrition -- they were shown test tubes filled with Crisco equaling the fat content of their favorite fast foods. Marisol Quiroz attended nutrition class with other parents and shopped with a nutritionist who taught her what to look for on food labels: no more than 3 grams of fat and 12 grams of sugar per serving, and high fiber -- 5 grams plus the child's age.
The family learned about proper portion size. If Quiroz serves white rice, she serves no more than a half-cup for each person. She began packing David's lunch, substituting white bread and tortillas with whole-wheat tortillas and whole-grain white bread, because David does not like whole-wheat bread yet. She began cooking fish and baking chicken instead of eating out so often. If the family ate out, they chose Subway over McDonald's, and ordered half-subs instead of foot-longs.
"The technique we use is not to make drastic changes, but small, permanent changes," Mirza said.
It's not about dieting; it's about life choices. If a child watches six to eight hours of television a day, the first goal is to reduce the amount by an hour or two. If a child consumes several sugar-laced Gatorade drinks, juices, sodas and VitaminWaters, Mirza asks them to cut back.
She encourages families to eat meals together slowly and wait before reaching for seconds, as it takes 15 to 20 minutes for the stomach to signal to the brain that it is full. New research is showing that many overweight children who, like David, developed uncontrollable appetite habits very young, are often unable to recognize when they are full and need to relearn to listen to their internal hunger drive.
Mirza asks children to get a good night's sleep, because when the body is sleep-deprived, it craves fatty, high-sugar foods. And she wants them to exercise. The children wear a pedometer and are asked to take at least 10,000 steps a day, or about five miles.
When David first put on the pedometer, he barely made it to 300 steps. His mother found a kid-friendly gym, FunFit, in Gaithersburg. She drives her sons there at least three times a week. They play around on mats and do a 30-minute circuit on a treadmill, stationary bike and kid-friendly machines. On days when the weather is good, she takes a walk with the boys and kicks a soccer ball in a park. Some days, David gets up to nearly 5,000 steps.
In February, David went again to Mirza's clinic. He now goes once a month. At his weigh-in, he had lost nearly 30 pounds. His BMI was 30, and his insulin resistance has been reduced by half. "To lose six BMI is amazing. I am very proud of him," Mirza said. "We're not at a camp. He's still living in the free world, and there's so much temptation out there."
David is proud, too. "I feel better about myself since losing weight," he said. He is no longer the last to finish the mile run in PE. He is able to concentrate better in school. He still does not go to school dances, though he is thinking he might for the first time.
But he struggles. On days when there are class parties with cupcakes, his friends circle him and remind him how well he is doing.
On a recent day at lunch, David opened his small blue lunch box and ate a sandwich with low-fat turkey and provolone cheese spread with low-fat mayonnaise. He drank a 10-calorie juice and ate a banana. He was finished before his friends made it through the lunch line and took seats around him with their pepperoni pizzas, fried chicken patties on buns, chocolate milk and french fries. The snack line stretched nearly into the hall as students bought ice cream, candy, cookies and pretzels. Vending machines lined the hallways and one wall of the cafeteria.
David walked through the lunch line to see if there would be anything Mirza would approve of. He found a tray of bruised fruit and another of wilted iceberg lettuce and tomato slices. The low-fat yogurt had 40 grams of sugar. He looked wistfully at his friends' meals. "Sometimes I miss it," he said. "But then I think of my health."
Change is hard. His mother said she sometimes finds french fry trays in his lunch box. And though he is eating healthier, he sometimes does not know when to stop. He still thinks the treadmill is boring. And his favorite thing on television remains the Food Network. He likes to watch the bakers on "Ace of Cakes" deliver confections like three-layer chocolate pound cakes.
"I'd love to do that," he said wistfully. Then he smiled. "I just hope I don't eat all the cake before I deliver it."