Extended Interview with
Daniel Delgado, MD, FAAP
Childhood obesity is the number one public health problem in our country. You always hear about it in the news, about the rates that kids are getting bigger and bigger. What I don’t think people realize is really the extent at which it’s affecting the quality of life for kids. Kids are coming in with co-morbidities that we only used to see in adults. They’re coming in with self-obstructive sleep habits. They’re coming in with high blood pressure, coming in with fatty liver. Our diabetes rates have sky rocketed, I see kids, fifteen, ten - actually five, years of age is the youngest type-two diabetic that we have in our clinic. It’s not just the numbers of obese kids, but really what it’s doing to their quality of life and what it’s doing to their life expectancy. And the general consensus is that this is the first generation that will live fewer years than their parents.
The general prevalence numbers for Santa Clara County: With our patient population one of the proxies that we use is the CHDP data, generally low income kids, using numbers that are collected every year. If we look at body mass index, the amount of kids that are overweight under age five is around fifteen percent. And then if we talk about kids that are obese it’s another fifteen percent, we’re looking around thirty percent are in the overweight obese category in Santa Clara county (we’re talking about the CHDP kids).
So adults: sixty percept of adults in the United States are overweight, and if we are looking at prevalence numbers, the numbers are actually getting worse and worse and we know that there are particular regions that are very affected. In the South, for instance, numbers have taken off, and we’re looking at obesity numbers - not overweight , obesity - numbers that are pushing in the thirty percents. And those are actually categories that didn’t exist, the CDC tracks this data and you can go to CDC website and you can click on the slide show and it will actually show you the amount, or the increasing percentage of obesity in our population. It’s staggering.
I think one of the biggest “knock your socks off” numbers was a report that came out stating that a kid who is born in the US after the year 2000, their chance of developing diabetes over the course of their lifetime is one in three. And if they’re Latino, it’s one in two. I think those are very staggering numbers, and those are numbers that we use with our patients when we talk to them in regards to really educating them that it’s not so much about weight loss, but its more about helping disease prevention.
If the trends of obesity continue in this country we as a country are going to go broke. We’re already spending a huge amount of our gross domestic product on taking care of ourselves. And we haven’t even had this generation become adults yet. And when they become adults they’re going to develop diabetes at a younger age, they’re going to need dialysis, they’re going to need regular diabetes care, not to mention what’s going to happen with their vision. We’re talking about heart attack rates, we’re talking about fatty liver disease that could possibly progress to cirrhosis, and this is one of the things I think that we don’t really understand and we’re definitely not prepared for. There is a tsunami of obesity-related disease that is coming that we are in no way shape or form prepared for as a health care system to deal with, and my prediction is that we will come to a point where we are going to have to ration care, because dialysis centers as they currently exist are already working at capacity, and the wave hasn’t even hit yet.
In regard to people hyping it, I believe that people hyping weight loss are really hyping the wrong thing. If people are hyping disease prevention, and health maintenance, I think they they’re on the right message. I frequently struggle with trying to get elected officials and other people that are in charge of setting policy to really understand what is going on with my patient population. And maybe it’s me being oblivious because I’m just caught in this one little corner, but the statistics don’t bear that out. My colleagues around the country who I have had conversations with; they’re seeing the exact same things. And so I think there’s been a lot of hype about the prevalence of obesity; I don’t really think there’s a good understanding as to how potentially ill these kids are going to get, and how it’s affects their quality of life.
There are other causes of obesity, and the subsequent co-morbidities that go along with it, is [due to] lifestyle. It’s the Western lifestyle. And generally that can be broken down in two different categories. Number one, being very sedentary, and [two], an excessive intake of calories. Or you can think of it as a poor quality of calories.
If we take the first one as far as sedentary behaviors, the changes that we’ve seen just even in the last ten or fifteen years in how active kids are, it’s multifactorial - you know you had PE programs that have been cut, there’s less money for after school sports, after school programs. Testing is supposed to provide a way for the government to see which schools are improving and which schools are not. You have a lot of lower end schools that have a tremendous amount on the line to produce good test scores. What ends up happening is you cut PE and your after school programs; as soon as the kid is done at school they have to go to an after school program where they do more homework. One of the things that I’m fond of saying is that our kids don’t go to school anymore, our kids go to work. They have a coffee break in the morning, which they call recess, which maybe lasts ten or fifteen minutes, and then lunch time is spend waiting in line to get a school lunch and then very little time to actually go and play, because they’re not getting PE. And then when they go home, they’re not really going home, they’re just doing the afternoon shift. And then by that time it’s already dark and they can’t go outside and play. So there’s been a huge shift.
If we talk about excessive calories, if we look at the average size of a meal, if we look at the processed foods, the decrease in fruits are vegetables, these are things that when we look at our lifestyle and how busy we are, and how difficult it is to find the time to prepare a healthy meal, all of this comes into play.
One of the things that I’ve realized is that obesity is a disease of low income, hard working people. If you and your husband work different shifts and one’s working the morning and one’s working the swing shift in the evening, when do you have time to sit down and prepare a meal, who’s sitting down and taking that kid to the park, or doing home work, or making sure they’re going to bed on time? In this day and age, it’s in many ways much more difficult to raise a child because they’re competing with so many things that my parents didn’t have to complete with. Being concerned about security, where they’re going to play. The list goes on and on, but it really is a lifestyle that we’ve kind of thrust upon ourselves.
No, not all calories are the same, and we talk a lot with our patients in regards to eating in a healthier way. We find more often than not that there’s a lot of what we call ‘empty calories’ in kid’s intake: juice, sodas, the junk foods. We do not put any of our patients on a diet. In fact, we’ve fond of saying that ‘diet’ is a dirty four-letter work, and we actually don’t use it in our clinic. And we say that our kids don’t need to be skipping meals or doing these other things or eating just a particular type of things; no, kids just need to be educated and smarter about what are the more healthy foods for them to eat.
Amongst parents the most misunderstood thing about obesity is the struggle that is the individual to blame. Are you overweight because you just don’t have the willpower? I think that’s one of the things that is really misunderstood. And I think there’s space now for a little bit of compassion in regards to how difficult it is to raise a child in a healthy environment. How much energy investment that it actually takes to be able to do that. Parents need help in order to be able to work two jobs, to make enough money to put a roof over their head and all these other things. When the only food available to you in your immediate neighborhood is a variety of fast food that doesn’t have a lot of healthy options, it becomes very tough. So there’s a constant struggle between the individual’s responsibility and whether we have the responsibility as a society. And absolutely an individual needs to take responsibility for their actions. But I think that we as a society can be a little more compassionate and understanding about that.
I think we provide a message of hope, and we provide a message that the child is not ill, but they’re at risk, and again the message isn’t about weight loss; it’s about health maintenance and disease prevention. And so, once a patient is referred into our clinic from their primary care provider, the first visit that they have is a group orientation session, where they get to see that they’re not the only ones in the boat, and that there are a lot of others just like them that are struggling with the same exact issues. And we talk about how diabetes develops and what you can do to avoid it. We talk about certain foods that are diabetogenic, such as the sodas, the chips, the other fast foods, the Cheetos, these things, and then we talk about really what are the steps that you need to take in order to be able to make a lifestyle change. And it really doesn’t matter if it’s stopping smoking or changing your lifestyle, you still need to go though those stages of change, the pre-contemplation, the contemplation, making a plan, and taking an action, going through maintenance, and actually having a relapse or a lapse in that. We try to provide an environment for our patients that is non-judging, where the patient feels that we’re there to help, and we do our best to try to be supportive.
If we are talking about a consensus that patients need to make, there are certain things that we look at that all kids should be doing, it doesn’t matter if you’re overweight or not. Eating a certain number of fruits and vegetables every day and not drinking soda or juices, looking at how many hours they’re watching, how many hours of sleep are they getting, how many hours of active play are they getting. Some of those things we ask at every single visit when a patient comes in. There are other things that are very nuanced. So the relationship that child has with food… Does that child have food insecurity? What are the different issues, what are the different stressors going on at home? If you are looking at making a big change in lifestyle and grandma was one of the people that did most of the cooking…Well grandma’s now in the hospital because she got really sick. How is that going to fit in? Is that even a good time to even start doing these things? Dad just lost his job, which can be a tremendously disruptive thing; you’re all of a sudden not only worried about food, but shelter. We try to turn that around. Maybe Dad can go searching for a job in the morning but you know what? He actually does have a little bit of time where maybe he can go in the park and play in the afternoon, and then we jump-start that. There’s a lot of nuanced things that we do that makes it really hard to have a one size fits all, but there are definitely some things that all of us could be doing that are helpful.
Their mouths drop when they see how much sugar is in a can of soda. Or how much fat is in a bag of Cheetos or chips. At our orientation session, we have our nutritionist put out models in regards to the sugar and fat content of these particular foods. And the kids are welcome to come up and play with them after the presentation, and they are surprised every single time. And that’s a very powerful thing because when they come in for subsequent visits, they remember that, and that sticks. And so that’s really the greatest thing is people really don’t have an idea in regards to what they’re eating.
Awareness only takes you so far. You can be aware that you shouldn’t do something, but if you don’t really have any other recourse, if you don’t have the infrastructure and support built around it, then it breaks down. Awareness is a key issue for people to be educated and we do our best to try to not just tell our patients they’re at risk of developing diabetes, we explain what diabetes is, how you actually get there, and what are the different things you can do to try to avoid it, and we try to give very specific examples.
Many of our patients that come into our clinic, the parents are very taken by surprise that their kid is not only at risk of developing diabetes but is already on their way to develop diabetes. They may have know that grandma developed diabetes and that means that I’m at a risk of developing diabetes which means that my child is at a risk for developing diabetes. What they don’t understand is that their kids may already be walking that walk. And so when they get sent in from their primary care provider, their primary care provider tells them that, ‘I’m sending you to this clinic because I’m concerned about your child’s risk.’ When they come in we actually examine their real risk assessment and they are fairly shocked to see that, ‘Oh my gosh my seven year old is kind of where my mom was when she was forty five and developed diabetes when she was sixty.’ That’s a very, very powerful message and that is for many parents kind of the motivator to be able to finally say, ‘Okay we need to as a family pull together and decide what we are going to do about this.’
What is the answer? If I knew what the absolute answer was I would probably be working at the White House or the House of Human Services. So what is the answer? The problem is multi-factorial, and the answer is also multi-factorial.
Most people that watch this, many people will think that it’s really up to the individual. So let’s address that first. Absolutely individuals need to take a certain amount of responsibility, but like I mentioned before, there needs to be a greater understanding that it is very difficult when you are a low income, hard working family to be able to organize and provide this type of healthy lifestyle.
The different things, the infrastructure: Let’s start with schools. Schools, I would say, mandatory PE every single day. After school programs, there should be a mandatory playtime before they do homework, because studies have shown that kids who are physically active actually do better on test scores. Oh and by the way, running and playing around like crazy on the blacktop actually helps avoid the development of diabetes. School lunch programs: School lunch programs need to be reassessed. I personally believe that we should relook at what we consider as an appropriate guideline. Instead of having meals that are being shipped in, being able to actually prepare meals. Setting an example in regards to what is appropriate eating and having a curriculum built around that. There are programs that we have here in Santa Clara County, Fit-For-Learning, where we actually have consistent food and health messages built into the curriculum.
If we’re talking about infrastructure in a greater sense, we’re talking about community parks, walking trails, these other things. Appropriate funding for programs that are based on prevention. Having a place where a pediatrician can send you where you can have a little bit more time to really sift out these details, also very important.
So what is the answer for parents? The answer for parents is that it’s really hard, and that it’s harder than it’s ever been. Despite that, you can make certain small changes that will make the world of difference in your child’s life. Taking ten minutes in the morning and just having breakfast with your child, is a life changer. Doing the same thing in the evening is also tremendously important. Taking, even if its fifteen minutes to go outside and run around and have fun with your child is very important. Understanding that you can set limits without actually having your child feel really limited is also very important. Having appropriate limits does not mean being a dictator, nobody enjoys that. No parent enjoys that. And it’s easy for somebody like me to sit here and talk about this. To execute that is very difficult. Just understanding that as a parent, as long as you’re trying, that’s really anything anybody can ask of you. Nobody is the perfect parent, and we shouldn’t expect that, but there are things that all of us could be doing to make a healthier society.
In regards to how much a family can change their lifestyle, I’m constantly amazed at the work that our parents and our patients are doing. And let’s be clear about it, this is work. It is very hard work. And we all know how difficult it is to stop smoking. But yet we think that changing our lifestyle is something you should just be doing. If we viewed them both as the same, the average amount of times a smoker needs to seriously attempt to stop smoking is seven. When we’re talking about a family who has to change their lifestyle, they not only have to learn how to eat in a healthy way, but you also have to change that whole dynamic about being active. I tell my patients, I could lock you up in a room for a week, and you know, you don’t need cigarettes to live, but you need to eat in order to live. And it’s very hard when you’re used to sitting on the sofa to get up and get out. With that said, I’m amazed when parents start off with just a few little steps, and create that guidance, and the thing that’s really impressive to me is when I have the mom that brings in her three year old, and I ask her if the child is drinking soda and the mom turns to me and she says, ‘No she won’t let us drink soda, because when we go to the store she says, ‘Mommy you know the doctor says you shouldn’t buy that.’ So it really does work both ways, and we’re very surprised. It’s not really something that we measure in our clinic, but we definitely see parents that their health is improving because their child works as the role model. So it’s a very fulfilling thing.
This is really important because if we’re talking about kids of different age groups, and how the approach varies, it does vary a lot because what you do for a child between the ages of two and six and a child that’s between ages seven and twelve, and a teenager, it’s markedly different, and we actually have different patient groups that we deal with.
If you take the younger ones, the two, three, four, five and six year olds, that’s a child that’s primarily under the influence of their parents. Hopefully we’re not having a child that’s walking down to the corner liquor store buying a soda and a bag of chips, so the changes that the parents make, as long as they are making appropriate changes without the child feeling over restricted, those patients do tremendously well. And that’s the group that I love to see because I feel that we can really make a long-term impact.
The group that does next best is teenagers. Because teenagers can be very concrete when they find a particular cause that they’re excited about, we’ve heard teenagers coming in saying, ‘Yeah, my mom still buys soda, but I’m not going to drink her drink.’ I mean how many times have you heard that in terms of ‘I’m not going to listen to their music ‘or what have you, and so teenagers have a certain sense of self, or individuality, that ‘I’m going to do this for me.’ And adolescents tend to be a little bit narcissistic to begin with, and so we can actually use that to their advantage.
The group that I struggle with a lot is the kid who is seven to twelve, and those kids are being bombarded with messages. Commercials after school and Saturday morning, at school, on the playground, having their friends bring unhelpful foods. Even though the child might have had their parents improve the environment at home, parents can’t be following the kid 24/7, and that’s where it becomes very difficult because for that eight year old, it’s a very tough thing to have a sense of self to be able to say, ‘Wow that bag of chips looks really great, but I know I shouldn’t be eating that.’ It’s very difficult. And again we try to balance those messages and we don’t tell our kids that they can’t ever eat potato chips. Yeah, that’s a sometimes food, so they can have it sometimes. But to be able to have them moderate that is very difficult.
In regards to kids and self regulation there are a variety of different theories that are out there. When we’re talking about patients that are obese, and are already having, by definition, disordered eating, you already started out behind the eight ball. You have to somewhat unwind all of these habits. And I view feeding as a continuum. There’s healthy eating habits, and the unhealthy eating habits, and how do you foster those. I think that we ask parents to do something that’s very difficult, in that you set appropriate limits without the child feeling limited. When we’re talking about a child’s innate ability to moderate their caloric intake, when they’re coming in and they’re eight years old, and they sit down and they eat an entire pizza by themselves, that’s a child that has absolutely lost that. And they’re already suffering from destructive sleep apnea, fatty liver, and their sugars are already borderline, we don’t necessarily have the luxury of seeing if they’re going to moderate after a while. And we just haven’t seen that. We’ve tried that, and it’s failed miserably with our patients. So there are a variety of different opinions out there on what to do. I’ve seen her model work. It’s not something that has been rigorously studied. But that’s somewhere where everything’s very nuanced. Each kid’s different.
There is no cure for obesity, unless you’re talking about bariatric surgery, and that’s very clearly been the only thing that’s been proven as an intervention to work long term. So we don’t focus in our clinic on weight loss, we focus on disease prevention. And we have seen, in our kids who begin to play more, eat more in a healthy way, that their blood sugars normalize, that their fatty liver improves, they’re no longer snoring, they’re doing better in school, their self esteem is improving, their waist size is smaller, their body mass index is maybe the same or has dropped a bit. So we have some patients who maybe haven’t lost very much weight at all, but they’re a lot healthier. And that’s the difficult thing of this business of obesity because what do you define as a success? If I have a kid who was pre-diabetic, and it is now no longer diabetic, but is still obese, I would consider that a success, because that kid has actually bought themselves years of a high quality of life and has probably tacked on a few years as well.
Early intervention is the most important thing. Because once somebody starts down that track of being obese, and any adult who has tried to lose weight before understands this. Once that thermostat is set at a particular weight, your body does everything possible to try and stay at that weight. So when we’re talking about preventing disease, preventing obesity, it very important to start early on, so you don’t have to dig yourself out of this hole.
So the portion distortion, we’re talking about what is an appropriate portion for a child of a particular age. This is something like the Holy Grail, because it’s different for every kid.
What I can talk about is parenting styles. If we have parents that are very laissez-faire, as far as their parenting style and we have parents who set appropriate limits around food for their kids and then we have parents who are very authoritarian, dictatorial. If we look at those three parenting styles, the kids who are actually most at risk for developing obesity are these kids whose parents are really strictly hawkish about their food portions and what have you. And when kids are feeling overly regulated, overly controlled, the natural thing for a kid to do is rebel. And so when they’re not within their parent’s eyes, they’re sneaking food, binge eating. It creates food insecurity, and the parents who actually are laissez faire, and say, ‘do whatever you want,’ those kids don’t do as badly as the kids whose parents are really trying to control them a lot.
We really are asking parents to do a difficult thing, setting appropriate limits without your child feeling limited, and we have so very good parents in our clinic that really are trying things and saying things that are sending messages that are very appropriate. But if you happen to have a child who has a personality that is very sensitive, you have no control over how they are going to interpret that. So even though you might be doing everything that you thought was appropriate and by textbook was appropriate, the child may not be responding in a particular way.
So we have to rework it. And everyone who’s a parent has got a story – well it worked for kid number one but not for kid number two. And that’s the difficult thing. As far as portion control, we divide responsibility. Parents are responsible for the what, the when, the where, and this is based on Ellyn Satter’s division of responsibility, but a little bit of a different take, admittedly. The parent is responsible for the what, the when, the where, and the kid is responsible for if they’re hungry, and if they are hungry, how much? And getting parents to be open about the ‘how much,’ is the difficult part.
If we’re talking about inflation of portion sizes, you just have to go out to eat, and you’ll see it. And the one thing people take away from this: when you go out to a restaurant just split a portion with somebody. Or ask for a lunch-sized portion. Nobody really needs to have a huge bag to carry away the food. And we’re very much into value and what have you. But instead [we need to] value, health… you’re actually paying somebody to put extra calories in. It’s very paradoxical, because then we pay someone to train us out if it. Portion sizes for adults in restaurants are very inflated, and I’m sad to report that even the kids’ menus often times are really inappropriate with how many calories are actually on that plate.
Some of the things that the parents do with the best of intentions that backfire is really forcing their kid to eat something in particular, really trying to be controlling. You know, ‘You’re not going to get up from that table unless you’ve cleaned off your plate.’ Those sort of messages over time really come back to bite you. And I see it in the clinic because I see the seventeen year old patient who is doing the family interview, and the seventeen year old patient will break down crying and scream at mom and say, “You never let me...eat, you always tried to …” So that’s not to say that was a bad mom, she was trying what she thought was appropriate, but in the end that’s something that backfired.
I think the biggest mistake that parents make is thinking that having a healthy life style is going to be easy. It is a lot of work. The amount of organization and time and energy it takes is brutal, especially considering everything is stacked up against them in regards to the infrastructure and the messages that the kids are being bombarded with. How that works in our clinic, is we actually gauge motivation. And we ask the parents, okay, look, you’re now going to work forty hours a week, you’re going to night school, you don’t have time to cook any meals, what do you think is doable? Because I could tell you that you need to take junior out and play for three hours every afternoon and you need to provide breakfast, lunch, and you need to pack his lunch for school, because school lunch isn’t so healthy, and you need to provide this healthy delicious meal, and so on and so forth. And I might as well be asking them to go out and win an Olympic gold medal, because it’s just not going to happen. It’s just really impossible for them. So what we ask is what do you think is doable? So you go to McDonald’s five days a week because that’s just what you have to do because you’re going back and forth from work and school. Maybe you pick something on the menu that’s a little bit healthier, maybe you only go three times a week, maybe on the weekends, in that small period of time you have in the morning, instead of going to the flea market you can maybe go for a hike. Those are the little things.
If we’re talking about how important the little changes are, the famous saying is, it’s greater than the sum of its parts. I’m still impressed by how little things make the world of difference. Walking home from school, just taking that extra time to ride the bike, having the kid eat breakfast instead of skipping it, maybe packing a lunch, these little things, when you add them up, make the difference. And we see it because the patients and the parents pick three changes this visit, three changes the next visit, three changes the next visit, and what we see is the body mass index rising, then leveling off, then going down. And it’s that cumulative effect that makes all the difference. And that’s what’s so hard, because you’re constantly juggling. Okay so finally I got a healthy meal on the table, but we weren’t able to go to the park, we weren’t able to do these other things. So it’s a constant struggle, but that message that the little things matter is absolutely important for parents to grasp.
I actually wish I could have people shadow us in clinic and shadow my nutritionists and myself to actually see the toll it takes on these kids. Sit down and review the lab tests with the families and understand really how ill some of these kids are, how personally affected they are, how much it’s going to cost our society in the future, how difficult it is to invoke this change, how much time it takes to sit down and actually talk about it. People constantly complain, well I saw my doctor and we only had five minutes. Well it’s not because the doctor doesn’t necessarily want to talk to you, it’s just that there are a lot of other things that have to be covered. And my primary care colleagues have to talk about school preparedness, maybe your kid’s asthma, shots, these other things, and so where’s life style fit in here? And that’s an entirely different conversation, it takes an honest, frank discussion, and even we feel rushed.
One of our programs in our clinic is called the Turning Wheels for Kids program. Turning Wheels for Kids is a non-profit that was started by two nurses at Santa Clara Valley medical center who were avid cyclists who decided, you know what, kids should have bikes. And the first year they got forty that they gave away, the next year it was four hundred, and now the program is giving away thousands of bikes a year. And we’ve partnered with them; they’ve been tremendously generous to our clinic and to our patients. We’ve partnered with them to the point where they will actually find a new bike and provide a lock and a helmet for our patients. So if we have a patient whose parents can’t afford a bike, don’t have a bike, and would ride it if they had a place to ride it, we go ahead and give the bike to the child. And almost every kid loves riding a bike, and so it’s kind of a no-brainer. We have kids who aren’t physically active, and we’re putting them onto something that they’re going to love, and it’s going to be healthy for them.