Childhood obesity and its challenges—a new epidemic

By Margarita Persico

Childhood obesity in the United States has tripled in the last three decades according to the Center for Disease Control.

In the United States childhood obesity has become one of the 10 top health concerns, according to the National Health and Nutrition Examination Surveys (NHANES). This epidemic has motivated the United States government to establish national health goals. A childhood obesity task force was formed in May, but NHANES findings suggest overweight and obesity will still be prevalent for at least another generation.

Dr. Abhinash Srivatsa, Boston (Photo: Margarita Persico)

Overweight children and teens are caught in a “tsunami of all these terrible things” such as cardiovascular complications, type 2 diabetes and kidney failure, according to Dr. Abhinash Srivatsa, a pediatric endocrinologist at Children’s Hospital in Boston. These kinds of illnesses were once common only to adults, said Srivatsa, who also teaches at Harvard Medical School.

Children's Hospital, Boston, MA (Photo: Margarita Persico)

Type 2 diabetes “is rampant” among teens, said Anne B. Minichino, a nurse at English High School in Jamaica Plain, Massachusetts.

Type 2 diabetes – a condition in which the body cannot use the insulin hormone properly – is linked to obesity, physical inactivity and genetics in certain groups such as African Americans, Asian Americans, Hispanic Americans, American Indians and Alaskan Natives, according to the Center for Disease Control’s (CDC) National Diabetes Fact Sheet, 2007.

Obesity also causes other complications such as increased cholesterol, non-healing wounds, liver inflammation, blindness, high blood pressure, heart attacks and strokes, said Srivatsa who sees patients with high blood pressure frequently at the Optimal Weight for Life (OWL) program, a clinic for obese and overweight children with type 2 diabetes.

At the OWL, almost one in every four children has liver inflammation, more formally known as nonalcoholic steatohepatitis (NASH) and much less formally as “fatty liver,” said Dr. David Ludwig, a Harvard pediatrician, who directs the OWL program at Children’s Hospital Boston.

This occurs when fat is deposited in the liver, a condition similar to fat under the skin, said Srivatsa. He said fat in the liver “inflames or irritates the liver, and in severe cases it can lead to liver failure.”

Srivatsa believes this condition is related to weight and diet, and compares it to foie gras, a French delicacy produced by force-feeding geese with high calorie grains, which in turn fills the liver with fat.

“That’s going on a milder scale in some of the children,” said Srivatsa, who blames excessive calories. “There have been instances of young adults needing liver transplant because their liver failed from this condition.”

Dr. Sara Nelson, a pediatrician at a Massachusetts General Hospital (MGH) branch in Chelsea, also sees a trend of liver problems.

“Liver issues, … we see that fairly frequently too. … It’s reversible with weight loss,” said Nelson, who works in Chelsea, a city with an overweight problem almost double the national average.

But researchers are not sure what causes obesity and suspect numerous factors such as poverty, processed food and lack of exercise, said Barbara B. Chase, nurse practitioner at MGH-Chelsea.

“Thirty to 35 percent of our kids fall into the overweight and obese category… based on national percentiles,” said Nelson. “That puts kids at risk for … the whole metabolic syndrome, polycystic ovary syndrome [and] cardiac problems.”

Srivatsa also sees frequently overweight girls and young women with a condition known as polycystic ovaries in which overweight girls tend to have extra male hormones. This causes facial and body hair growth, as well as irregular menstrual periods.

“The ovaries aren’t working properly because the hormones aren’t working properly, [which] can lead to … infertility,” Nelson said.

This condition, Srivatsa said, in many cases, is linked to overweight.

“But no one has figured out … how the weight causes extra male hormones,” said Srivatsa.

Other problems also concern doctors regarding the young overweight population.

“Excessive weight even in children is associated with what’s called insulin resistance,” also known as pre-diabetes, said Srivatsa.

Nelson, Srivatsa and numerous pediatric endocrinologists are identifying this in many obese patients.

“Overweight Hispanic children, even if they don’t have diabetes and any other problems yet, [they] already have a lot of problems in how their insulin works,” said about insulin resistance Dr. Enrique Caballero, director of the Latino Diabetes Initiative at Joslin Diabetes Center. “And that is very sad because these are the overweight kids that might develop diabetes and heart disease early in life.”

Physical warnings make it easy to identify pre-diabetes early on. The skin on the back of the neck getting thick and dark is a sign, according to Srivatsa. He believes most pediatricians and specialists are checking for this, but he does not think parents are instructed to look for it.

In his book written for patients and parents, “Ending the Food Fight,” Dr. Ludwig explains that pre-diabetes skin changes reflect “a skin condition called acanthosis nigricans, indicating that insulin levels in the body are already elevated – a risk factor for diabetes.”

Srivatsa worries about overweight kids’ future.

“Studies of patients with cancer and patients with type 2 diabetes … comparing quality of life, have shown that patients with type 2 have a much poorer quality of life than those who survive cancer,” Srivatsa said. “Each year or each decade you live with a history of diabetes the risk of getting these complications is higher and higher.”

The prognostic is reversible, though, said Srivatsa, if taken care quickly and boldly.

“I tell my patients there is a point of no return,” Srivatsa said. “Most kids recede … before they really get diabetes, and at that stage it’s still reversible,” he tells his pediatric families. “Kids … are growing tall all the time so it’s easier for them to slim down.”

Longwood Ave., Boston, MA (Photo: M. Persico)

But diabetes in children is not an easy problem to tackle. High school nurse Minichino said kids are being bombarded with television ads selling junk food, which may be worsening the problem of eating high-fat foods.

Nelson agrees.

“The worse part of TV isn’t the two hours that you are sitting watching TV. It’s probably the … advertising because it encourages kids to drink the soda, eat the junk food, go to McDonald’s,” said Nelson, the pediatrician. “People are constantly surrounded by inexpensive, low nutrition, high-fat food, and there is not a lot of places to exercise.”

The childhood obesity epidemic with its related diseases is also sweeping countries as diverse as India and Costa Rica.

Srivatsa, who grew up in India, has seen huge changes in his country with the overweight issue and attributes the problem to “better economics status especially in the fast, rapidly developing countries like China and India.”  He believes several factors are causing this worldwide phenomenon besides genetics: lack of awareness, poor health education, and more access to high calorie foods peddled by the food industry.

“It’s a worldwide problem wherever there is an economy that is improving,” added Srivatsa.

Hospital Nacional de Niños, San Jose, Costa Rica (Photo: Margarita Persico)

Now obesity in children is becoming more prominent in countries such as Costa Rica, where the problem was practically unknown until seven years ago, said Dr. Erick Richmond-Padilla, director of pediatric endocrinology at Hospital Nacional de Niños, the only hospital treating this condition in the country. In 2009 they had thirty type 2 diabetic kids — the youngest was a seven-year-old boy. (The youngest type 2 diabetic patient at the OWL clinic was eight years old.)

This phenomenon frustrated Richmond-Padilla because some of his type 2 diabetics had been his prediabetes patients, which means parents are letting the disease evolve.

Dr. Erick Richmond-Padilla, Costa Rica (Photo: Margarita Persico)

“And we had done interventions with nutritionists, psychologists, and it was not effective. Now, we see them as diabetics in a more advanced stage,” regretted Richmond-Padilla, whose government-run pediatric practice sees patients 15 years old and under.

Back in Boston, one of Srivatsa’s concerns is the risk of getting diabetic complications at such a young age.

“Can you imagine the quality of life when you’re 25 or 30?  When you have your first heart attack or a stroke, kidneys are all set to be replaced by someone else’s, and you’re starting to have eye disease and wounds that don’t heal. You can’t do anything then,” Srivatsa emphasized.

“That’s why we tell the teens [now] is the time to do something about your future because by the time you get it, it’s too late.”

(A version of this article first published in 2009 at Bay State Banner and El Planeta)