With a sweet face and bright blue eyes, Brandon was a 10-year-old with a smile that would melt ice.
But at 5 feet 2 inches and 235 pounds, he was severely obese. His parents, Tammy and John, after more than a year of telling themselves that Brandon was just naturally heavy and that he would grow out of it as he matured, brought him to see me. I first saw him in my waiting room, where he sat forward in the bariatric chair, his eyes darting around the room examining every detail of our office. His mother later told me how grateful she was that we had a chair his size.
I introduced myself and brought Brandon and his parents down to my office, where we began to dive into his eating habits. Every morning, Brandon and his dad went to a local diner for breakfast. Brandon and his dad described their daily breakfast to me: fried-egg sandwiches with cheese and bacon, home fries, and sometimes sausages on the side. Dad would have a coffee or two (each with 4 creams) and Brandon – a large Coke. It was clear that this morning routine was important to Brandon: His eyes brightened as he talked about this daily outing with his dad.
For lunch at school, Brandon had the cafeteria food—pizza, hamburger, French fries, grilled cheese sandwiches. Many days, he would eat two lunches. After school, he ate potato chips, Fritos, bottles of soda and cereal with whole milk front of the computer. Dinner was huge plates of pasta or hot dogs or more pizza, with whole milk, and cookies and ice cream for dessert. He ate a lot, he told me, because he was hungry all the time. Dad said they tried to decrease his food intake, but they were concerned because he was a growing boy. “Besides,” mom added, “he gets so hungry sometimes that if we don’t give him another serving, he bursts into tears.” “I do not!” Brandon argued, with tears welling up as he spoke. Clearly, this was a very sensitive topic.
Brandon did get some exercise. He enjoyed riding his bike, and he played baseball which his dad helped coach. Dad did mention that Brandon was having increasing difficulty rounding the bases without getting out of breath. This caused Brandon’s eyes to well up again, and he quickly turned his head away from us. I explained that it was great that he was active, but we needed to work on his eating habits. Brandon’s weight was creating adult-size health problems, even though he was still so young.
Brandon had gained almost 25 pounds in the last year, despite growing only a half inch. At 235 pounds, he was well above the 99th percentile on the Body Mass Index BMI. This placed him into the severely obese category according to national charts (more about that in the next chapter).
Brandon has other worrisome physical symptoms of his obesity. Much of his weight was clustered around his abdomen. This is the bad fat, because abdominal fat tends to contribute to adult diseases, which Brandon was exhibiting. Although I hadn’t completed his physical yet, I could see a dark ring around his neck- a sign of insulin resistance. His blood work (carried from his Pediatrician’s office) showed that he had low levels of HDL, the “good cholesterol,” and high levels of LDL, the “bad cholesterol.” His total cholesterol count was more than 200, and his triglycerides (a way fat is carried in the blood stream) were twice normal. All of these findings put him at risk for many adult diseases, and were far too high for an 8-year-old child. His fasting insulin level (measured by drawing some blood after a twelve hour fast) was very high- confirming insulin resistance. A normal fasting insulin level in a healthy child should be less than 8 during non-growth stages. Brandon’s insulin was 38. That meant his body’s wasn’t able to use up insulin secreted by his pancreas as effectively as it should, and the extra insulin makes that child hungrier- almost five times hungrier in Brandon’s case than a non-obese child. What makes it worse is that extra insulin turns off fullness signals as well. This helped to explain Brandon’s appetite.
Brandon also had an elevated blood pressure. Children have different guidelines than adults. Brandon’s blood pressure of 124/84 put him in the 95% range for blood pressure for his height and age.
His waist and hip measurements, vital signs, and blood work led me to diagnose Brandon with “metabolic syndrome” – a cluster of conditions affected by excess fat. About half of the obese children I see have the condition. If left untreated, it can lead diabetes, and put children at increased risk for heart disease, stroke and a dramatically shortened life.
Laying out these results for Tammy and John, Brandon’s parents, was painful. They were a close-knit family, and they were very proud of their happy, bright son. But they knew something needed to be done about their son’s weight. Tammy teared up as we talked. Like a lot of parents of overweight children, she blamed herself for Brandon’s weight condition. John grimaced and stared at the ceiling. He and Brandon were close, and he loved their morning diner routines. Indeed, I’d concluded, much of John and Brandon’s bonding activities revolved around food, and we would have to figure out a way to help father and son find less fattening ways to connect and share time together.
One of the first actions I took was to start Brandon on Metformin, an oral medication that is used to treat Type 2 diabetes. Increasingly, doctors are using it with children who are insulin resistant but haven’t yet developed diabetes to prevent it. Basically, Metformin helps to move the insulin back into the cells where it belongs, moving it out of the bloodstream where it plays with hunger and fullness signals. This is such an important initial step for children- because it helps to control their hunger immediately.
Also, with his parents’ help, Brandon kept a food diary for several days. Afterward, my nutritionist went through it and calculated that he was eating more than 5,000 calories a day—far too high for his height and weight. She calculated his resting metabolic rate at 2,380 calories a day (more on that later) and determined that he should be eating significantly less. As you will see in my approach with children, I try to keep it simple for the kids, by focusing on what they are doing right, and eliminating what they are doing wrong. My team will teach our patients and their families about calories, fat and carbohydrates, but we never talk about them in terms of “numbers to reach”. I do emphasize protein, however, because despite their size, many of our children are starving inside due to a net lack of protein. I teach them how to read labels, so they know how certain ingredients are disguised by fancy names.
When a child has to lose weight, many physicians error on the side of caution and tell parents that the child shouldn’t lose more than one pound a week and that a growing child will eventually catch up to his weight. Some worry that if they lose weight too quickly, they will stop growing. In truth, growth is more affected by Vitamin D levels, and because it is a fat-soluble vitamin, most overweight and obese children are Vitamin D deficient. Without vitamin D, calcium cannot get into the bones and growth can be prematurely stunted. I believe, therefore, that the child will achieve better growth potential without the fat. And as long as calcium and Vitamin D are followed and replaced if needed, weight loss has never been shown to negatively impact growth if appropriate protein is on board. We decided that Brandon could easily aim at losing 2-3 pounds per week without negatively impacting his health.
Brandon and his family next met with our Behaviorist, Johanna, both alone and as a family. Her goals are to evaluate Brandon’s eating behaviors, and determine if there are any underlying emotional issues affecting his weight. She started by focusing on his meal patterns, and walked him and his family through a detailed questionnaire aimed at pinpointing any trouble spots. He was eating out a lot, which means it was difficult for him to control his portions and calories. He was only getting about two hours of exercise a week. There were no signs of an underlying eating disorder—he wasn’t trying to lose weight by making himself vomit, for example, or going on very restrictive diets. He did occasionally skip breakfast- especially if he was running late for the bus.
She also wanted to determine whether or not Brandon was engaged in the process, or dragged to our office by his parents. He answered right away when she asked him whether he wanted to lose weight. “Yeah,” he said, “before it gets out of control.” She asked him why he wanted to lose weight, and again he answered quickly. “I want to be able to run faster and play sports better,” he said. Brandon was confident he could do this, which boosted his chances for success. On a scale of 1 to 10 (1 being not confident at all and 10 being extremely confident), he rated his confidence that he could significantly change his eating and exercise habits as a 10. Also, in answer to her question, he told her he would definitely be able to find 30 minutes a day for weight control.
It may sound silly to ask an eight-year-old child these kinds of adult-oriented questions. But I’ve found that kids do best when we involved them thoroughly in this process, and they are very sophisticated thinkers. Often, kids face up to the fact they have a weight problem even before their parents do!
Brandon and John really enjoyed eating out together, but Johanna wondered if there weren’t other ways that father and son would enjoy spending time together. Brandon suggested that they go on walks together and eat breakfast at home instead of the diner. John gladly assented. He admitted that he needed the exercise, too, and wouldn’t mind eating at home. He and Brandon started walking twice a day.
Two weeks later, Brandon and my nutritionist, Jess, met for a session. Brandon’s hunger had abated now that he was taking Metformin, which was good news, and he wasn’t bugging his mom for more food as much. Mom revealed to Jess that there were no “food fights” as she called them, where Brandon would lose his cool because he couldn’t get what he wanted. In fact, she noticed that overall, he seemed to be eating a lot less.
Jess started working her magic. She explained to Brandon and his mom about portion control and healthy eating. She reviewed his food diary and started the elimination process, replacing his soda with water, and switched the constant munching out of the chip bags to specific snacks of cheese sticks and fruit, which he found surprisingly, that he enjoyed. She showed the family how to read nutrition labels, and had a long discussion on protein sources. She set up specific “treats” of 100 calorie desserts at night, and reviewed the diner menu so that Brandon could make healthy choices for breakfast. Jess gave Brandon a shopping list of healthy food substitutions, and Brandon became engaged in the grocery shopping process.
Over the next eight months, Brandon lost 55 pounds—an average of 1-2 pounds a week, and he grew one and a half inches. That moved him down into the 85 BMI percentile, a much more satisfactory level for him. Exciting for any physician treating an obese child is watching his body return to a healthy state by following the blood work. His insulin levels dropped down to 10, his blood pressure normalized to 105/68, and his cholesterol and Triglycerides dropped down to healthy levels again. His glucose dropped below 90 fasting, indicating that he was no longer a pre-Diabetic, and his risk of diabetes was the same as an average weight child. Brandon was now walking in the mornings and on weekends with his parents, and running the bases as fast as his teammates.
He did it! Brandon was so proud of himself—and rightly so. Because Tammy and John had let Brandon take the lead—picking out food, planning menus, making decisions about how to get more exercise—he had “ownership” over the process. Since the whole family was involved, Tammy and John lost weight as well, and their John was no longer a diabetic. The family vowed to never return to their old ways. And, two years later, they still look and feel great.