Battling childhood obesity
Zohra Khamis worried about her daughter.
Beginning at age 5, Sarah began to gain weight. Fast-food dinners, a lack of exercise, and extended family gatherings that centered around food contributed to the problem. As she got older, Sarah was picked on at school. Clothing didn't fit; people stared at her.
Khamis tried to encourage Sarah to slim down, but her efforts backfired: The two got into shouting matches and succumbed to name-calling.
When Sarah was 9 years old, her pediatrician chimed in with concerns and asked whether Sarah would like to join a study testing a new method to help children manage their weight. The Massachusetts General Hospital program, which focused on improved education and support for physicians and patients, was the latest of many efforts attempting to solve a problem that is both complex and growing.
"I clearly couldn't do it by myself," says Khamis. She and Sarah signed up. "I told them, whatever you want us to do, we'll do it.''
Sarah is not alone in her struggle against obesity. More than 17 percent of youth in the United States are obese, according to a nationwide health and nutrition survey conducted by the Centers for Disease Control and Prevention. In Massachusetts, that number climbs to a whopping 30 percent.
Though there are some differences in prevalence among ethnicities and classes, obesity affects youths in every demographic, says Cynthia Ogden, who oversees the survey at the CDC. "Our whole population is challenged with this problem."
The causes of the epidemic are clear. "We live in a society that's profoundly unhealthy for children," says Steven Gortmaker, director of the Harvard School of Public Health Prevention Research Center. The culprits include sedentary lifestyles and easy access to sugary drinks and high-calorie junk food.
Yet solutions have been uncertain. What can be done to help children like Sarah?
Pediatricians sometimes refer patients to specialized weight-management programs, but they can be prohibitively expensive, and there simply aren't enough of them for all affected children.
"Once you talk about treating children with obesity, you're talking about treating 1 out of 6 kids," says Gortmaker. "That's a lot of people and families."
Some efforts have enlisted pediatricians to provide weight-management guidance, but studies show that most are hesitant to do so. They do not receive formal training about the problem in medical school, says Elsie Taveras, chief of pediatrics at Mass. General, and most don't have time to keep up-to-date with the latest evidence-based solutions.
"They don't know what to say, or how to have the conversation in a sensitive way," says Taveras, who feels the same pressure when counseling her own overweight patients.
In an effort to make it easy for pediatricians to intervene, Taveras and her team at MGH invited 14 pediatric offices in Massachusetts to try out a new system involving visual prompts embedded in electronic health records to help doctors engage with and treat overweight patients.
If a patient's body mass index (BMI), a measurement that compares weight to height, was in the 95th percentile or higher when he or she came in for a check-up, a neon yellow alert popped up on the doctor's screen.
"They had to stop and acknowledge this, and it gave them step-by-step instructions of what to do for that child at that visit," says Taveras.
Those instructions included scripts for how to talk with a child and their family, and a list of behavioral changes backed by medical evidence. Sarah was one of 549 children, ages 6 to 12, who participated in the study, called the STAR trial.
The study focused on introducing four key behaviors each day: sleeping at least 10 hours per night, avoiding sugary drinks, performing one hour of moderate to vigorous exercise, and spending no more than two hours in front of a screen.
"If you could, in every environment where children spend a lot of time, change these things, that would be enough to change the obesity epidemic," says Gortmaker, who was not involved in the study. "All of these are pretty simple, yet important."
All four behavioral goals are backed by scientific evidence. For example, dozens of studies have found a convincing link between too little sleep and increased weight in children, perhaps caused by decreased activity during the day because of tiredness or simply having more time while awake to be eating.
Prior to joining the study, Sarah went to bed whenever she wanted, had a TV in her bedroom, and ate plenty of junk food. With the guidance of their pediatrician and handouts from the STAR trial, such as a poster emphasizing the four guidelines and a behavior calendar with star stickers to track progress, Sarah and Khamis set out to make a change.
Khamis removed Sarah's TV from her bedroom, set a strict bedtime, and began cooking more at home with fresh fruits and vegetables.
In addition to the electronic prompt system for pediatricians, half the families in the STAR trial were assigned a family coach who called and sent texts with questions about their progress and notes of encouragement. Sarah loved the texts, says Khamis. "They gave reminders in such a positive way."
Texting has proven to be a very good method by which to connect with youth about their health.
A 2010 study at the University of Michigan found that adolescents responded especially well to tailored text messages on weight management, such as meal suggestions and recipe ideas.
"They told us things like the messages helped them get through the day and reminded them to make healthy choices," says Susan Woolford, medical director of the UM Pediatric Comprehensive Weight Management Center who led the study.
In the end, both groups of children in the STAR trial — those who worked only with their physicians and those who also had coaches — had improved BMIs compared to children whose doctors did not have the support tools.
Sarah lost weight and is now more confident and happier, says Khamis. She spends less time watching TV or at the computer and asks for carrots and grapes instead of chips and doughnuts.
The STAR interventions — electronic physician prompts and virtual coaches — are easy and inexpensive to implement, notes Gortmaker. Taveras hopes to disseminate the program widely with the help of companies that make electronic health record software.
Her team is also looking into additional types of virtual support for families, such as Facebook groups and video chats with physicians.
It's important to continue to try out new solutions, says Melissa Wake of the Royal Children's Hospital in Australia, who has led numerous trials of childhood obesity treatments. In fact, few treatments have had the success of the STAR trial: Most fail to lower BMI.
"Some studies have no effect compared to control; others have a little, but not nearly enough to change the obesity epidemic," says Wake. "We need to do something different."
It is likely no single intervention will solve the childhood obesity epidemic, adds Woolford. "Obesity is such a complex issue. We need changes in media, schools, poverty, and more. It is daunting."
But, she allows, it is possible. For example, most clinical trials for childhood obesity result in a handful of children who lose a lot of weight, says Wake. Perhaps by tracking those children — their behaviors, genetics, and degree of family support — we can learn more about what drives obesity and how to intervene.
Sarah, now 13, is one such success story. Today, she and her mother go on regular walks together, water bottles in hand. Their relationship has improved, and Sarah is now often the one giving Khamis nutrition advice.
"I am so happy, she is happy," says Khamis. "I know we're going to make it."