Treating obesity at ground zero
I found myself in the trenches of the war on obesity in 2000 when I began working as a general pediatrician at a local community clinic in Southern California. I immediately became aware of the day-to-day barriers that my patients were facing and I began to take on the responsibility of making sure that the children I was seeing would not only survive, but also thrive.
Besides treating their ear infections, asthma, rashes, and getting them through their school physicals, I wanted my patients to be safe by wearing helmets and using properly fitted car seats. I wanted them to be developmentally stimulated so they could do well in school. Above all, I wanted them to fulfil their potential to be whole, healthy human beings.
When children presented to me suffering from obesity, a potentially life-threatening condition, I was as thorough and conscientious as I could be. I checked their diets and their body mass index (BMI). I would make the diagnosis of “obesity,” and at times I’d even get fancy and point out “acanthosis nigricans.”
As for our plan, my case manager found a 6-week treatment program that geographically was far away from where we were. I referred many patients, but my families often couldn’t or wouldn’t go. I quickly discovered there were no other doctors in the area treating or even screening for obesity. I had no plan B, which left me with actually no plan at all.
The turning point
Around this time my dad underwent bypass surgery—he wasn’t even obese!—and this brought home the harsh realities of cardiovascular disease and obesity. With great resolve I rolled up my sleeves, read journals and books, and went to conferences to speak with specialists, but ultimately it was my patients who taught me how to treat childhood obesity.
One patient at a time, I started to identify the barriers to a healthy lifestyle and worked with each family to overcome these obstacles. Within 9 months, I had 2 boys in 2 different families that each had lost 100 pounds. Flushed with this success, I was hooked. I was treating a disease just as serious as cancer but without expensive and painful surgery or chemotherapy. Even more enticing was the fact that I was treating not just the patient but the whole family, and the whole family was getting healthier as a result. Mom’s diabetes would get under control. Grandpa’s hypertension would improve. The list went on and on.
One of the boys was interviewed by a local paper and said, “Now I feel like if a bad guy were to chase me, I could get away.” I was shocked after reading that. It had never occurred to me that a 295-lb, 12-year-old could feel so vulnerable. After that revelation, I stopped patting myself on the back and realized that I still didn’t have all the answers.
Creating a plan
During my studies at Boston University School of Medicine and my residency at the Children’s Hospital of Orange County, California, I had always been impressed by multidisciplinary clinics that treated complex medical cases such as craniofacial abnormalities, cancer, and spina bifida. It was exciting to be part of those rounds with social workers, specialists, pharmacists, and dietitians. The multidisciplinary approach seemed the ideal model to combat complex medical issues.
I turned to my mentor, Dr. Gwyn Parry from Hoag Memorial Hospital in Newport Beach, California, and asked how I could assemble a multidisciplinary team to combat this epidemic of obesity. He directed me to a new funding source from tobacco tax (Proposition 10) revenue in California run by the Children and Families Commission of Orange County.
My clinic wrote the grant, but we made a political decision to de-emphasize my plans to treat obesity because in 2001 obesity, especially childhood obesity, still was not on many people’s radar. Instead, we said that this program was to “help with the safety net for those most vulnerable.” I figured I was already a pediatrician at a community clinic, and it was impossible for me not to screen for food insecurity, socioeconomic stressors, or poor medical or dental access. We got the funding.
Dr. Riba’s Health Club (DrRHC) began as a half-day-a-week program with a multidisciplinary team that included a psychologist, social worker, medical assistant, registered dietitian (RD), case manager, and pediatrician, me. We started seeing 1 child at a time in a very comprehensive manner. Each of us met with the families, then we sat as a team and discussed each case. The RD would complain, “I can’t get this mom to serve vegetables.” The social worker would chime in, “Well, that’s because they are living in a garage and they don’t have a refrigerator.” Given barriers like that, the concept of developing healthy habits is a luxury. These families are on survival mode just trying to get through their day.
These were tough cases. Every one required my team to piece together what was going on at the home and how best to support the family. My social worker taught me to stop trying to solve each family’s immediate needs all on my own and instead link them to appropriate resources so they could learn to solve their own problems. We connected family members to dental access and medical homes. We referred for counseling, shelters, and even food banks. For the family living in the garage, we helped them find more suitable housing and even found a way to get a refrigerator donated to them.
The psychology of feeding children
Stress is an important component. It is never about just the food. It is never about just the eating. You really do have to treat the whole family and their whole life.
Having said that, of course, when it comes to obesity, food is something you can’t ignore. My RD, in a very unassuming way, found a way to teach the whole team about nutrition while innocently explaining for each case what foods were in the house, who was feeding the child, and how she educated that family and overcame barriers. She also dragged me to an Ellyn Satter Institute conference and indoctrinated me into what I call the proper psychology of feeding children, which is grounded in Ellyn Satter’s Division of Responsibility in Feeding: Parents are responsible for what is being served and when, and children are responsible for if they are going to eat and how much.
As I applied these principles in my patient care, I found that the psychology with which we approach food could make all the difference in the world. One major revelation is that portion control creates more psychological harm than it does physical good. Maybe a few children will have short-term success with portion control, but the majority will convert to a lifetime of dysfunctional relationships with food, just as intimidation tactics and shaming are detrimental to children.
One patient, an 80-lb, 3-year-old boy (whose weight should have been around 33 lb at that age) came to see me, and he was carrying a measuring cup. I thought it was so cute, that maybe he wanted to be a chef when he grew up. I discovered that he had previously seen an RD, who told him that he could only eat carbs in a quantity that would fit into the cup. So, he was carrying the measuring cup with him everywhere he went in anticipation of his next portion of food. Not only did this restrictive portion control make him completely insecure about food, but he also proceeded to escalate from overweight to obese. This is the sort of psychologically damaging effects I have seen because of portion control, which makes a strong case for when it just doesn’t work.
Adding more models
In 2008, I obtained additional funding that enabled my team to begin treating childhood obesity throughout the county. I started to evaluate our program because I wanted to know if we were helping only an anecdotal few or making a statistically significant impact. I wanted to know what was working or not working and make adjustments to improve success.
We also began to create other models to treat and prevent obesity, and our current programs include:
- Health Club: Individualized patient care plans are delivered by a multidisciplinary team. Our latest evaluation found that 84.5% of patients improved their BMI percentiles.
- Fit Club: The program targets children aged 4 to 18 years who are at risk for childhood obesity and type 2 diabetes, and offers year-round after-school and summer sessions. This year, our after-school session found that 93.3% of overweight or obese children improved their BMI percentiles and 100% improved their fitness levels.
- PC-Fit (Parent-Child Feeding Interaction Therapy) Program: A collaboration between DrRHC and the Child Guidance Center, and recently funded by the Harvard Institute of Coaching, PC-Fit aims to prevent and treat eating disorders.
- ·Fit Scouts: This troop of children is dedicated to having a healthy heart through nutrition, exercise, and helping others.
Medical provider education and training: DrRHC offers provider education and training programs conducted by a pediatrician or RD on the appropriate psychology of feeding children.
Community education classes: DrRHC encourages teaching obesity prevention and health concepts at an early age through specially designed classes on health and nutrition for parents and young children.
Today, we continue this multidisciplinary approach and look at everything—obstructive sleep apnea (OSA), exercise, and psychology, to name just a few. The team now consists of 2 dietitians, 3 fitness instructors, 3 medical assistants, a case manager, and me. We see patients at 4 different clinics and refer to social workers, psychologists, and other specialists. We treat everyone the same way—obesity, underweight, failure to thrive, and picky eaters. In fact, we also treat all family members of all sizes the same way.
Treating obesity at ground zero
Our philosophy includes:
Keep healthy, natural food at home. Offer 3 meals and 2 to 3 snacks a day.
Follow the Division of Responsibility in Feeding for children.
Avoid coaxing or bribing, or artificial comments such as “Mmm, this tastes so good,” when feeding children.
Talk about your day at mealtimes. Nourish each other with sincere compliments that are not food related, such as “You had such nice manners when I took you to the store today.”
Be active 60 minutes a day.
In general, the goal is to treat families for 6 months over 9 visits; I want to follow my patients past that initial hump of weight loss in the first 6 weeks of treatment to see if these changes could actually be maintained. That being said, I seldom graduate anyone in October with Halloween, Thanksgiving, and Christmas break lurking ahead. On the other hand, I had 1 year in which 3 patients each lost about 20 lb between October and January, and so I graduated them immediately. I miss being their general pediatrician so I could witness the full extent of the loss or the long-term patterns of my patients, and I hope to find grants to help sustain my follow-up more extensively into the future.
We collect our results annually to match the fiscal year of most of my grants. Over the years, we have evolved in how we evaluate our program. The BMI percentile for age seems to be the best tool when the goal is to normalize the velocity of growth. Because BMI fluctuates with age, you could be a fraud for saying that BMI was going down in children aged 2 to 5 years because it is supposed to go down. Or, you could be falsely thinking you are failing when a BMI is going up between ages 6 to 18 years when actually the child is getting slimmer.
We have statistically significant results so far, but I know that although the data we have collected over the past 5 years look good (amazing, in fact, with 84.5% of our patients improving their BMI percentile in 2012–2013), the scientist in me wants to see how all this will pan out over the next 50 years. Are my patients going to maintain a healthy weight? Are their younger siblings healthier than they would have been? How about their children?
What you can do
As a practicing community pediatrician, I see on a regular basis that many things we do can’t be measured and don’t add up to neat statistics. However, my amazing team and I have narrowed down some basic premises that seem to be most effective for combating this very misunderstood yet very manageable disease. Yes, the scientist in me has to live with the fact that no, I don’t have 50 years of data, but neither does the rest of the scientific community. With pediatricians out there every day being told to do something for this problem for which we have not been formally trained, I feel that I must share these pearls garnered from my experience with my fabulous team and my forthright patients. My 5 most important recommendations include:
Get sugary drinks and processed foods out of the house.
Serve fruits and vegetables with all meals and snacks.
Look for stressors in the house (including bullying, dieting, and nocturnal enuresis) and support and refer these patients.
Teach families good psychology when feeding children.
Never underestimate the power of a good night’s sleep (always rule out OSA).
The plight of overweight children can be extremely heartbreaking and challenging for both providers and families, but it doesn’t have to be. There is an answer, and it doesn’t cost the earth—just a little dedication and a lot of love.