January 28, 2005

Clinic devoted to child obesity offers new treatment options

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Greg Plemmons, M.D., director of the new obesity clinic at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, examines 15-year-old Sarah Howard during her first visit to the clinic.
photo by Anne Rayner

Clinic devoted to child obesity offers new treatment options

A pediatrician at the Monroe Carell Jr. Children's Hospital at Vanderbilt has opened a clinic to help families tackle the problem of childhood obesity. Greg Plemmons, M.D., assistant professor of Pediatrics, opened the clinic in December 2004 and immediately had eight referrals.

Calley Stroud was one of the first parents to come to Plemmons' clinic. Her 9-year-old daughter, Catie, weighed 163 pounds just before the holidays.

“She was a nine-pound baby,” Stroud said. “I was overweight at pregnancy. She's been overweight her whole life.”

Stroud said she, herself, had recently undergone weight loss surgery.

“Catie’s doctor says she will be tall when she grows up, so if we can just keep her weight the same until she's an adult, she should be fine.”

Catie is a fourth grader at Black Fox Elementary in Murfreesboro, where other children have begun to give her a hard time.

“I came to the clinic because I was looking for emotional and medical support. Catie is seeing a counselor to help her self-esteem. Kids are really hard on her,” Stroud said.

Plemmons says he didn't start this clinic because of any particular interest in obesity, even though he overcame the problem himself as a child. He says it was a simple matter of seeing a need.

“Several of our pediatricians, including Paul Hain and Veronica Gunn, had been seeing these kids in our consultation clinic. Basically that's where community pediatricians refer parents for a second opinion to find out why a child might be overweight.” Plemmons said. “Our endocrinology clinic was also being inundated because most families think it's a thyroid problem, but 99 percent of the time it's not.”

Plemmons said parents were frustrated and didn't know where to begin to help their children.

“I watched her getting stretch marks,” said Stroud. “She's in love with food. When she gets things she likes, she eats as fast as she can, she asks for her sister's food and even occasionally sneaks food.”

Plemmons begins by giving parents the basics of why treatment for childhood obesity is different from treating obesity in adults. Older teens will continue to be seen in the Adolescent Medicine Eating Disorders Program.

“Adults try rapid weight loss programs or even surgery, but we don't generally recommend either of those things for children because the science is not in to prove it's safe,” Plemmons said. “Our goal is to catch the weight problem early and stabilize it as they grow into their size, or if a child is truly obese, help them lose weight slowly while creating better habits that will last.”

Body Mass Index, or BMI, is the common measure doctors use to track obesity. A BMI of 25 to 30 in adults is considered overweight, over 30 is obese.

“But children are not adults,” Plemmons said. “Specific charts have been developed by the CDC to determine appropriate BMIs for each age. Generally, if a child's BMI is above 85 percent of other children their age, they are considered overweight. If they have a greater BMI than 90 percent of children their age, they are considered obese.”

Sarah Howard is experiencing physical symptoms that could be helped by weight loss. Sarah is a ninth grader at Jo Byrns School in Robertson County. She is a percussionist in the band.

“She has polycystic ovary syndrome,” said her mother, Debra Howard.

Sarah is already taking a drug, metformin, that has some benefit for the disease as well as obesity, but it is not a “magic pill.” Working with Sarah on diet and long-term lifestyle changes will be harder, but just as important.

Debra Howard said she needs practical, simple advice she can use daily to make gradual changes. Plemmons says parents today are bewildered and are sometimes even in denial because they live in a world designed for convenience that subtly stacks the deck against these children.

The obesity epidemic has now reached early childhood.

A recent report by the American Heart Association states that 10 percent of children ages 2 to 5 are overweight, up from 7 percent in 1994. “Some toddlers are consuming incredible amounts of juices and milk,” Plemmons said.

“For instance, on-the-go sippy cups are now the norm. Thirty years ago, when bottles were made of glass, parents never let kids walk around and drink out of them. We've seen 2-year-olds take in 60 or 70 ounces a day, just carrying those around.”

Activity habits have also changed, Plemmons says, “No one walks to school anymore, and almost 85 percent of children now have TVs or computers in their bedroom.”

As kids enter school, Plemmons says, it becomes increasingly important to encourage physical education, helping a child develop a love of activity through sports, dance, or some other type of sustained aerobic activity.

“There are also cultural differences,” said Plemmons. “Weight is not viewed as negatively in some cultures as others. So far we've seen all cultures and all age groups. Each brings a separate set of challenges to the clinic”

Catie has been seen in the clinic twice. She and her mother first met with registered dietician Andrea Klint, who recommended some changes to her diet, then Plemmons talked with the family in a style he calls “motivational interviewing.”

“I try to help the families come up with their own plan,” Plemmons explains. “If they make the choices, they are more likely to follow through. Most parents and children are already aware of the health risks, and don't want to be lectured. We encourage the family to come up with simple goals. We really encourage family time activity, like a hike together, indoor swimming, or even something as simple as a trip to the mall, we suggest they park at the end of the parking lot and walk the full distance of the mall.”

Plemmons says he hopes soon he can add a psychological component to the clinic. He says a large number of the children are plagued with poor self-esteem and there may be underlying factors that lead to obesity that need to be addressed.

He is about to add the services of a physical therapist who will help out with assessing the children's condition and building an exercise prescription.

Plemmons says insurance is doing a better job of covering the services offered in the clinic.

He says he realizes he has an uphill battle. About 30 percent of families who come to childhood obesity clinics never return, while the rate of success in the best programs that address childhood obesity is about 30 percent.

Catie is in that last 30 percent. She has lost four pounds since December.