“You can’t fight obesity sitting down.”

Wow, what an amazing and motivated bunch of people.  31 dedicated souls including doctors, nurses, parents and weight loss surgery patients braved the uncharacteristic rain and competed in the Reno Rock-N-River Run to raise awareness of childhood obesity.

The Reno Rock-N-River marathon, half marathon and 10K begins in the old streets of downtown Reno and then takes a route that follows the Truckee River as it flows through this valley, around and over rocks on its way then east and to Pyramid Lake.

Our group proved to be the largest group running to raise awareness for a charitable program and we all completed the 10K.  Several of my past Roux-en-Y gastric bypass and laparoscopic adjustable gastric band patients completed in the run.  That even included one patient of mine who had undergone surgery only two weeks ago!  She kept up a brisk walking pace and completed the race handily.

Another former patient of mine told me that she maintained the weight that was even lower than what she weighed her last year of high school. She ran the entire 10K, something that she could never have done even back as a high school senior.  What a long way she’s come.

The race organizers have invited the Obesity Prevention Foundation to serve as the official race charitable organization partner, and we could not be more excited about it.  How many people can we enter in the race next year?  35?  50?  100?

What are the Health Effects? – Complications of Obesity in Adolescents

A recent review by Karam in Pediatric Endocrinology Reviews (August 2008, Volume 5, supplement 4, page 980) discusses the growing problem of type II diabetes among adolescents. Since most type II diabetes (previously referred to commonly as “adult onset diabetes”) is related to weight gain, and since weight gain and obesity continue to rise among children and adolescents, we see a parallel rise in the development of new cases of type II diabetes among children ages 13 to 17. The authors discuss methods to attempt to prevent the onset of diabetes in this patient population chiefly by recognizing when kids become at risk for the disease through weight gain at an early age.

These are the types of efforts that are very difficult, but are the same efforts being undertaken across the country and across the world in school districts and community programs and through nonprofit foundations like the Obesity Prevention Foundation.

Identifying adolescents who are at risk for diabetes involves measuring height and weight, calculating a Body Mass Index, and intervening with counseling and education of both the kids and the parents. The hope is this will lead to improved and healthier eating, reduce calorie intake, increase physical activity and a correction of the weight gain curve toward a more normal Body Mass Index. In this way, it is hoped that some kids will avoid developing early onset of type II diabetes.

Sometimes identifying kids who are overweight and targeting them specifically with counseling and education can seem intrusive or discriminatory. There might also be a perception of being judged or a misplaced focus on appearance and social norms instead of on health and diabetes prevention.

Navigating all of these personal, political and social obstacles is no easy task, but with the rising rates of type II diabetes among our young people, what other choice do we have but to try hard to protect the health of our young people?

I recently talked to groups of children about being overweight and obesity. The amazing thing is they really understand this problem. Even speaking to kids who are first and second graders, one finds that they very quickly understand that:

• It is a rapidly growing problem.

• It is very bad for one’s health and limits the amount of fun one can have in life.

• Things like sugared sodas and sweets and treats are what cause a large part of the problem.

It is also clear that they absolutely love all the sweets and treats, video games, cartoons, and TV/couch time. They are just looking for someone to tell them that there are limits.

That is our job. As parents, as doctors, health care providers, as community leaders, our job is to set limits on all the things that are harmful for our young people and children. So, a little TV is okay, but more than an hour a day of any “screen time”, including TV, videos and computer time is too much, with the possible exception of computer time that involves homework, such as writing reports or doing school projects. Likewise, treats and desserts are okay once in a while. But dessert every day – too much. Dessert after every meal is way too much. Breakfast cereals that are basically themselves desserts – absolutely unacceptable. Meals that involve over 700 or 800 calories because of the inclusion of things like milk shakes and French fries: Absolutely unacceptable. French fries may be one of the world’s delicious foods, but it should be treated as an unusual, special treat. It certainly is not a staple.

You can’t fight obesity sitting down.

May 3, 2009 will be the Obesity Prevention Foundation run in Reno, Nevada to raise awareness and raise funds to fight childhood obesity. The run will be a 10K, part of the Reno Rock-N-River Run that also supports a half marathon and a marathon. The Obesity Prevention Foundation Team will collect a minimum of $5.00 per kilometer per team entrant with the goal of raising over $50.00 per participant and the goal of raising $2,000.000 for the foundation’s work.

I am donning my running shoes in anticipation and looking forward to the run!

Additionally, Thank you to all who attended the seventh annual Western Bariatric Institute fashion show that took place last weekend at the Reno Convention Center. This year the focus was and continues to be on “giving back” and there is still much work to be done to prevent childhood obesity in our communities.

I think just about everyone would agree  that one of our top priorities should be to ensure the health of our nation’s children.   And although some of us point to a failure of personal responsibility as a component of the problem of weight gain and obesity, few can make a compelling claim that our nation’s children bear the responsibly for their own obesity and unprecedented suffering with diabetes (and other obesity-related health problems).

And what of the causes of this devastating increase in childhood obesity and childhood diabetes?  Numerous recent studies have noted the striking rise in obesity related illness among kids.  A disturbing, growing percentage of our nation’s youth have a condition known as “prediabetes” or impaired glucose tolerance that leads to outright diabetes.

The best evidence points to multifactorial causes.  We are a more sedentary society.  Our children spend more time in front of screens than out kicking balls and running through the grass.  Physical education has disappeared from the school curricula.  A greater fraction of the child’s meals are fast foods and prepared foods.  And these same fast foods are more delicious than ever and higher in calorie content than ever.  And finally, our children have exhibited a stunning increase in the consumption of carbohydrate sweets, especially table sugar (sucrose) and high fructose corn syrup, that parallels the epidemic of weight gain and obesity. As a weight loss expert having worked with so many overweight people over the years, the consumption of sweeteners stands out as accounting for a disproportionate amount of the problem of weight gain.

Scientific studies further link the consumption of high fructose corn syrup-laden beverages and increasing rates of childhood obesity.

In 1970, the average per capita consumption of soft drinks, sodas, in the United States was 28 gallons per person per year.  In 2008, it was 56 gallons per person per year (of beverages usually sweetened with high fructose corn syrup).  Over the same period of time, the rate of obesity (Body Mass Index greater than 30) has increased from around 5% to over 15% among children and adolescents in this country.  Between 1970 and 1990, the US per capita consumption of high fructose corn syrup has increased tenfold or more than 1000%.  According to a comprehensive review undertaken by the American Journal of Clinical Nutrition in their article published in 2006 (American  Journal of Clinical Nutrition, Volume 84, page 274-288), the comprehensive review of all of the clinical trials and evidence-based, peer-reviewed studies demonstrates that “the weight of epidemiologic and experimental evidence indicates that a greater consumption of sugar sweetened beverages is associated with weight gain and obesity”.

So how do we as individuals, as communities, as governments, as schools, and as corporations lead, protect and nurture our young people?  How do we, as the adult stewards of our young people, prevent them from suffering the scourge of obesity, type II diabetes and its complications (blindness, amputations, stroke, kidney failure)?

My belief is that the solution lies in every community in the country, every government chamber in the country, every school in the country, every corporate boardroom, and every home.  It will take all of us working on many solutions to fix a problem that is so widespread and so damaging to kids.

When tobacco was shown to cause health problems (cancer, heart disease, birth defects), initially the tobacco industry dug in and created an advertising, public relations response that tried to deny the science.

Now we see the same head-in-the-sand response by the makers of high fructose corn syrup. Instead of acknowledging the obvious role of sweeteners in fostering childhood obesity, diabetes and disease, the industry is mounting a public relations campaign to dispel the science.

Instead of stepping up and taking responsibility, the industry is putting out spin with ads like these from the corn council.

Sure, there are differences among tobacco, alcohol and sweeteners. But if we are to reduce the alarming rates of childhood diabetes, it is undeniable that we must find a way to reduce consumption of these high calorie, high carbohydrate sweeteners.

As a physician and parent, I would appreciate industry taking a leadership role in educating kids and parents about the damaging aspects of high fructose corn syrup. Imagine a responsible corn industry running ads that say that consumption of this sweetener needs to be limited in kids and overweight adults. Consuming too much of this sweetener leads to weight gain which causes real health problems for kids, like diabetes. So enjoy our delicious sweeteners, but do so in moderation, and make sure your child is staying on a healthy growth curve and not gaining weight beyond a healthy level.

I suspect it is a matter of time before governments force the Corn Council to step up and act responsibly. Based on this sad spin campaign that ignore our childrens’ health and serves only to promote more profits for the purveyors of high fructose corn syrup, it does not appear that the corn industry is prepared to act responsibly on its own.

Weight loss surgery for adolescents continues to be a controversial topic. Increasing studies confirm the effectiveness of weight loss surgery in treating what is otherwise a very challenging problem, severe obesity among adolescents and teens. A 2008 study by Fielding’s examined the outcome for 73 adolescent patients who underwent laparoscopic adjustable gastric banding. In that study, the mean Body Mass Index was 48. The percentage of excess body weight loss at six months was 35%, then at one year was 57% and at two years was 61%. Two of the 73 patients had their bands removed, and one of them had a serious complication of a gastric perforation and reoperative surgery.

Overall, in the Fielding study, the adolescent patients aged 13 to 17 had excellent weight loss results and excellent improvements in their health with resolution of comorbid conditions. The authors followed their patients closely and encountered and treated vitamin deficiencies and other behavioral problems during the course of their follow up. These authors recommend adjustable gastric banding surgery as the appropriate procedure for adolescents because of its reversibility and lower degree of invasiveness.

That same opinion is echoed by a physician paper from the Society of Adolescent Medicine. They note that while there is a requirement for follow up and band adjustments, and the risk of noncompliance in adolescents, these are not reasons to dissuade adolescents from having LAGB surgery. In their words, a laparoscopic adjustable gastric banding is, “the optimal surgical option for pediatric patients with morbid obesity.”

The less invasive laparoscopic approach and the reversibility of the gastric band have led our center to favor adjustable gastric banding for adolescents in our study, which began in 2005. The possibility of more severe complications, and the possibility that future decades may bring improvements in the treatment of metabolic diseases and obesity, lead us to believe that gastric bypass or duodenal switch procedures are not as attractive as options for our adolescent patients pursuing weight loss surgery.

Weight loss research is happening at many wonderful institutions across the country and around the world.

What is done at centers near you? What is your experience?

New York’s governor, David Patterson, favors a tax on sugared beverages such as popular soft drinks, Coca-Cola, Sprite, Pepsi and others. His argument is that weight gain and obesity cost the public tremendous amounts of money and healthcare dollars and they take an enormous toll on the health and well-being of all citizens. The governor further notes that heavy taxes on cigarettes have helped reduce the consumption of these tobacco products which also contribute greatly to disease and burdens on the healthcare system.

Opponents of such attacks say that taxing sugared beverages is just a cynical means of raising money for cash-strapped governments, and they doubt whether raising the price of Coca-Cola will have any impact at all on the obesity epidemic.

What do you think?

When I studied public health at the University of California Berkeley, I learned that government can influence personal behaviors through public policy changes including taxes. I was also taught to look “upstream” at the root causes of major health problems and try to come up with ways that public policy could impact those root causes.

But it is hard to know whether a tax on sugared beverages would discourage people from drinking them. Judging from the tobacco taxes, it has taken very high taxes to impact a person’s behavior significantly. Are societies prepared to levy taxes on soft drinks of 50% or 100% or 200%?

And then the problem of obesity becomes even more muddled. How much of it really stems from sugared beverages? And if sugared beverages become prohibitively expensive, will people just get there “sugar fix” by turning to other less expensive treats? Perhaps public policy should take into account that the consumption of calories in general and high carbohydrate foods in particular, contribute to the obesity epidemic. It is true that this places a great burden on the tax payers. But how to construct a fair and equitable tax to address these questions? For example, should we tax only foods that are high in calories and high in carbohydrates? And would we apply those taxes across the board or only to certain subgroups? For example, should we just tax sugared beverages but not sugared ice creams and cakes?

No matter what the ultimate answers to these questions, the sobering truth is that the consumption of more high carbohydrate foods and beverages is contributing to an alarming and devastating rise in type 2 diabetes, cardiovascular disease and obesity. With nearly a third of our nation’s children overweight or obese, an alarming increase in the number of pre-diabetic kids and adults, creative public policy solutions need to be found. But is this the right one? Tell us your thoughts.

A major problem with weight gain among kids is that it produces serious health problems and sets the stage for early development of even more serious disease. For example, kids who gain weight develop what is called “impaired glucose tolerance”, meaning that they have a type of pre-diabetes condition. This means that the overweight, or obese child does not process ingested sugars easily and the serum blood sugar level rises. There are also problems with insulin production and resistance of the tissues to insulin, both critical factors in the development of diabetes.

In addition, the circulating blood lipid levels rise in overweight kids and they develop early plaques on the inner lining of the arteries, known as atherosclerosis.

The combination of an expanding waistline together with high lipid levels and elevated blood sugars are the core findings of the metabolic syndrome, a collection of serious cardiovascular abnormalities associated with early heart attacks, strokes and death.

The kids who start out on this path at such an early age have a poor chance of living a normal, long life. Many of the metabolic results of weight gain as a child are well described in a volume by Weiss called The Metabolical Consequences of Childhood Obesity (Best Practice and Research Clinical Endocrinology and Metabolism, volume 19, issue 3, page 405).

The connection between being overweight as a child or adolescent and then later having adult obesity and cardiovascular disease is made clear in a study by Srinivasan in the journal Metabolism (volume 45, issue 2, page 235, February 1996). In this study, 783 subjects surveyed first as adolescents and then again as young adults age 27 to 31. They found that the excess weight present in the adolescents persisted into young adulthood and had a strong and negative impact on health as measured by multiple cardiovascular risk factors (high blood pressure, elevated cholesterol, adverse lipid profile and diabetes).

So, unfortunately, while we would like to think of some of the youngsters as still retaining some of that “baby fat” and hoping that it will melt away as they age into adulthood, the facts speak otherwise. Childhood weight gain and obesity lead to adult obesity and disease.

We cannot afford to neglect childhood weight gain and adolescent obesity as serious problems and as an important opportunity to intervene for improved long-term health.

We always lament the increasing amount of “screen time” that adults, and especially children, are getting these days. One of the real pushes from the Obesity Prevention Foundation is to limit screen time for youngsters to no more than an hour a day. It is believed that too much screen time (whether it’s television or computer screen, video game or handheld gaming device) means just that many more hours that are not spent being active outdoors getting exercise. And because the TV shows, movies, computer games and internet options are so much more interesting and entertaining, we seem to be losing the battle with kids spending more time in front of the screen and less time outdoors using their muscles.

But one exciting and positive development is the Wii Fit and some other games and entertainment systems either on the drawing board or filtering out into the marketplace. These entertainment systems involve physical activity, monitoring, scoring and advancing through levels of physical accomplishments, even yoga poses. And so far, adults and kids seem to find the Wii Fit pretty darn entertaining. It offers levels of challenge, levels of accomplishments, exciting awards when reaching levels.

Have you tried WiiFit or other active games? What do you think?

Childhood obesity has grown to become one of the nation’s most pressing health problems. We have already seen a tremendous surge in adult obesity in the last 30 years. That rise in obesity among the adult population is shortening life expectancy and creating a terrible amount of early disease and suffering, with conditions like diabetes, heart disease, stroke, depression, sleep disturbance and degenerative bone and joint disease.

Today, at least 1/4 of American children are seriously overweight. That number is expected to rise in the future unless we can do something about it.

But how do we tackle such a difficult problem?

As with any complex multifactorial problem, the best solutions start with understanding the root causes of the problem. In the field of Public Health, we talk about the “upstream, downstream” theory. In the upstream, downstream theory we recognize that problems are usually identified at some point downstream where they have begun to cause symptoms or disturbances. Sometimes those problems (example: Heart attack) demand immediate solutions right there in the stream. However, a broader understanding and approach to a more comprehensive solution requires turning and looking upstream to the root causes of the problems (example: Smoking and obesity as causes of heart attacks). Only when we look upstream can we truly identify root causes of complex problems and begin to offer solutions.

So looking upstream at childhood obesity we see many causes.

• We see a tremendous rise in the dietary consumption of high calorie, high carbohydrate meals.
• We see portion sizes increasing in meals across the board.
• We see an influx of high calorie, high carbohydrate commercial foods being brought into the schools and displacing more traditional meals that are prepared on site with fresher ingredients.
• We see a rise in the consumption of high fructose corn syrup and sugared soft drinks.
• We see a tremendous sophisticated effort on the part of the commercial food industry to market and advertise directly to our children and promote consumption of high calorie, high carbohydrate unhealthy food.
• We even see government subsidies of corn crops, and effectively, high fructose corn syrup.
• We see falling, strained budgets for American schools and greater reliance on commercial purveyors of fast food and soft drinks to fund extracurricular activities in schools.
• We see increasing concern about outdoor safety and security for our children and less willingness to let them run loose in the streets or parks.
• We also see tremendous increase in the sophistication and appeal of video games, movies and computer entertainment, which involves very little physical exertion.
• We see a tremendous rise in the average weight of the parents of the at risk children.

Wow! That is a stunning and formidable list of root causes, and there are certainly more.

How might we tackle this problem or at least begin to make inroads?

Well, before I founded the Obesity Prevention Foundation, I grappled quite a bit with these very questions. And while certainly there are no simple solutions, the recognition of these root causes leads to some avenues for intervention that might help us turn the tide on this terrible epidemic of childhood obesity.

For one thing, we must engage as many people in our communities as possible to work collectively to fight this problem. The best solutions are going to come from many fronts and are going to include some policy changes at the levels of local and state governments, school boards and the U.S. Congress.

We are all stewards of our nation’s young people. It is in everyone’s interest that we raise a generation of healthy active kids. It helps no one to promote obesity among our young people, no matter what the short-term profits are for soft drinks or fast foods. Not even the most cynical business person would argue against the idea that our collective interests lie in raising a generation of healthier eaters and less overweight kids.

So solutions begin with raising awareness and promoting education among all of the stewards of the community. This includes business leaders who understand that an educated, productive work force comes from a healthier, normal-weight generation of kids. It comes from educating our teachers and school administrators because they play such a critical role in forming school policies and childhood education programs. It comes from engaging and educating parents who can serve as better role models and encourage healthier eating among kids. And it comes from educating legislators and political leaders who need guidance and direction about how to attack the problem most effectively.