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Monday, March 14, 2011
Tackling the issue from all sides
According to the most current statistics published by the National Health and Nutrition Examination Survey (NHANES), nearly 17 percent of children in the United States aged 2 to 19 years are obese. The rate of obesity in this age group has tripled during the past thirty years, so this generation is at high risk for many obesity-related medical conditions. Alison Hoppin, MD, a gastroenterologist at MassGeneral Hospital for Children (MGHfC) who practices pediatric obesity medicine at the Massachusetts General Hospital (MGH) Weight Center, stresses the importance of a multi-disciplinary approach when treating patients who are struggling with obesity.“A wide-ranging initial evaluation is key to getting to know the patient and their condition thoroughly,” says Hoppin. “Here at the Weight Center, most patients see a physician, a dietician and a psychologist all within the same day. Each of these providers gives an important perspective to understand the causes of weight gain and obesity in a particular patient, and to help them develop a strategy to reverse the process.” A Thorough Medical ExaminationHoppin says that there are important biological reasons why some people might be more prone to gaining weight than others. In many cases, the environment that we live in also contributes to weight gain because it is easy to eat more than our bodies need and there are limited opportunities to be physically active. Most often, the cause of excessive weight gain in a child is a little bit of each: biology and environment. For a few individuals, weight gain is caused by a specific medical condition or by certain medications, such as antipsychotic drugs used to treat bipolar disorder.“Our team works together to assess what the patient’s personal needs and goals are,” says Hoppin. “One of my roles is to look for the medical problems that might make the patient an easy gainer of weight. I am also looking for medical problems that might be caused by the excess weight, such as sleep apnea, insulin resistance/diabetes, fatty liver disease, or hypertension. For many of the young people treated at the MGH Weight Center, those medical conditions haven’t happened yet, but we look for risk factors that might signify an impending issue.”The key indicator used to define obesity in adults, body mass index (BMI), is also used in children. BMI is expressed as weight in kilograms divided by height in meters squared (kg/m2). For adults, obesity is defined as a BMI at or above 30 kg/m2. For children, weight categories are based on percentiles that are shown on BMI-for-age growth charts. Children with BMI values at or above the 95th percentile are categorized as obese, and those with BMI values between the 85th and 95th percentiles are considered overweight.Hoppin says that there are three main ways where biology can play an important role in determining the likelihood of weight gain. First, some individuals have a strong genetic predisposition to obesity, because their families have more weight gaining genes in their gene pools. Second, the environmental and nutritional conditions during pregnancy and early childhood may have permanent effects on the baby’s ‘metabolic program,’ causing a tendency for obesity or diabetes, a phenomenon is known as ‘epigenetics.’ Lastly, some individuals have specific factors such as low thyroid hormones or weight-promoting medications that might also contribute to excess weight gain.Assessing Individual and Family-based Dietary HabitsDietitians also play an important role in the treatment of patients suffering from obesity and excess weight gain. “I evaluate and assess new patients, and their stories, in the context of the whole family,” says Marianne Tsikitas, a registered dietitian with the MGH Weight Center. “What is most important is to not make it so much about food, but about their relationship to food and what dynamic drives their choices. I am careful to ‘do no harm’ as children often already feel bad about their weight and we don’t want to further damage an already fragile self-esteem that may have in part been brought on by well-intentioned adults.”Tsikitas does a thorough diet history for school days and weekends, and includes types of meals, where they are eaten and the manner in which they are eaten. She inquires about the onset of weight gain and when, and if, weight became a concern for the pediatrician, parent and child. This client-centered approach focuses on modifiable behaviors such as the consumption of caloric beverages, meal skipping, screen time and physical activity, rather than simply the excess weight alone.“Families are important to consider in these situations because many parents themselves fall victim to our current toxic food environment, and are confused about what food choices to make in the context of their busy schedules,” says Tsikitas. “Kids are not going out to play as much or are at after-school programs, home alone with or without siblings or being looked after by extended family who may have different attitudes toward feeding than the parents do.” A lack of structured meals and exposure to different feeding practices can promote weight gain and other eating disorders.Psychological Evaluations Provide Valuable InsightA psychological assessment is the final piece to a comprehensive evaluation of patients suffering from obesity. “We try to help prepare patients for whatever kind of treatment they might be seeking or that might be prescribed for them, so that they derive the maximum benefit,” says Stephanie Sogg, PhD, a psychologist at the MGH Weight Center. According to Sogg, the psychologists look at more than just psychopathology, such as depression, anxiety and eating disorders. They also look at much more general things like behavior patterns, body-image issues and motivational factors. “We’re looking at what factors – biological, emotional, logistical, cultural, familial – have been contributing to their weight problem,” says Sogg. “For instance, if the patient has severe body image issues that make them unwilling to exercise in front of others, then we work on solving that problem with them.”Research Towards Future SolutionsFinally, research also plays an important role in discovering what works best in diagnosing and treating obesity. Amy Fleishman, MD, a pediatric endocrinologist, is particularly interested in the components that lead to diabetes in children – specifically the role of mitochondria, the tiny energy production units within cells at the level of the muscle, and how they might impact someone’s risk for diabetes. “In a prior study, we looked at almost 100 kids, both normal weight and overweight kids, and did MRI-based studies of their mitochondria to see how they process energy,” says Fleischman. “We found that those kids who were less efficient in producing ATP or energy were more likely to be insulin resistant. To follow up on these findings, we are doing a randomized controlled trial of an in-home exercise intervention to see if the kids who had inefficient mitochondria might get better through exercise.”The exercise program is set up by recruiting kids from multiple clinics including the MGH Weight Center and randomizing them to either an 8-week exercise program at home or healthy lifestyle advice. The program includes modern exercise bikes as equipment and Wii videogame based cardio equipment. The study is still recruiting healthy overweight individuals between 10-18 years of age who can join by calling 617-643-4420.
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