Endodoc

Here I will add to my previous postings about treating children with obesity. The earlier discussions focused mostly on principles of approach. Here we will get into the specifics of developing a workable plan.

Step one: the referral

Let us create a hypothetical patient: John is a 9 year old male child referred by his primary care physician for evaluation and treatment of excessive weight gain. The referral was agreeable to the parents and to John. In fact, it was John’s mother who expressed concern to the doctor; John had come home from school crying the week before. Apparently, he had been teased about his weight. John had been seeing the same doctor since birth and excellent growth records were available. They showed normal growth in height but excessive weight gain beginning at about 6 years of age. The present BMI was > 95% for age. John’s general health had been excellent and he was taking no regular medications.

I do encourage referrals from primary care doctors as opposed to self-referrals; in my experience it is very helpful to have each child’s primary care doctor “in the loop” and not opposed to our seeing the child.

Step two: learn all about the child and family

Before we can develop a treatment plan, we need to learn as much as possible about the child and family. We ask lots and lots of questions including whether the child and family understand the reason for the referral and what their sense is of the seriousness of the situation.

We want to know if the child has any chronic medical conditions, including any that might have been caused by the obesity (e.g., sleep apnea, limited exercise tolerance). Is the child taking any medications on a regular basis?

We want to know what the child’s growth pattern has been. Usually the primary care doctor sends us old growth records. We are interested in learning if the linear growth has been normal, basically eliminating endocrine gland disorders as possible causes for the obesity. We are also interested in learning when the excess weight gain begain and whether there were any “triggers.”

We want to know about the family structure- who lives in the home, ages of siblings, other care-givers, etc. We want to know the child and family routines- when do they eat their meals, is it a sit-down evening meal or is it in front of the TV?

We want to know what the child and family members typically eat. Does the child have breakfast at home or at school or both? Does the child buy the school lunch or bring lunch from home? What does the child eat for lunch? What about an afternoon snack; is it supervised, what does he typically eat for the snack?

We want to know about the child’s eating patterns- is he a fast eater, is he a big helping, seconds and thirds eater or a megasnacker or both? Does the child drink sugar-containing sodas, sport drinks, fruit juices and how much? Who does the cooking? Does anyone monitor the child’s portion sizes?

We want to know how often the family eats out, where do they eat, and what do they eat?
We want to know about the child’s activity pattern; does he have physical education classes at school? Is he a couch potato or always on the move? How much time does he spend watching TV and playing computer games?

We want to know how much the child and family members know about nutrition. Do they know what are high fat foods? Do they know how to read food labels?

Psychosocial issues

We need to learn about the child’s self-image and psychological impacts of the obesity. For example, many overweight children are teased over and over by children at school and even by sibs. This can be very upsetting to the child who may not even tell the parents about it. Sometimes, the child will retaliate by fighting with the teasers; this almost never results in less teasing.

Family history

We need to learn as much as possible about the family medical history- how many relatives are overweight, have diabetes, heart disease, high blood pressure, etc.? How many relatives have had premature deaths, possibly from obesity-related conditions?

Physical examination

A brief but complete physical examination is important. We measure the blood pressure, height, weight, and calculate the BMI. The skin is examined for evidence of insulin resistance (a skin condition called acanthosis nigricans). Pulmonary and cardiac status are assessed. Sexual staging is performed (i.e., is the child pubertal?). Musculoskeletal status is assessed with an emphasis on the child’s capacity for exercise.

Step four: the plan

Now that we have gathered lots of information, it’s time to put a plan together. Our first plan is usually quite simple and does not require that the family have an in-depth understanding of nutrition principles. Our program dietitian usually participates in developing the plan- depending on the child and family, we may or may not arrange a separate consultation with the dietitian shortly after the family’s initial visit to our clinic.

We give the child a three-ring binder with lined paper and begin to make specific suggestions. If the child and parents agree with the recommendations, we write them down in the notebook (the child is expected to bring the notebook to follow-up visits). A typical set of recommendations for our hypothetical 9 year old male child might look lilke the following:

1. One breakfast each day- either at home or at school, not both

2. Bring lunch from home 3 days a week

3. Afternoon snack is to be pre-prepared or supervised and limited to about 120 calories

4. The evening meal is to be a sit-down family meal without TV 5/7 days each week

5. The child should be the last family member to take their first bite of food

6. Smaller portion sizes at each meal and no seconds

7. No sugar-containing sodas

8. Limited use of sport drinks, fruit juices, etc.

9. Eat out no more than 2 times each week and follow portion size rules

10. Watch out for certain high fat foods- cheeses, spreads, salad dressings, etc.

11. More regular exercise, 1 hour TV/computer time during the schoolweek

Now what?

Now we have a list of “how to eat” that we have all “signed off on.” The child and family now have a relatively simple plan that they can start following immediately. The underlying principle is as follows: “it’s not yes or no but how much and when.” I do not favor listing foods as either good, bad, or so-so, as some weight loss programs do. I could not in good conscience tell a child pizza is a “red light food.” Who can live without pizza? So if John, our 9 year old patient likes pizza, that’s just fine. Maybe he can go for 2-3 slices not a whole pizza and maybe try Canadian bacon instead of sausage?

Calorie and weight loss goals

You may have noticed that I did not mention any specific calorie level goals (except for the afternoon snack). You may also have noticed that I did not discuss specific weight loss goals. I do not find that setting a calorie level and weight loss goals work very well. I can assure you that if the child just follows their written plan, caloric intake will be down by quite a bit and weight loss will follow. Anyway, in children success is often a slower rate of weight gain (remember they are still getting taller) than before rather than any weight loss.

In earlier postings I have discussed various aspects of childhood obesity including demographics, health consequences, and causation. In the entry of 3/17/06, I  listed some general principles for treating the problem. Now it’s time to get down to specifics.

Children are not small adults

In some ways treating children who are overweight is easier and in other ways harder than treating adults. For children under about 10 years of age, the responsibility for success falls mainly on the parents (or whoever has primary responsibility for the child- e.g., grandparents, foster family). Parents can fully control access to food in young children; after age 10 or so, it is exceedingly difficult to do so. For young children to be successful with a healthy eating plan, all care-givers must understand the plan and be willing to support it. For example, the plan is doomed to failure if the parents do a great job supervising adherence to the plan when the child is with them yet the eating is completley uncontrolled when the child spends 3 days a week at grandma’s house. Obviously, grandma and whoever else the child spends time with on a regular basis must know what the plan is and agree to follow it. This includes the school: teachers, nurses, lunchroom personnel, etc., must know the game plan. For example, we often find that overweight children are having a breakfast extravaganza on schooldays; the child has breakfast at home and then a second breakfast at school! Parents are generally completely clueless about what really goes on at school with regard to what their child is eating.
One particularly difficult and not uncommon situation is where the parents are divorced and the child spends significant amounts of time with each parent. I find that typically the routines differ quite a bit in the two settings, and unless both parents are “on the same wave length,” things usually don’t work out very well. Sometimes, the divorced parents compete for the child’s affection and may use food in an effort to accomplish it.

If the primary care-giver is concerned that not everyone involved in the care of the child is “on the same team,” it may be very useful for the health-care provider to meet with all of the “team members” to explain what the plan is and answer any questions.

What I have learned from families with children who have the Prader-Willi syndrome

Prader-Willi syndrome is a genetic disorder that is strongly associated with obesity. Children with this disorder typically have virtually no control over their appetite and don’t know when to stop. The only way to keep these children from gaining and gaining is to limit their access to food, all day and every day. That is easier said than done, but many families have great success over many years if they are committed to the task.

I mention this special situation of children with the Prader-Willi syndrome only to illustrate that failure to achieve some measure of success long-term in young children with obesity is usually the result of either unwillingness or inability of the parents to control the child’s access to food. I don’t mean this in a mean-spirited way; it may be a daunting task, but it can be done.

What should you tell your child about the “healthy eating plan?”

One sometimes sticky subject is what to actually tell the child about why they need to see a doctor about their weight and why they need to stop going to McDonald’s 3 times a week for a quarter pounder with cheese, large fries, and a sugar-containing megasoda. In general, my advice is to keep explanations as simple as possible and focus on developing a healthy eating plan for the entire family. The younger the child, the less specific one needs to be; in a 4 or 5 year old it does not do much good to make a “big deal” out of the new approach to eating. It is important not to make the child feel like he or she is being singled out and that they are “bad” for being overweight (even if a parent doesn’t mean to imply that the overweight child is to blame for their health problem, the child may get the message anyway).

In older children (10 years+), it is important that the child know what the problem is (it’s overweight that may lead to health problems later), and to make them true partners in any management plan; a plan that is imposed on a child old enough to understant what’s what, will fail miserably and create tension at home unless the child is willing to pursue the proposed treatment plan- I’ll get to the details on how to do this in an upcoming posting (I hope the suspense won’t be too great a stress for you to handle).

I just finished reading a very interesting article in the New York Times (Sunday March 25, 2007, Section 3, pages 1,9,10-www.nytimes.com) entitled “Will Diners Still Swallow this? The article was written by Andrew Martin and discusses the new T.G.I. Friday’s initiative to offer smaller portion sizes at lower prices. Apparently, the company’s strategy is to increase business by appealing to the health-conscious consumer.

Portion size and the obesity epidemic

Some of you may remember one of my recent postings about the U.S. obesity epidemic in which I discussed the role of increased portions sizes contributing to our current largesse. Apparently, T.G.I. Friday’s will offer 10 items on their menu that are about 40% fewer calories and about 30% cheaper. It may not work well as a marketing strategy but I applaud the effort and dare other chain restaurants to do the same. I doubt T.G.I. Friday’s efforts will “cost them” since customers can still order gigantic portion sizes and probably will, but maybe not? It will be interesting to see the data in a year of so; how many customers are going for the smaller portion size items and what did it do to the bottom line. Of course, maybe T.G.I. Friday’s will support this initiative even if it doesn’t do wonders for the company’s profit? We’ll see. At least for now, three cheers for Richard Snead (chief executive of Carlson Restaurants Worldwide).

I just read an interesting book review in the New York Times (Friday, March 23, 2007, page B28)- the review was written by William Grimes and it is available at nytimes.com/books. Dr. Groopman is a professor of medicine at Harvard Medical School and I know he has written articles for the New Yorker for a number of years. Anyway, based on the review I intend to read the book.
I’ve always wanted to know how doctors think. Actually, the thought process that goes into medical diagnosis and treatment is not all that well-understood and defies computer modeling. You’d think one could design a computer program to provide diagnostic possibilities given a set of signs, symptoms, and laboratory test results. The problem has been that just generating a computer list of possible diagnoses, perhaps with statistical probabilities, does not work nearly as well as an intelligent and knowledgeable physician who has the time and interest to “sort things out.” Just having a long list of possible diagnoses based on the computer input, doesn’t get one much closer to diagnosis and treatment. Where computers help is in making one aware of drug incompatibilities, side effects, etc., that might be of great importance once a diagnosis is made and treatment planned.

Of course, most of medicine is quite pedestrian; whether we are generalists or specialists; most of what we see is the same thing over and over again, maybe with a few twists here and there. The really good doc can somehow tell when a problem may not be so run-of-the-mill. In my experience, the best physicians look at diagnosis and therapy as steps to the best possible outcome, whatever the problem. The “steps” are careful follow-up with a willingness to rethink the problem at any point along the way if the pieces are not fitting together as they should. No one is perfect, and we all make mistakes; we can only hope that we do not make many mistakes and that we learn well from each one.

It’s hard now that we have so many fancy diagnostic tests available; there may the temptation to order many expensive tests to make a diagnosis without thinking things through carefully. I have noticed that many younger physicians (I won’t define what I mean by “younger”) jump to diagnostic testing even before they have obtained key information from the history and physical examination. Some also order a “battery” of tests when they could start with just a few key tests and see what the results show. I’m not talking about a medical emergency where one might have to act quickly and ask questions later (what’s that old joke about “ready, fire, aim?”).

Anyway, I looking forward to reading Dr. Groopman’s book. Maybe it will make me smarter?

In recent posts I have discussed what causes hypothyroidism in children and how to diagnose it but I didn’t really discuss typical signs and symptoms.

Newborns: don’t wait for clues

The majority of newborns with hypothyroidism have absolutely no signs or symptoms. That is why we have newborn screening for hypothyroidism. If there was severe prenatal hypothyroidism, a newborn might present with “classic” signs and symptoms that include hoarse cry, poor feeding, lethargy, constipation, enlargement of the tongue, and overall decreased muscle tone including an umbilical hernias. Lab tests would show very low serum free T4 and very high TSH (often as high as the lab assay goes, 200-300). Lab tests might also show hypoglycemia (low blood sugar levels) and hyperbilirubinemia, a high level of bilirubin in the blood. Bilirubin is a yellowish pigment found in bile and if elevated in the blood can cause the skin and whites of the eyes to take on a yellowish color called jaundice- almost all newborns have some degree of hyperbilirubinemia but it tends to be worse and last longer in hypothyroidism.

Children and adults with hypothyroidism can also have a yellowish tint to the skin due to high levels of carotene in the skin called hypercarotenosis. This is due to slow metabolism of the yellow pigment carotene, found in a variety of foods, particularly carrots. People who eat huge amounts of vegetables that contain carotene can have this yellow staining of the skin even if they do not have hypothyroidism. The pigmentation is harmless and will go away when hypothyroidism is treated (or the carrot-lover cuts back). One way to tell if a yellowish tint to the skin is due to hyperbilirubinemia (high bilirubin levels in the blood) or simply due to carotene in the skin is to look at the sclera (the whites of the eyes). If the sclera do not have a yellowish tint to them, it’s hypercarotenosis (you’ll be just as clever as Dr. House- the guy from the TV show called “House,” for those of you enlightened people who do not watch much TV).

Children: think poor growth and excellent school performance

In children, the signs and symptoms of hypothyroidism are similar to those in adults with one major exception, growth. Linear growth (growth in height) is markedly impaired in children with hypothyroidism (only if the free T4 level is low). In addition, these children may be overweight. It is interesting that school performance usually does not suffer; children with hypothyroidism have a much slower metabolism than normal and they are not very distractible- they can really concentrate on their schoolwork! In fact, one of the difficulties in treating children with longstanding severe hypothyroidism is that they can go from being the perfect child, quiet and well-behaved, to a hyperactive, highly distractible child. Thank goodness the hyperactive “phase” does not last forever, although the child may never go back to being so easy to deal with. I always warn parents about this temporary “side effect” of treating severe hypothyroidism in the hopes of avoiding telephone calls from angry parents asking what have I done to their wonderful child! Please note that this Jekyll and Hyde personality/behavior change occurs only when the hypothyroidism has been severe and longstanding.

Sometimes the diagnosis is delayed for quite a long time while doctors are trying to figure out why their patients have dry skin, anemia, constipation, and poor growth. In severe cases, the thyroid gland is usually not enlarged (it has been destroyed by the autoimmune process found in Hashimoto’s thyroiditis).

Adults with hypothyroidism

In adults, signs and symptoms are not really much different than those found in children. Of course, in adults one cannot assess linear growth as a clue to the disorder. Fatigue and weight gain are common but, unfortunately, most people with those symptoms do not have hypothyroidism. Remember it’s easy to tell from two simple laboratory tests, free T4 and TSH.

In my last posting, I discussed how easy it is (usually) to diagnose hypothyroidism. I did not even mention what causes the condition. Probably the easiest way to think about causes is to divide them into those due to some problem within the thyroid gland itself and those caused by problems that affect an otherwise normal gland.

Problems within the thyroid gland: congenital hypothyroidism

Congenital hypothyroidism affects about one in every 5000 newborns. In most instances, the condition is the result of some mix-up in utero that affects development of the gland. Most often the gland is simply mssing or just a small remnant. Sometimes there is a gland, or part of a gland, but it is ectopic; the gland normally migrates from the base of the tongue down the neck to its usual location, but once in a while it “parks” before it gets to where it is supposed to go- sometimes still at the base of the tongue which is called a lingual thyroid. Anyway, congenital hypothyroidism is very important to detect and to detect quickly since hypothyroidism can cause irreversible brain damage during the first two years of life. It is not surprising that all 50 States in the U.S. require newborn screening for hypothyroidism. Treatment is easy- just a little pill every day for life (if you are wondering, the pill is crushed up and given with liquid in infants). A delay in treatment for even a month or two can be disasterous.

The typical form of congenital hypothyroidism is not considered genetic and we actually do not know what causes it. Rarely, congenital hypothyroidism is due to a genetic disorder. For example, some people have thyroid glands but are unable to make thyroid hormones. There are a number of steps in the formation of thyroid hormone and abnormalities in each of the steps have been described. The most common of these genetic causes of congenital hypothyroidism is called Pendred syndrome and was first described in a Swiss family. In this syndrome, congenital hypothyroidism is associated with deafness. Generally it is easy to tell if a newborn infant with congenital hypothyroidism has an abnormality in thyroid hormone synthesis- the thyroid gland is enlarged. Anyway, the treatment is exactly the same whatever the cause of the hypothyroidism.

Occasionally we do see congenital hypothyroidism that is transient; examples would include hypothyrpoidism due to a medication the mother took during pregnancy (e.g., medications to treat maternal hyperthyroidism, ingestion of large amounts of iodine during the pregnancy).

Chronic lymphocytic thyroiditis

By far the most common cause of hypothyroidism after the newborn period is chronic lymphocytic thyroiditis, or Hashimoto’s thyroiditis as it is usually called. This condition is an autoimmune disorder, where the body’s immune system attacks this or that part of the body. In this instance, the autoimmune process directs lymphocytes, a type of white blood cell, to attack the thyroid gland. In some instances this leads to complete destruction of the gland; in other cases, the gland shows only minor damage and its ability to crank out normal amounts of thyroid hormones is unaffected. I have made the diagnosis in children as young as 6 months of age, but typically the disorder is found much more often in older children and adults. The thyroid gland is usually enlarged but rarely tender. The diagnosis is usually easy to make once suspected; blood levels of free T4 and TSH (as discussed in my last posting) and thyroid antiperoxidase antibodies. The presence of the thyroid antibodies in the blood test pins down the diagnosis even if the free T4 and TSH are normal.

The condition is seen quite frequently in certain medical conditions including type 1 diabetes mellitus (about 25-30% of patients), the Turner syndrome (about 50% of patients), and Down’s syndrome (about 40% of patients). It is much more common in females than males as are all thyroid disorders except for thyroid cancer and congenital hypothyroidism. Treatment is generally simple- a small pill every day.

Other causes of hypothyroidism due to problems within the gland

There are many other causes of hypothyroidism but they are relatively rare compared to congenital hypothyroidism and Hashimoto’s thyroiditis. For example, subacute thyroiditis is a condition that can cause hypothyroidism. Typically, people develop pain and swelling in the thyroid gland which generally subsides over 2-3 months. Hypothyroidism is transient, lasting only a month or so and people with the condition often present with evidence of an overactive thyroid gland early on: the damaged gland releases large amounts of stored thyroid hormone. So the “classic” pattern is early hyperthyroidism leading to hypothyroidism after a few weeks, and eventually, back to normal. Much is written about this condition in endocrinology textbooks. I confess that I am not sure if I ever saw a single case in a child during the past 40 years.

Other causes of hypothyroidism include certain drugs, iodine deficiency (basically unheard of in the U.S.), and consumption of certain foods such as large amounts of soybean products: soy products inhibit absorption of iodine which is critical for thyroid hormone synthesis. Nowdays there is so much iodine in our diets (e.g., salt, bread) that even aggressive tofu eaters need not worry (in the 1940s when soy milks were first introduced for baby formulas, there was an “epidemic” of iodine-deficiency goiters- a goiter just means enlargement of the thyroid gland. The problem was sorted out very quickly and eliminated by adding iodine to soy milk formulas.

Hypothyroidism caused by problems outside the thyroid gland

Just for completeness, you should know that hypothyroidism can be caused by problems in the messenger system that controls how much throid hormone the gland produces. Up in the brain, the hypothalamus normally sends a hormone signal, thyrotropin-releasing hormone or TRH to the pituitary gland which in turn sends a hormone signal, thyrotropin, or thyroid-stimulating hormone or TSH to the thyroid gland (it’s not as complicated as it may seem). If there is anything wrong with this signalling system in getting the proper message to the thyroid gland, the person will develop hypothyroidism. This is called secondary hypothyroidsim to distinguish it from primary hypothyroidism, where the problem is with the thyroid gland itself. Typically causes of seconary hypothyroidism include a variety of brain tumors, radiation to the brain, head trauma, and hypopituitarism (often with a variety of hormone deficiencies which we will discuss in a future posting).

It is generally easy to diagnose secondary hypothyroidism ,although maybe not so easy to determine the underlying cause: blood levels of free T4 will be low and the TSH normal or low. It is important to measure the free T4 not just the “total T4″ since the latter can be affected by the levels of the serum proteins that carry most of the circulating thyroid hormones; if the serum proteins that carry thyroid hormones are low, the total T4 level will be low but the free T4 level will not be affected. Now that we have reliable free T4 assays, life is good for pediatric endocrinologists.

What is the Thyroid Gland and What Does it Do?

The thyroid gland is normally located in the neck just a bit below the thyroid cartilage, the “adams apple.” If you are intensely curious to actually locate your thyroid gland or someone else’s, you need to first put your thumbs on the thyroid cartilage (gently). Next, slide them down the front of the neck about half an inch until you reach a lump, this is the cricoid cartilage. Next. slide your thumbs down a bit and you should be feeling the isthmus of the thyroid, the part of the thyroid that bridges the right and left lobes. The lobes have upper and lower poles but the upper ones are more prominent. The thyroid gland looks a lot like a butterfly. You may not be able to feel the thyroid gland as it is normally quite small. Watch someone swallow and see if a small butterfly-like shape slides up and then down in the neck where you would expect the thyroid gland to be.

In many medical schools, students are taught to feel the thyroid gland standing behind the patient. The idea is that one can use the fingers the feel the gland rather than the opposed thumbs; the fingers are supposed to be more sensitive than the thumbs for feeling nodules and who know what. In my opinion, any advantage in sensitivity is off-set by one’s being unable to see what is going on.

What does the thyroid gland do?

The thyroid gland is basically a factory for thyroid hormones, called T4 and T3 (mostly T4). Think of thyroid hormones as the gas pedal on a car, which controls the speed of the vehicle. Thyroid hormones control the body metabolic rate. If the thyroid hormone levels are low, the metabolic rate decreases and this is called hypothyroidism. Typical signs and symptoms include fatigue, weight gain, swelling of the feet, constipation, and dry skin. Severe hypothyroidism is very serious and can lead to heart failure. The other side of the coin, hyperthyroidism, is associated with rapid heart rate, nervousness, weight loss, heat intolerance, and excessive sweating. In some forms of hyperthyroidism there is prominence of the eyes, called exophthalmos. In adults, hyperthyroidism can be associated with an arrhythmia of the heart called atrial fibrillation.
Thyroid testing

It is relatively easy to diagnose thyroid conditions. thyroid hormones circulate in the blood and can be measured very accurately by most laboratories. Generally the best test to assess blood levels of thyroid hormone is called “free T4.” This is the portion of the circulating thyroid hormone, tetraiodothyronine (a thyronine molecule with 4 iodine molecules attached) that is not tightly bound to serum proteins and best reflects the metabolic state. One other hormone, thyrotropin, or TSH (thyroid-stimulating hormone) is also useful to measure. TSH is produced by the pituitary gland in the brain and regulates thyroid hormone production. If there is too much circulating free T4, the pituitary gland decreases the secretion of TSH thereby slowing down the production of T4 in the thyroid gland. Conversely, if the circulating level of free T4 is too low, TSH levels go up in an effort to drive the thyroid gland to produce more T4. If the gland is damaged or affected by certain drugs, it can’t respond to the pituitary message and the free T4 level stays low. Sometimes, the TSH message succeeds in stimulating the thyroid gland to make enough T4 to get the free T4 level back to normal but only if the TSH stays elevated. That condition is called compensated hypothyroidism.

So what’s the bottom line?

In summary, except in very rare circumstances, if the blood levels of free T4 and TSH are in the normal range, hypothyroidism is highly unlikely (as is hyperthyroidism). If a person has compensated hypothyroidism (normal free T4 and elevated TSH) it would be very unusal for them to have any symptoms due to hypothyroidism- they might have signs or symptoms that suggest hypothyroidism, such as fatigue and weight gain, yet not have them the result of hypothyroidism.

Mysticism and the thyroid gland

Some physicians believe that many patients have hypothyroidism even though the test results are normal. Their reasons vary but in my experience, they don’t make any sense and are inconsistent with our very firm understanding of thyroid gland physiology and pathophysiology. Quite a number of people who do not have hypothyroidism are treated long-term with thyroid hormone. The other side of the coin are the many people who do have hypothyroidism and are not being treated. For example, hypothyroidism is very common in people over the age of 40 years, mostly women. It’s easy to diagnose, right? Just have your physician order a serum free T4 and a serum TSH.

This is the part I have been dreading; it’s been relatively easy describing the problems and their causes but fixing the problems is another thing. There is good news and bad news about treating obesity (we’ll tackle diabetes issues later). First the bad news- there are no treatment approaches that have been shown to be highly effective and safe over an extended period of time, 5 years or longer. Almost any weight reduction plan will work in the short run; take your pick of diet books, commercial weight reduction programs, or whatever. None really work well for the majority of people, children or adults. That’s not really surprising given the power of the brain appetite center and our way of life.

The good news

All is not lost. It is still possible for people, children and grown-ups, to lose weight or, at least, not gain excess weight year after year as most people do. It does, however, require that a person recognize his or her problem and commit to a solution long-term. Dealing with obesity is no place for the timid.

Where to start: Goldstein’s principles

1. First, I do not really believe in “diets” as most people use the term. In most instances a diet implies some plan to consume fewer calories until whatever weight goal is achieved. Thereafter, most “diets” get a little fuzzy about what to do and inevitably most people (note- I didn’t say everyone) regain all the weight they have lost and then some. I believe the primary reason most “diets” fail is that they do not really give a person a satisfactory way of eating life-long. In fact, there are considerable data showing that the best way to lose weight and keep it off is to lose weight slowly through a new approach to eating that can be sustained long-term. We should stop taking about “diets” and begin talking about healthy eating plans. A healthy eating plan should be the way all of us eat, overweight or not.

2. People who are significantly overweight (BMI >35) need to face their situation squarely in the mirror- literally and figuratively; they are at great risk for serious consequences of their obesity. They have to come to the conclusion themselves. For children it’s a bit tricky and parents need to be very sensitive to the psychological side of their child’s obesity. This is particularly true for teen-age girls. I have encountered many mothers who create enormous stress by continually nagging about their child’s “problem.” The mothers clearly mean well and are genuinely concerned about the short- and long-term consequences of their child’s obesity; many of these mothers struggled with their weight as teens and many are still struggling. Parents must not press too hard, despite the seriousness of the situation. I was told about a recent report on CNN describing a high prevelance of bulimia in teenage girls placed on diets (there’s that word again!).

3. Let’s forget about “guilt trips” and anti-obesity bias. Most people got overweight by just living in a “machines can do almost everything for us” era and by listening to their brain appetite centers. Most people who are overweight are not suffering from serious personality disorders characterized by lack of restraint. It’s not a disease (it could be a symptom of a disease such as hypothyroidism), although over time it certainly can have serious health consequences. Those of us who are lucky enough to have desirable BMIs need to stop looking at overweight people with some measure of distain or even revulsion. It’s an irrational bias that doesn’t often help people who are overweight deal with their situation (our society has the same type of bias against short people- that’s called heightism. We’ll discuss it at another time). Many physicians have trouble working with people who are overweight simply because of this anti-obesity bias and their belief (probably subconscious) that the patient is to blame for his or her problem.

4. Keep it simple. While a very complicated weight management plan might be a great idea for a neurotically obsessive-compulsive person, most people do best with simple, easy to understand plans that are also easy to implement. I already discussed my aversion to “diets” and I especially do not like diets that offer a gimmicks as their draw; usually it’s completely avoiding a certain type of food (e.g., don’t eat anything that is white in color, don’t eat bread or pasta) and often the plan includes purchasing expensive foods or supplements. It’s amazing- just because someone writes a book (or a blog?) people tend to “believe.” Certain diet plans are also trendy and come and go as quickly as the “beautiful people” find they are hard to follow or, as is usually the case, do not work long-term.

I confess that I am being a bit heavy-handed with my criticisms of many diet plans out there but in my experience simple and nutritionally sound eating plans work best.

5. People who are overweight need to know as much as possible about nutrition principles. They need to understand the differences between carbohydrates, proteins, and fats. They also need to know about saturated fats and trans fats. They need to know how to read food labels (maybe we’ll cover that subject in the future?); if whatever food they are contemplating purchasing has 18 grams of fat in each portion and that fat is mostly saturated fat, they need to appreciate what that means for their eating plan (answer- maybe good tasting but not anything very good for their eating plan). Children as young as 6-7 years can be taught quite a bit about nutrition.
Not to be overly critical of physicians, but most don’t have a clue about good nutrition; it is generally not taught at all in medical school or in residency/fellowship training or if it is taught, addressed in a very cursory way. Even though I think I have a better-than-average understanding of nutrition principles, the program I direct for children with obesity (it’s called the University of Missouri Children’s Hospital Health and Fitness Clinic) relies on a pediatric dietitian to help educate patients and their families.

6. Healthy eating plans must be individualized and the specifics depend on the unique characteristics of the overweight person and his or her family. Unfortunately, developing a customized healthy eating plan requires that the health-care provider know a great deal about the overweight person and family; the plan will be doomed to failure unless it takes into account the way the overweight person and family “operate.”

For example, if an overweight child comes home after school and is all alone, maybe a major contributor to the overweight is the afternoon megasnack? Is it a very busy family, always on the run, with many meals at fast-food restaurants (or meals eaten in the car to or from some activity?). Does the family tend to spend many evenings watching TV and snacking? You get the picture? It helps to know a great deal about how the overweight person and family eat and live before trying to fashion a healthy eating plan. Of course, in many instances given the genetic aspects of obesity, the healty eating plan is appropriate for the entire family.

Up to this point I have not addressed directly psychological factors that might contribute to obesity, except the psychology of portion size vs. plate size. While I believe by far the major factors contributing to obesity are genetic predisposition related to appetite control and inactivity, psychological factors play a role in some people. I do not really know what the term “nervous eating” means but quite a few overweight people tell me they eat too much because they are anxious or nervous and the food makes them feel better. Another frequent explanation for eating too much is that “I eat when I’m bored.” I have no idea whether these two common reasons for overeating are important independent from appetite centers out of control; maybe the perceptions of anxiety or boredom are really just hunger? I read or heard on the radio the other day that about 20% of people in the U.S. admit to binge eating at least once a week- the binge eating is defined as eating to the point of being uncomfortable. I do not know whether binge eaters are more likely to be overweight than people who do not binge or whether binge eating is always on a psychological basis? Now I’m worried- I love pizza and sometimes I eat more than I should (don’t we all?). Maybe I’m a binge eater too.
Psychological factors as “add-ons” to genes and inactivity

It is clear that once a person is overweight, psychological factors can contribute to the obesity and make it more difficult for a person to trim down. For example, some people deny their obesity and refuse to confront the problem. Denial is a powerful psychological mechanism for relieving anxiety and I suspect this is a fairly common feature, especially in people who are very overweight (i.e., BMIs > 35-40). In other people, it’s more like giving up rather than denial- they may have tried losing weight and maybe even lost a bit but regained all they had lost and then some. There is not much evidence that psychotherapy is a highly effective method of treating obesity. Of course, every person is different and there are certainly some people whose overweight is primarily related to psycholoigical factors. But, let’s not forget that the single common pathway to obesity remains more calories in than are burned up.

Activity levels and obesity: a summary

Clearly, one important component of the obesity epidemic in the U.S. is our rather alarming state of inactivity. But, lack of exercise can not fully explain things. For example, we all know some people who get virtually no exercise and are not overweight. Some people do try hard to get regular exercise and still gain weight year after year. It can’t be just inactivity. I do not mean to imply that lack of at least reasonable physical activity (I won’t try to define what I mean by “reasonable”) is not an important factor in explaining the obesity epidemic. Even 100-200 “extra” calories burned per day through physical activities, can have a profound effect on energy balance; all other things equal, each 100 calories per day in increased energy expenditure translates into about 12 pounds of fat not gained per year!

What about the caloric intake side of the energy balance equation?

If a person has an appropriate body weight at time-point A and then increases calorie intake by 100 calories per day (assume no change in energy expenditure),there would be about a 12 pound increase in body weight at at point B one year later- I bet you figured it out before I told you the answer! So can we put part of the “blame” for the obesity epidemic on increases in calorie intake? The answer is “you bet.” Studies have shown that on average, people in the U.S. are eating about 200 calories more per day than in 1977- that’s a 10% increase in calories consumed per day. How can this be? Well, I can’t give you an easy answer but I can give you some possibilities.

Food is cheap

Food in the U.S. is really cheap. I know that some families still struggle to afford enough high quality foods to allow good nutrition and adequate calories. But for most people in the U.S. it’s almost a free-for-all; at present, we spend only about 17% of our incomes on food, including eating out. That’s far less than what we spent on food 30 years ago as percent of income. We already know that many of us have brain appetitie centers that are not satisfied with just enough calories in to maintain body weight (or to gain weight appropriately for a child). So easy access to really cheap food helps to explain where the 200 “extra” calories per day come from.

Portion sizes and types of foods

Partly because food is so cheap, we as a nation have made drastic changes in portion sizes. We do it at home and restaurants have done it to us when we eat out. I remember when a “regular” hamburger was the only size available at McDonalds (it only cost 15 cents then). Now at McDonalds or any other fast food chain resturant that sells hamburgers, we can feast on a a megasandwich, which is incredibly cheap considering the gigantic number of calories (mostly fat calories, of course). At home and in resturants we use much bigger plates than in the past- about 30% bigger over the past 30 years so I am told. The psychology of plate size is fascinating. Left to our own devices, we will take about 30% more food if our plates are 30% bigger. It’s the same for glasses; people using a short fat glass will take about 30% more liquid to drink than if the glass is tall and slender.

Who is to blame for portion-size inflation and for such cheap food?

I don’t know that anyone in particular is to blame for the mess we have created. The “why” of our cheap food is complicated and I refer you to the books I mentioned in an earlier posting (“The Omnivore’s Dilemma,” by Michael Pollen, and “Fast Food Nation,” by Eric Schlosser). In a nut-shell, our government subsidizes the production of much of the food we eat, particulary soy bean and corn-based products (in about 70% of what we eat!). That’s why it’s so cheap. Don’t get me wrong, I am not advocating more expensive food just to keep us from eating as much and as much that is not very good for us. It’s all so complicated. We are weak (at least our appetite centers are) and the food advertisers are strong. The food industry has a big problem. They have become so efficient at food production that we have gigantic surpluses; the food industry produces about 500 calories more per day per person in the U.S. than we can stuff into our mouths. Of course, no one is forcing us to eat so much and so much that is of questionable nutritional value.

What about the children?

The one real problem I have with the food industry is the way it puts so much energy into getting children to eat more and more of what is of questionable nutritional value. Children are bombarded with food advertising on television, billboards, and even at the schools. The entertainment industry plays a part in all of this too by working with the fast food industry to entice children to go eat fast food because they can get some little toy creature. Even so, parents could control this if they would. And of course they should take control; remember, most overweight children become overweight adults.