Sadly, children are the most vulnerable to this disease. Given the early onset of these complications, they will have significantly more long-term related morbidities than adults. 17 % of our nation’s children are overweight or obese. That number increases to 25% in our black and Hispanic children. It is widely estimated that because of their obesity, this is the first generation of children that will not live as long as their parents.
When they finished residency, our pediatric colleagues never expected to be caring for type 2 diabetes, sleep apnea, and joint pain. Nor did I, as an Internist, expect to be caring for diseases in a 13-year-old that are commonplace in a 50 year old. A 13-year-old patient spontaneously told me after she had lost 15 lbs that she could not believe how much better she was sleeping and did not feel like she was going to fall asleep all the time. While pleased that she was feeling better, I was heartbroken that this 13-year-old girl’s words could be interchanged with that of many of my 65-year-old patients.
Ultimately, the etiology for obesity is excessive caloric intake. As physicians, we cannot ignore the problem of obesity. It is imperative that we take an extensive history to find out the what, when, where, and how, as they pertain to their eating habits, both in the home and outside the home. What is the structure regarding food? What are the parental projections onto the child regarding food? What permissions are given to the child regarding food? Is food a battle that the parent has been given up? Is the child forced to clean their plate? Are soda, juice, chips, and cake in the house regularly? How much frozen prepared food is used? How frequently does the family eat out? What size meal does the child order? Is the child allowed to order whatever they want when they go out? How good a role model is the parent? Can the parent say no regarding food? How do they do say no regarding other behaviors? Are new foods regularly introduced? Was the child breast fed?
The wrong foods, (high sugar, high fat, high salt) act like a drug to our midbrain (the ventral tegmental area), causing release of dopamine and thereby activating very strong emotional, reward-signaling cues. These urges are very hard for adults to work with; one might hypothesize that the earlier these neurohormonal and behavioral pathways are established in children, the more difficult they will be to extinguish.
Eating outside the home is a huge pitfall. There are rarely good choices on a child’s menu and most children quickly outgrow the child’s menu and then move on to the even more dangerous adult menu. If the child has been taught to clean their plate, they are now encouraged or urged to “eat it all” (“We paid good money for that!”), which, in most cases, is far more calories than even a grown adult needs. Unfortunately, restaurants and businesses are now encouraging parents to bring their children with specials of “kids eat free.” Childhood obesity is definitely not free.
Cognitive restructuring is absolutely imperative in working with all patients who are obese, whether they are choosing medical or surgical treatment for their obesity. Highly structured, well-planned eating, with good environmental control, allows people to avoid the foods that can cause a “drug-like response.”
Treating a child with obesity necessitates treating the whole family. It has to be a family affair because the child is at the mercy of the choices of the parent. The parent does the shopping, the cooking, and, hopefully, makes the decisions about the food. The most successful families that I have treated are ones where several members have worked together toward a common goal of improving the health of the family.