Treating childhood obesity with family-focused interventions
Many Canadian children struggle with their weight. The number of kids with childhood obesity has been growing since the 1970s, with measured rates rising from 6% in 1978 to 13% in 2004. In addition, 18% of children are overweight. It’s part of a larger global trend: 23% of children in developed countries were overweight or obese in 2013. In response, governments have set out to reduce childhood obesity, with both the federal government and provincial ones crafting plans to address the issue. In part one of our two-part pediatric obesity series, we look into treatment options for children and teens.
Harmful health impacts
Childhood obesity raises the risk of other diseases, including diabetes and high blood pressure, both in childhood and later in life. Obese kids as young as three have elevated inflammatory markers, which are linked to vascular damage in adulthood. And a 2009 study found 83 percent of overweight kids remained overweight as adults. (Like adults, kids’ weight status is defined by their body-mass index – their weight-to-height ratio. Overweight children have a BMI over a set threshold; obese children have even higher BMIs.)
Those long-term effects may be worse than we can predict right now. “As a medical community, we just don’t have any experience with managing type 2 diabetes for five or six decades of life. We don’t know the ramifications of hardening of the arteries in teens,” says Yoni Freedhoff, medical director of the Bariatric Medical Institute in Ottawa. “This is brand new territory.”
The stigma around weight also affects mental health and self-esteem. Obese children are more likely to have anxiety, depression and ADHD. “There’s an enormous amount of bullying, isolation, anxiety and depressive symptoms,” says Catherine Birken, staff pediatrician at SickKids’ obesity management program for children.
Clinics focus on the family
Managing childhood obesity is as complex as its causes. The common view that overweight kids need to just eat less and exercise more has been compared to telling a person with depression to cheer up.
Weight management programs for children should include the whole family – kids whose parents are more involved in treatment tend to be more successful. And obesity is often a family issue: children with two obese parents are more than twice as likely to be overweight.
That family approach is taken by the Pediatric Centre for Weight and Health in Edmonton’s Stollery Children’s Hospital. They work with about 50 to 60 kids a year, offering one-on-one counselling and group-based education to two- to 17-year-olds. They also look at parents’ marriage problems, kids’ relationships with food and how much time they spend on sedentary pursuits like video games. “It’s kind of like peeling an onion – there are lots of layers underneath. The challenge for us is to try to help families get to the middle of the onion and the core of the issues,” says Geoff Ball, director of the centre. Kids who complete the intensive group-based program lose 5 to 10 percent of their weight on average.
The SickKids Team Obesity Management Program (STOMP) also offers comprehensive care for teens. The two-year-long, group-based program treats adolescents with severe obesity from across the province. Patients work with a multidisciplinary team, including a doctor, psychologist, dietitian and exercise therapist, and attend group sessions that offer education and mental health support. STOMP also looks for families not being able to afford enough or healthy food, and at mental health issues.
The team recently developed an Early Years version with Toronto Public Health for kids under 5 who live in the greater Toronto area. They must be above the 95th weight percentile, and many children have other health issues, like sleep apnea or high cholesterol.
“The earlier you intervene in terms of promoting healthy lifestyles for the entire family, [the better],” says Julia Orkin, a pediatrician at SickKids and researcher at St Michael’s Hospital. “The evidence is very clear that if you put them on the right trajectory for health, the long term outcomes are significantly improved.”
In Freedhoff’s Family Reset program, they take a different approach – they treat the parents, not the children. That’s because they’re concerned about the effects of treatment on children’s self-esteem and their relationship with food.
“Young kids are life’s passengers, not life’s drivers. And trying to scare a passenger about where their car is going when they’re not driving is a little bit unfair,” says Freedhoff, adding that research shows programs that exclude children are as effective as those that involve them.
Most families he sees are trying hard to help their kids, but focusing on the wrong things. Some overlook drinking too much juice, since it’s often touted as a fruit substitute. “Just yesterday there was a family where their child was drinking more than two litres of juice a day,” says Freedhoff. (That’s about 4,000 calories.)
The program received $1.8 million from the Ontario Ministry of Health for a three-year pilot. “Our costs are markedly less per patient than Ontario’s hospital based childhood obesity treatment programs,” says Freedhoff.
The challenges of change
Even with the best support programs, making changes is difficult. Only about 10% of families who walk through the doors at Ball’s Edmonton clinic are “ready, willing and able,” he says, adding many parents are disappointed it’s so hard for their children to lose weight.
He recently ran a study on 165 childrenwho had gone to his centre. Nearly three-quarters had dropped out by the 11 month mark. “Most [families] aren’t able to make dramatic changes,” says Ball.
Freedhoff hasn’t studied success rates for his new program, though he thinks things are going well. “Ultimately, though, this is a service, not a product,” he says. “We just can’t force change.”
Research has shown how difficult it is for adults to lose weight and keep it off, and children face the same issues. Many teens and kids are successful in losing the weight and keeping it off for three to six months, before it starts creeping back, say Ball.
Some obese children may also be healthy. “We’ve done some research showing that a third of the kids that we see at our clinic are what can be called metabolically healthy obese,” says Ball. “They’re big, but they don’t have high blood pressure, they don’t have insulin resistance, they don’t have high lipids.” What’s still unknown, he adds, is whether they will stay healthy over the long term.
Bariatric surgery’s risks and rewards
A rarer treatment is bariatric surgery, an operation that makes the stomach smaller. It’s an option for adolescents who have had their growth spurt, are mature enough to offer consent, and are psychologically ready for both the surgery and to follow the post-surgical recommendations. Body-mass index levels and other conditions, such as diabetes or sleep apnea, factor into the decision of who needs surgery.
Risks of the surgery include bleeding and infection, regaining the weight afterwards and not getting enough vitamins and minerals. But the benefits include the possibility of substantial weight loss, and reducing diabetes and hypertension. However, teens may be less likely to comply with the diet and exercise recommendations that follow surgery.
SickKids is the only hospital in Canada that offers bariatric surgery to adolescents. It performs sleeve gastrectomy and Roux-en-Y bypass surgery, which make the stomach smaller. Less than 10 children per year have the operation, which also requires participation in the STOMP program. “It’s about having the right timing,” says Birken. “In the right setting, with the right supportive environment, [the surgery is] extremely effective.”
Access issues for rural areas
All these programs are hard to access for kids who live outside of major urban centres, like Melissa. (Name has been changed to protect her privacy.) She was referred to the STOMP program when she was 13, but her family was discouraged to find out there was a wait list and they would have to drive into the city multiple times a month for Melissa to attend. Her mother simply couldn’t afford the cost of gas and time away from work to drive to Toronto from their home in the Waterloo area. A year later, Melissa hasn’t found any other treatments, still struggles with her weight and is bullied at school because of it.
Most people in rural and remote areas have few resources to deal with obesity. “There’s an opportunity for us to do a better job of providing accessible service, and that can include things like providing health services on the weekends and distance support,” says Ball. His clinic uses videoconferencing, email and the phone, but it doesn’t solve the overall problem, he says.
Making the situation worse is that people in those areas are also more likely to be obese. That includes First Nations children, many of whom have weight issues: 55% on reserves are overweight and obese, and 41% of those off are. People with a lower socioeconomic status are also more likely to be obese.
Birken agrees access is a major problem. “In my mind, it would be most beneficial if family physicians or pediatricians had access to some of the services we do, and were able to provide these interventions in the community,” she says. “It makes no sense for all families to have to come down to SickKids. Eventually, I don’t think we should have this program.”
With that goal, they’re developing partnerships with family healthy teams, many of which already include a social worker, a dietitian and parenting programs.
The missing piece in childhood obesity
The environment is another important aspect of this issue. “If we’re going to see change, we need to stop focusing solely on the individuals,” says Freedhoff. “When you’ve got a flood, you have to know how to swim, but somebody’s also got to build a levy. We’re really good at telling people they should go get swimming lessons, and really bad at filling sandbags and stacking levies.”
Healthy Debate will address some of the policy changes that could help stem the tide on obesity in part two of this series. Look for it on July 3.