Last year in our November/December issue (click here to see article: www.parkhurstexchange.com/columns/pediatrics/nov10_diabetes-in-children) I discussed the alarming increase in type 2 diabetes in the pediatric population and its strong link to the epidemic of obesity. This month’s issue is again partly devoted to the important theme of diabetes, so I’ve decided to discuss an approach to childhood obesity that hopefully will impact on the incidence of diabetes in kids, adolescents and adults. Because obesity is associated with diabetes, cardiovascular disease and the metabolic syndrome, any advancement primary care physicians can make on obesity will have a profound impact on the future health of pediatric patients. The graph from The Economist on the facing page shows the world-wide extent of the obesity problem.

All is not lost

Although this chart is for adults, it can be extrapolated to the pediatric population. The prevalence of obesity has tripled for children 2-5 and 12-19 years and quadrupled for those 6-11.¹ I won’t “flog a dead horse” as we’re all aware of the enormity of the issue. We’re also quite familiar with the abysmal failure the medical profession has had in dealing with this problem. However, we must not give up.

A recent Cochrane review² examined 64 RCTs (5,230 subjects) examining lifestyle, drug and surgical interventions. There were no RCTs of surgical interventions found. Twelve studies looked at physical activity vs sedentary, six diet, and 36 accounted for behavioural oriented studies. Ten of the trials looked at pharmacological interventions (metformin, orlistat and silbutramine). The authors concluded that “combined behavioural lifestyle interventions compared to standard care or self-help produce a significant and clinically meaningful reduction in overweight in children and adolescents.”² Clearly, a research project providing an intensive program of behavioural and dietary interventions isn’t possible for the large number of obese children but I believe primary care physicians can make a difference using some simple behavioural modification techniques. What follows is my own idiosyncratic approach, being neither an obesity expert nor a diabetologist. I admit at the outset that my success rate is low but there have been occasional surprises.

• First, you need the buy-in of the family. One has to be sensitive to the issue as the following vignette illustrates. Once, an obese mother and her two obese children arrived in my community office for an annual physical exam. I decided to try and tackle the issue of obesity and I thought I had done so very sensitively, pointing out that being overweight was not a cosmetic concern but one for the future health of her two children. I patted myself on the back for having explained everything so clearly. At the end of the visit, after the kids had left the examining room, the mother said to me that she’d never return to my office again! And she never did!! The lesson for me was that one should not use the term “obesity.” As I recently read, it’s better to use the expression, “Your child’s weight is a little unhealthy” as an entrée into the subject. Be sensitive! Most parents are already feeling guilty about their child’s weight.
• Try to help the family examine the circumstances in which a child overeats. We know that watching TV and playing video games encourages overeating of snack foods and soft drinks.
• Another myth parents have is that physical activity is the answer. I always suggest that indeed physical activity is an important pillar of good health but as a weight loss strategy, it’s not very effective. It must always be combined with decreased caloric intake. I use the example of the body’s efficiency: a 25 kg child would need to run for 15 minutes to burn off 68 calories (a tablespoon of fat)!
• My final technique is to suggest to the parents to develop for themselves, and teach their kids, “mindful eating,” which may help reduce caloric intake. Try to instill a sense of the caloric density of various foods in your patients. An apple at 100 calories, for example, is more satiating and healthier than a cookie with 250 calories, which is less filling. Children can learn to like 2% or skim milk. And have patients avoid processed foods, as they always have a high percentage of fat, carbohydrate and sodium.

Physicians need to spur on policy makers and governments to take action to reduce the sodium, trans fat and other fat content of many foods in the food chain. Perhaps a higher tax on snack foods and soft drinks would help. Advocate for healthy eating choices in school cafeterias and hospitals. Obesity is a problem for all of us, not just the obese patient.

Finally, use the occasion of the periodic health exam to review all aspects of healthy, active living by going to the Canadian Paediatric Society’s web page (www.cps.ca) and clicking on Children’s Health Topics.