Confronting Childhood Obesity from Every Angle

Children's Hospitals Today, Fall 2005
By Anita Blumenthal

Children and adolescents are weighing more and exercising less, causing a surge in overweight and obesity that exacerbates serious conditions now and bodes ill for the health of tomorrow’s adults. According to a recent Institute of Medicine report, over the past three decades the obesity rate has more than doubled for preschoolers ages 3 to 5 and for adolescents ages 12 to 19 and has more than tripled for children ages 6 to 11.

Children’s hospitals are addressing the obesity epidemic from several angles, from helping children with special needs lose weight and educating pediatricians, to implementing education programs and offering bariatric surgery.

Special Needs, Special Challenges

Weight management poses additional challenges for children with special needs, such as those cared for at Shriners Hospitals for Children — Northern California, in Sacramento. The hospital treats children with burns, spinal cord injury, spina bifida and orthopedic problems. Many are in wheelchairs. Adding to the problem is the fact that spina bifida patients are short in stature and have lost lean body mass so they burn fewer calories, explains Amanda Liusuwan, chief clinical dietician at the hospital. Excess weight can limit a child’s mobility, makes it harder to transfer between venues (a bed to a chair for example) and increases the risk of pressure sores.

In addition to the hospital’s outpatient weight management clinic, a research project now under way involves parents and children in a 16-week program. Liusuwan tailors her nutrition sessions to the needs of the children, many of whom are cognitively slow and need much repetition. She focuses on teaching one idea per session, but her hands-on activities are adaptable on many levels. For example, Liusuwan compiles a menu of offerings from fast food and other restaurants the children frequent. The children “order” meals, and then she reveals how much fat and how many calories are in the order. Because she has given each child an exact daily calorie allotment based on previous testing, Liusuwan can show how much of it the child has used up in one meal. This, she reports, often comes as a shock.

At separate breakout sessions for parents, a hospital psychologist addresses issues such as guilt. Some parents feel guilty about their children’s disability and use food to compensate or as a reward. The sessions cover other ways to be supportive.

The fact that many of the children enjoy competition opened an avenue for physical activity. A computer game cycle is delivered to each child’s house. Game cycles, which take forms such as car races, function with an arm crank. So the more competitive the children are, the more they will exert themselves during a game (as the heart monitors they wear during play attest).

As an incentive to use the cycles, attend nutrition sessions, attain goals and keep food logs, the children receive raffle tickets, which they collect and exchange for prizes. Preliminary results of the first round of the program are encouraging, says Liusuwan.

Programs for Pediatricians

The KidShapers program at All Children’s Hospital, Inc. in St. Petersburg, FL, offers pediatricians up and down Florida’s west coast a weight management curriculum to follow with patients. The program comprises six office visits at one-month intervals; each session includes handouts for the parents and incentives for the child, such as T-shirts and pedometers. The doctor chooses an eating plan based on the caloric requirement for the child’s ideal weight. However, the plan is presented to families not as a calorie-counting process, but rather as a color-coded program outlining portion size and number of servings.

“It is important that pediatricians have a stronger handle on appropriate calorie intake for older kids,” says KidShapers Medical Director Frank Diamond, M.D. “Pediatricians are very good about [tracking weight in] newborns, but are not so clear about what older children need.”

In fact, a study by Children’s Hospital of Pittsburgh (published last year in Pediatrics, August 2004) reviewed the records of 244 obese children and found only one-third of pediatricians noted obesity in the physical exam; only 7 percent ordered lab tests (such as cholesterol levels or screening for Type 2 diabetes); and only 5 percent recommended the children watch less television.

The KidShapers pediatrician outreach program offers its curriculum kit at cost – $30 – which the doctor passes on to his patient.  As for reimbursement for the visits, Diamond says doctors are paid most of the time, possibly because insurance covers co-morbidities — conditions such as high cholesterol and high insulin levels that accompany obesity.

To date, Diamond reports, the outreach team has talked with 67 pediatricians; 34 have taken kits. Thanks to a grant from the Centers for Disease Control, Diamond is planning a rigorous evaluation of KidShapers, as well as expansion of the outreach effort and the hospitals eight-week, in-house weight management program for children ages 8 to 12.

If Mom Won’t Eat It …

“Kids will eat what’s accessible. You really must start with the parents,” says Linda McDonald, a dietician in the multifaceted Family Education Nutrition program at La Rabida Children’s Hospital in Chicago.

Thanks to a substantial grant from the U.S. Department of Agriculture Food Stamp program, La Rabida carries out a range of activities that target low-resource families in the largely African American South Side community.

Along with in-house classes, provided at eight to 16 community sites a week, is a six-week daytime program for parents, which includes exercise, nutrition education and cooking sessions led by a chef. Other activities for all ages are hands-on and interactive, including nutrition bingo and nutrition Jeopardy. The youngest children learn the five-a-day rule as they toss beanbags shaped like fruits and vegetables. In these programs the children aren’t weighed; the emphasis is on healthy living. (La Rabida runs a separate program, Fit Matters, for obese children.)

La Rabida distributes nutrition information at public resource centers where people sign up for food stamps and at Women, Infants and Children (WIC) offices and food pantries. McDonald says the dieticians encourage adults to try new foods and healthier approaches to cooking. If the food pantry is distributing less common vegetables, like eggplant or asparagus, the La Rabida team offers recipes on how to cook them.

Like all healthy lifestyle programs, the program encourages more physical activity. Thanks to a grant from General Mills, the La Rabida team visited eight day camps this summer and distributed 800 pieces of sports equipment. Kids were given the piece of equipment they chose, such as jump ropes and various kinds of balls.

Bariatric Surgery - BeforeBariatric Surgery

When adolescent obesity causes serious illness or is life-threatening, bariatric surgery is a last resort — one offered by a growing number of children’s hospitals. Although the surgery has been performed on a limited basis for the past 20 years, a new approach for adolescents has developed over the past few years, led by Thomas Inge, M.D., Ph.D., surgical director of the Comprehensive Weight Management Center at Cincinnati Children’s Hospital Medical Center.

Inge was lead author of a major article published last year in Pediatrics, which spells out criteria for working in a cautious, stepwise, conservative fashion when evaluating an adolescent patient’s candidacy for the procedure, explains Craig Albanese, M.D., co-author of the article and a pediatric surgeon at Lucile Packard Children’s Hospital in Palo Alto, CA.

At Packard, a multidisciplinary panel made up of a dietician, psychiatrist, surgeon, social worker, physical therapist, as well as pediatricians, meets monthly to discuss bariatric candidates.

Bariatric Surgery - After“There are very strict criteria,” Albanese says. “We really want the children to lose weight by way of the hospital’s weight management clinic, without surgery. Besides, the operation is only part of the fix. We have to care for the needs of the child. These kids might be 16, but they are as fragile as 12-year-olds. They tend to be withdrawn, not accepted by peers. Some are home schooled; some have been ostracized and bullied.”

Despite their immaturity due to development issues, Albanese was surprised and impressed at how well the kids who underwent bariatric surgery complied with requirements — from keeping food and exercise logs to taking six medications daily after the operation. Part of his program’s contract with patients is long-term follow-up. When teens come of age, they can transfer to the program at Lucile Packard’s adult counterpart, Stanford Hospital.

At Cincinnati Children’s, Inge and other physicians continue to research the effects of bariatric surgery on the health of adolescents. Inge received a two-year, $298,000 grant from the National Institutes of Health (NIH) to examine the role of bariatric surgery in affecting Type 2 diabetes, and Meg Zeller, Ph.D., a psychologist at the hospital, received a two-year, $149,000 grant — also from NIH — to study psychosocial status and quality of life in adolescents before and after bariatric surgery.

Who pays for adolescent bariatric surgery? Albanese says insurance has paid for all his cases, “although it took two or three tries.” He believes the question of insurance coverage “will become less of an issue for insurers if the procedure is for the right indications and in the right center.” In the future, he says, “The presence of tracked outcomes, a national database and the correct preoperative work-up will make it more likely that insurance companies will pay.”

Anita Blumenthal is a freelance writer based in Potomac, MD. She wrote about telemedicine in Children’s Hospitals Today, spring 2005.

Child and Adolescent Obesity Studies

  • Only 12 percent of pediatricians feel effective in treating obesity, according to research conducted at the University of North Carolina at Chapel Hill. Researchers also found that nearly half of all pediatricians who are overweight don’t identify themselves as such. Pediatricians who do think they are overweight are four times more likely to report difficulties in counseling children. (Ambulatory Pediatrics, June 2005)

  • Morbid obesity in children and adolescents directly affects the structure of their hearts and puts them at increased risk for heart attack, according to a Cincinnati Children’s Hospital Medical Center study. (Presented June 30, 2004, at annual meeting of the American Society of Echocardiography)

Beating Obesity-related Disease with Data

Each year, more than 13,000 children are diagnosed with Type 1 diabetes and increasing numbers of young people are being diagnosed with Type 2 as child obesity rates rise. Data from the NACHRI Case Mix program show inpatient diabetes cases have increased approximately 12 percent between 2002 and 2004, and average adjusted estimated costs have grown approximately 10 percent during the same time frame — information that could be useful to a hospital seeking support to establish a disease management program.  

NACHRI maintains the nation’s largest pediatric-specific inpatient database, housing over 3 million discharge records from 72 children’s hospitals. Data from the NACHRI Case Mix program help participating hospitals achieve proper Children’s Hospitals Graduate Medical Education funding levels, as well as support improved clinical operations through comparative peer group benchmarking.  To find out how to access this rich data, contact casemix@nachri.org.