Our increasingly sedentary, overweight kids are in big trouble.

 

Pediatric obesity rates have tripled since 1980, with one out of every three American children now overweight or obese. As these children develop the debilitating chronic diseases of their parents and grandparents, pediatricians are routinely encountering illnesses many of them never expected to treat -- from fatty liver disease to type 2 diabetes.

 

It’s one thing to bemoan America’s expanding waistline. But with obesity making our children ill, it’s not merely a social issue -- it’s a full-blown medical crisis.

 

From a new childhood obesity clinic to community-based interventions, Duke caregivers are adopting sweeping new strategies to address the health of a generation.

 

When pediatrician Sarah Armstrong, MD, left Baltimore last year, she left with a purpose. Armstrong is still early in her career, but she was already noticing a disturbing trend among patients in the inner-city clinics where she worked.

 

“High blood pressure, adult-type diabetes, sleep apnea, cholesterol problems, early puberty,” she says, ticking off a list of diagnoses she was making with increasing frequency. “Sixty percent of overweight kids are already exhibiting a clinical risk factor for heart disease.”

 

Armstrong joined the faculty at Duke to form a new clinic, the Duke Children’s Healthy Lifestyles Program, that is the first multidisciplinary clinic at the medical center devoted exclusively to caring for overweight and obese children. The program provides individual family assessments and interventions to help reverse weight gain in children and treat the medical conditions that may be developing as a result of a child’s obesity.

 

Healthy Lifestyles fills a new clinical and research niche, by trying to catch these kids before their health problems necessitate specialty care. But it’s joining an already robust array of initiatives at Duke that have been battling childhood obesity for a decade, from individual patient interventions to community-wide programs.

 

Researchers and clinicians here say that pediatricians need to prepare to treat a mounting wave of obesity-related chronic illness. But more important, they say, there’s much that doctors can be doing to help reverse the problem before it gets any worse.

 

At the Duke Clinic on Roxboro Road, Armstrong and her staff have carved out a dedicated space for the Healthy Lifestyles Program. Within its first four months, word-of-mouth had drawn more than a hundred families to the program -- most of them referred by local pediatricians, who haven’t time during a typical office visit for the type of intensive intervention offered here.

 

A patient’s experience with Healthy Lifestyles begins with a two-hour-plus evaluation by three specialists. 

 

A registered dietitian meets with the family to go through their entire diet history and recommend practical and healthful meal plans.

 

A social worker screens for behavioral and emotional problems in the patient and the family (such as depression), then helps the family create healthy -- and hopefully permanent -- lifestyle changes.

 

The team doesn’t use the words diet or exercise. Instead, the game is all about activity and making healthy choices.

 

“Some kids say they don’t do any activities because they don’t like group sports,” says Armstrong. “We help them find dancing, swimming, skating -- things that they’ll enjoy.”

 

Patients leave their initial assessment with an information packet -- a sort of battle plan.

 

“We write in what their specific goals are, what their specific recommendations are, a couple of sample meal plans if that’s appropriate,” says Armstrong.

 

Patients are also offered the option to continue with an intensive program of five monthly sessions that address specific lifestyle modifications. All families return for a six-month follow-up.

 

In the Healthy Lifestyles nutrition room, a shelf overflows with plate-less mounds of green beans and cornflakes in search of a bowl. Rounds of cut corn and free-form grits flank tiny steaks, drumsticks, fruit -- all plastic replicas in properly portioned sizes.

 

“Most people have no idea what a single serving of bread is,” says Armstrong. She picks up a plastic bagel that looks miniature but is actually the boiled bread’s originally intended size -- half that of your average bagel-stand fare.

 

Posters with positive food images decorate the walls of every room in this clinic -- one displays an enticing rainbow of fresh fruits and vegetables.

 

Healthy Lifestyles is an oasis of healthful eating advertising that looks quite different from the fast-fried world awaiting families when they leave.

 

Susan Yaggy, chief of the Division of Community Health, says that addressing these climate-related causes of obesity is essential to the long-term success of programs such as Healthy Lifestyles.

 

“We have to change the environment in which kids live and work and play,” she says. “Food is cultural, it’s familial, it’s part of religious observances in the home. Because of all that, to help a family make lasting changes, we need to bring a lot of forces to bear in a combined, collaborative effort.”

 

Her group has devoted attention to childhood obesity since its inception in 1996.

 

“When our division was formed, our first projects were studying asthma, and obesity was there,” she says, because asthma is yet another chronic illness more common among obese kids. Her division has helped communities throughout the state to implement physical activity and nutrition programs.

 

Many of these communities have had great success with the families enrolled, but the obesity problem in North Carolina overall continues to worsen.

 

“It’s a problem that takes a lot of work, a lot of organizing, and a sustained effort,” Yaggy says. “And those are hard.”

 

However, there are increasing opportunities now, including funding for new programs, that weren’t there before.

 

“There’s more willingness to use the social good of government to help people make good choices.”

 

One example, she says, is the Partnership for a Healthy Durham, established by the Durham County Health Department -- the local organization for the national Healthy People 2010 initiative. Yaggy serves as chair of its obesity and chronic disease committee. That group has created a Web-based map to help families find physical activity and nutrition resources near their home, from farmer’s markets and trails to gyms and after-school programs.

 

The hope is that a new community infrastructure offering obesity-combating programs, exercise opportunities, and nutritious food choices will take root, slowly supplanting our well-entrenched toxic eating environment.

 

“Research shows that multiple, reinforcing strategies -- not single interventions -- are what work to help patients and families make long-term changes in their health behaviors,” Yaggy says. “So when a parent walks out the clinic door with his child, they should know about healthful options, whether it’s at the parent’s workplace or the child’s school or weekend events at church, to support changes that they make at home. That kind of community support is needed to reinforce your decision to change your family’s health behaviors.”

 

Often, Yaggy says, a key trigger for a family to make that decision is a physician expressing concern about a child’s weight.

But according to Duke’s director of adolescent medicine, Terrill Bravender, MD, MPH, many pediatric practices don’t even chart their patients’ body mass index (BMI).

 

“Pediatricians think they can identify a child who’s overweight by looking at that child, but that’s simply not true,” he says. “The normal BMI for adults is static; you’re overweight with a BMI of 25, and obese at 30. For children what’s ‘normal’ changes from year to year.”

 

Many pediatricians also report feeling uncomfortable discussing children’s overweight with their parents.

 

“Some parents are shocked when you bring it up,” says Bravender, because for so long obesity has been considered a private, cosmetic, even moral issue more than anything else.

 

Physicians, says Bravender, can be pivotal in changing the conversation to one based on health.

 

“That’s why we’re talking about it, after all,” he says. “I don’t care if my patient is overweight, if that individual is healthy. There’s always a wide variation in what’s ‘normal,’ and frankly if a kid looks like he’s genetically determined to be in the 90th percentile for weight but he’s active and doesn’t eat poorly, I’m less concerned about that child. It’s the health implications that I’m worried about.

 

“My father smoked when I was young,” he says, “and I remember he went to the doctor and the doctor didn’t mention his smoking. So my dad’s take-home message was, ‘Well, I guess I don’t smoke too much because the doctor didn’t say anything.’ And I think it’s the same with obesity. If you don’t say anything, many patients and parents interpret that as tacit approval.”

 

Bravender calls our culture an obesigenic one, noting our dependency on cars for transportation and the sedentary style of much of our work and entertainment.

 

“It’s very easy -- even for kids -- to make it through the day without expending any physical energy at all.”

 

Combine that with the expansive variety of pre-prepared, readily available food, the cheapest of which is generally the most nutrient-poor and calorie-dense.

 

“I tell my patients all the time,” he says, “that when you think about it, it’s really no surprise that we have an obesity epidemic.”

 

Perhaps the ugliest fact about the pediatric obesity epidemic is that lifestyle modification, as a strategy for lasting weight loss, often fails.

 

That’s because, as evidenced in many behavior-related diseases, it’s extremely hard for people to permanently change entrenched patterns of behavior.

 

Pediatric endocrinologist Michael Freemark, MD, says that’s why it is incumbent upon pediatricians to try to prevent overweight and obesity before it emerges.

 

Freemark has overseen Duke’s Pediatric Insulin Resistance Clinic since it was established 10 years ago. He says that this patient population has not only swelled, but also worsened in health status.

 

Meanwhile, pediatric obesity remains a phenomenon that’s poorly understood -- which is why Freemark has taken the helm of the Healthy Lifestyles Program’s research component. He’ll coordinate studies with Armstrong’s clinic to better understand the disease’s etiology, prevention, and treatment.

 

Studies will aim to characterize the metabolic function of obese mothers and their babies, to learn at the physiologic level how to identify the children at greatest risk for excess weight.

 

Among the interventions that will be studied in these very young children is banning sugar-sweetened beverages for infants born into high-risk families.

 

“We want to determine whether eliminating those sugary drinks right from birth can prevent weight gain within the first two years.”

 

For the legions of children who are already obese, Freemark’s group is exploring what weight-loss medications might be safest and most effective to use in children.

 

Studies by Freemark and other investigators suggest that metformin, a drug developed to treat type 2 diabetes in adults, can be useful in helping obese adolescents with impaired glucose tolerance, severe insulin resistance, or polycystic ovary syndrome. Among drugs used to treat obesity, metformin likely has the fewest side effects and the best benefit-to-risk ratio.

 

Other medications approved for treatment of obesity, including orlistat and sibutramine, may cause diarrhea and hypertension, limiting their use in the general population.

 

Freemark and his colleagues will study metformin’s usefulness in preventing problems in overweight children who are at highest risk for developing type 2 diabetes and fatty liver disease.

 

Freemark notes that early weight-loss drug intervention is a topic of much debate.

 

“A lot of people are not wild about the idea,” he says. “They believe that only lifestyle interventions are justified until major complications have developed. I’ve argued that medications may be considered if pre-diabetic conditions persist despite a good-faith effort at lifestyle change.”

 

Freemark explains that the debate stems from the many questions that need to be answered about the effects of anti-obesity drugs in still-changing bodies. He thinks it often comes down to the particular patient one sees in the clinic.

 

“Everyone agrees that lifestyle intervention should be initiated before drug therapy and should be maintained during and after such therapy if possible,” he says.

 

“But if my patient has multiple family members with type 2 diabetes and early-onset cardiovascular disease, and the kid has been obese and insulin-resistant despite lifestyle counseling, my feeling is, it’s justified to try to do something more. But this idea is not accepted by everyone.”

 

Bravender would count himself among those who are more leery than Freemark of using drug therapies in obese children.

 

But he does agree with Freemark in the most important way: “We need to find a safe and effective medical treatment for this condition,” he says, “because there is no behavior modification that consistently works.”

 

He thinks this behavioral failure speaks to the level of pathology in the environment around us, as well as the intense, inborn drive to eat.

 

“There’s nothing more basic than the needs to eat and drink to survive,” he says. “When you’re surrounded by food, what else are you going to do?”

 

Yaggy says the solution needs to come from an evolution in our overall culture.

 

“It won’t just be one clinic or one community program,” she says. “It needs to be an interrelated community, government, medical, and family enterprise.”

 

In short, she says, the issue of obesity must, like smoking, become something “that’s civic, not something seen only as a personal responsibility and a personal failure.”

 

Armstrong echoes that sentiment. “In this country there are a lot of organizations working on the problem of childhood obesity,” she says, “but they tend to operate in silos.” She hopes that the Healthy Lifestyles Program will be something that doctors throughout North Carolina will be able to use and replicate in their own communities.

 

Armstrong notes that the program is little more than a toolkit to help inform and equip individual families to make healthy choices.