Endodoc

There was an interesting article in the New Y0rk Times today written by Roni Caryn Rabin and entitled “Calorie Labels May clarify Options, Not Actions” (NYT Tuesday July 17, 2007, page D6).  The article summarized quite a bit of data on the effects of food calorie information on food choices when people eat out.  In summary, data show that consumers want to have such information available (New York City has a law requiring that fast food and chain restaurants post calorie information on the menu or menu board) but such information does not often get consumers to make lower calorie choices- studies show (no references included) that only 10-20% of diners would choose lower calorie options knowing the calorie content of various menu items.  That’s a rather interesting disconnect between knowledge and action.  It’s like the lecture I gave last week to our University Hospital Pediatric Department entitled “Why there so much childhood obesity and what to do about it.”  The lecture was well-attended and the audience was attentive and asked great questions but guess what they had to eat at the sign-in table?  Glazed donuts!  As part of the talk I gave a “nutrition quiz.”  I was surprised to learn how few people knew even some of the answers.  How would you do on the test?  The questions were as follows:

1. What are trans fats and what’s good about them and what’s bad about them?

2. How many calories in a gram of fat?  Is that good or bad or both good and bad?  How many calories in a gram of carbohydrate?  What about in a gram of protein?

3. What percentage of foods in a supermarket are derived at least in part from corn?

4. How many grams of sugar and calories are in a “regular” soda?

5. How many Hostess Twinkies were eaten in the U.S. last year and how many calories total does that represent?  How do they get the cream filling in the twinkies anyway?

I’ll post the answers to the quiz in the next day or so.

Is this a post-Avandia knee jerk response or is it a bad drug?

I was more than a little bit surprised that an FDA advisory panel nixed use of the appetite-suppressant rimonabant. The drug acts in the central nervous system to inhibit a cannibus receptor, thereby decreasing appetitie (maybe you didn’t know that people who use marijuana typically have huge appetites). The drug has been available in other countries, including most of Europe for some time under the name Accomplia (it was to be called Zimulti for the U.S. market). Apparently the main concerns are related to the reports of depression and even suicide in some people who have taken the drug (not entirely surprising given the psychological effects of marijuana). Whether these serious side efects of the medication are specific for patients who can be identified as “at high risk” or not remains to be clarified.

Studies have shown that the drug does promote weight loss but the results have been somewhat disappointing, particularly given the enormous enthusiasm for the drug when it was first introduced. Not surprisingly, stock in the company that makes the drug, fell after the FDA announcement.

Where to go from here?

Clearly, the FDA needs more information about the drug’s side effects but I hope they will not summarily reject use of the drug in certain circumstances. For example, perhaps the drug can be used prior to considering bariatric surgery in very overweight patients (e.g, BMIs >40)? In such patients, surgery has many risks and perhaps rimonabant is “the lesser of two evils?”

I can’t believe it’s been so long since my last entry- about two weeks. It’s not really been “writer’s block,” more like “writer’s ennui.” I just couldn’t get inspired to write about anything and now I have a long list, just since this morning. I want to start with an article published in the New York Times today written by Alex Kuczynski entitled “A Sense of Anxiety A Shirt Won’t Cover.” The article appeared in the Thursday Styles section, page E1. The gist of the article is that many boys and young men are having surgery to reduce their enlarged breasts. The procedure is called a reduction mammoplasty and is generally performed by a plastic surgeon.

What is this all about?

Almost all males develop some breast enlargement early in puberty. Typically, a 12 or 13 year old male notes breast enlargement and some tenderness. The breast tissue is generally not more than 1-2 cm (less than an inch) in diameter, and disappears over the next 1-2 years. Occasionally, we see much more striking breast enlargement which requires careful medical evaluation. As an endocrinologist, I have seen many boys and young men for evaluation of gynecomastia. The minor degrees of breast enlargement are easy; generally reasurance is all that is needed. It is the patients with exraordinary breast enlargement that present a dilemma.

First, a detailed medical history and physical examination need to be performed, then perhaps some laboratory studies. The article listed some of the medical conditions that can cause gynecomastia, which include liver disease, certain medications (e.g, psychotropic drugs), hormonal disorders (e.g., congenital adrenal hyperplasia, estrogen-secreting tumors, any condition with low testosterone levels), and illicit drug use (e.g., marijuana). The condition is common in a condition called Klinefelter syndrome- males with a chromosomal disorder, XXY. Not surprisingly, overweight males often have prominent breasts, but in many instances it is simple fat deposition rather than true glandular breast tissue (fat does secrete estrone, a form of estrogen which does stimulate breast tissue formation). Often gynecomastia is hereditary; what do they say-”like father like son?” Rarely does one ever find a specific medical cause for the breast enlargement. The question then becomes what to do about the condition. If there is considerable breast enlargement, it is not surprising that the patient might be quite distraught and even have significant psycholological problems (imagine a 14 year old male with breasts as big as Anna Nicole Smith’s!).

What to do?

In the “old days” we tended to tell patients that their massive gynecomastia would go away if they just gave it time. We now know that that is not true- breast enlargement greater than 4-5 cm. in diameter is not likely to regress much. So, why wait? Why not have an experienced plastic surgeon remove the tissue IF it is a major concern to the patient (some patients are not bothered much by anything)? The argument in favor of waiting is that over time the breast enlargement will go away and that a better surgical result can be obtained by waiting several years. In typical adolescent gynecomastia, I would agree with those arguments, but not when there is a great deal of breast tissue. I do not consider this a simple “cosmetic” issue given the psychological problems that are so common in these patients.

I believe the New York Times article may have done a disservice to these patients- the article focused mainly on the transient nature of the problem and the desire for some males to have surgery to look more “buff.” I am not talking about those types of situations, but rather, males with a large amount of breast tissue who are having psychological problems. Tincture of time and watchful waiting will not improve the situation for these unfortunate patients. Over the years we have been quite succesful in getting insurers to cover the procedure once they understand the situation- a photo often does the trick..

Gina Kolata, an excellent science reporter from the New York Times, has been getting quite a bit of attention lately- an appearance on Comedy Central, a review of her new book, “Rethinking Thin,” in the New York Times Book Review section (May 6, 2007), and her own article in yesterday’s New York Times (“Genes take Charge and Diets Fall By the Wayside,” page D1).

The Kolata message

Ms. Kolata’s basic thesis is that we are fat and that we cannot do much about it because the causes are mostly genetic. She cites various well-known studies that demonstrate the strong genetic effects on obesity. She seems to be telling us that we can try to diet but we are probably doomed to failure because genes rule.

Is the Kolata message correct?

I (as did the book reviewer, Emily Bazelon) think Ms. Kolata, who writes very well, is off the mark. She is correct in identifying some of the data supporting strong genetic effects on body weight. What she basically ignores is the large body of data showing an enormous upsurge in obesity over the past 50 years or so; from the plethora of news reports in the past few years and warnings from the U.S. Government, one would think the epidemic has occurred entirely in the past 5-10 years). The obesity epidemic cannot be “blamed” on genetics alone; many studies have documented the environmental factors- cheap food, larger portion sizes, decreased activity levels, etc. Ms. Kolata acknowledges these phenomena but hardly considers them important enough to consider dealing with given the power of the genes.

I believe we can have an impact on the environmental factors, and while success in this area will still leave us with plenty of obesity to go around, we can have major successes in decreasing the prevalence of obesity. Of course, we individually and as a society will need to come to grips with our passion for large portion sizes and extraordinary inactivity.

In earlier entries about obesity, I discussed some of the research on the psychology of portion sizes- bigger plates mean bigger portions eaten, etc. I hope you remembered. In case you didn’t, today in the New York Times, David Leonhardt wrote an article that made the front page of the Business section (don’t ask me why the article is in the Business section?). The author discussed Brian Wansink and his book, “Mindless Eating” which was published last year. Professor Wansink has done much of the interesting research on the psychology of eating as it relates to portion sizes. The article is a good review of the subject.

The gist of Professor Wansink’s “message” is that people make decisions about eating and drinking, i.e., how much to eat and drink, not based on appetite, but rather, on various cues such as the size of the plate, the bowl, or the glass. The data are rather compelling.

Do the professor’s data help explain the obesity epidemic?

Professor Wansink’s studies and similar studies by others leave me wondering one thing. If we do eat more at time-point A than our appetite centers compell us to do, is the appetite center smart enough to “recommend” less intake at time-point B, resulting in no net increase in caloric consumption over and above what the appetite center has “calculated” we need overall? Given the steady increase in obesity in the U.S., I suspect the appetite center is not capable of such fancy adjustments, but I’d like to see some data on the subject.

Anyway, I intend to read Professor Wansink’s book and I hope many others will also do so. Let me know what you think.

An Apology

I apologize for the long time interval since my last entry. My excuse is a good one- I was visiting my daughter, her husband and their children, twins (Evan and Sophie). In fact my son-in-law is my webmaster and he taught me how to do links which I will try to add to many of my entries. Their family is rather interesting, although maybe not so much in California, where they live. They are judicious vegetarians and the grandchildren do not seem to have suffered any for it. The children have never, to the best of my knowledge,
set foot in a McDonald’s restaurant.

The “News”

There have been an increasing number of news reports about the “alarming” epidemic of obesity in children. Hello- where have people been the last decade or so? Also, more and more celebrities are wanting to get into the act. For example, there is a report in the New York Times today that former President of the United States, Bill Clinton is “teaming up” with Rachael Ray of the Food Network to promote healthy eating for children. The article is written by Kim Severson (“Dining In” section, page D4). Apparently, the cooking duet episode will be televised tomorrow (recorded April 12, 2007). President Clinton was Ms. Ray’s surprise guest and they are to be “partners in the fight against childhood obesity.” According to the report, President Clinton is flagellating himself for his previously terrible eating habits that may have contributed to his heart disease and recent quadruple coronary artery bypass surgery. Ms. Ray intends to work with the Alliance for a Healthier Generation, an organization founded jointly by President Clinton’s foundation and the American Heart Association to combat diabetes and obesity. Ms Ray apparently intends to help by talking about “how fun healthy food is, period.” Good for her.

Will any of this help? I doubt it but who knows? It can’t hurt

More News: Are Any Swedish Children Overweight?

In yesterday’s New York Times, there was a short report that Swedish children, like children in most developed nations (I won’t define what “developed” means), are getting heavier. It’s really not a surprise but somewhat of a disappointment for me- the Scandinavians have been “out front” in promoting health education, including nutritional education and physical education for some time. The only solace I have is that the increased prevalence of obesity is only a fraction of what we have seen in the U.S.

Even More News: Treating Obesity with Drugs

Also, in yesterday’s New York Times Jane Brody wrote an excellent review of current drug therapies for obesity, entitled “Weight-Loss Drugs: Hoopla and Hype.” She discussed both over-the-counter medications/products and prescription drugs. Let me summarize: don’t believe the claims about the over-the-counter products and watch out for the side effects of prescription drugs, especially given their (?very) limited benefits. Nothing new here but I think she did a nice job in sifting through a great deal of data. Darn, we are still going to have to suffer with healthy eating (remember it’s mostly too many calories in and not enough burned up through activity).

I was pleased to read today in the New York Times (Wednesday, April 4, 2007 page A10) that the Robert Wood Johnson Foundation plans to spend a great deal of money over the next 5 years to “reverse the increase in childhood obesity.” From the news report it is difficult to tell exactly what the foundation intends to do- the article says that the foundation “plans to invest in programs to improve access to healthy food, encourage the development of safe play spaces, increase research to enhance understanding of obesity and prod governments into adopting policies to address the problem, among other things.” That sounds like quite an ambitious set of initiatives.

I’m not sure what I think about the foundation’s plans. Certainly we are in the midst of an obesity epidemic and we actually understand quite a bit about it. It’s genetics, cheap food, inactivity, etc. The question is whether focusing on the children in the ways the foundation intends will improve things appreciably in the long run? I do not want to seem the skeptic but I do not believe that unless we can “get to” the parents, we are not very likely to be successful in the long run; I don’t think it’s an analogous situation to childhood immunizations. Remember, the childhood obesity epidemic just mirrors what we see in the adults (60% of adults in the U.S. are overweight). Will “working on” the children change the way their parents feed them at home and when they eat out? Will it change the way the parents promote physical activities in the home setting? Maybe? Will it have any impact on what and how much the adults feed themselves and how much physical activity they engage in? Maybe?

In my last posting (31 March 2007), I put together a healthy eating plan for a hypothetical 9 year old boy. At first glance, you may think that the list of do’s and don’ts are obvious and can’t possibly be all that it takes to effect substantial weight loss? You would be wrong, and I will try to explain why.

Why do children get overweight?

In earlier postings, I discussed the many reasons for the present obesity epidemic. Regardless of the specific mechanisms involved, most obesity boils down to too many calories in and too few expended. In most instances, the positive calorie balance is only 100-200 per day. What that means is that some combination of 100-200 calories per day not eaten or “burned up” means no excessive weight gain; add another 100 calories or so to the negative side and it results in weight loss- remember that a negative calorie balance of only 100 per day results in a weight loss of almost a pound (0.45 kilograms) each month. That may not seem like a big deal but it’s almost 12 pounds in a year.

Where can I “find” those 100-200 calories per day?

If you re-examine the eating plan for John, our hypothetical 9 year old boy with obesity (posting of 31 March 2007), you will find that most recommendations are designed to cut back on calories consumed or increase calories expended.  For most people, It doesn’t take much of a change in their eating and their activity routines to find those 100-200 calories.  For example, each sugar-containing soda is about 160 calories.  Each extra spoonful of whatever is 50-100 calories or more.  Each slice of bread is 60-120 calories.  Each bedtime snack is- you don’t even want to think about it!  Each 30 minute walk is 100-200 calories depending on intensity.

You get the picture.  It’s only a question of knowing the plan and working hard each day to follow it.

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).