Is Your Kid Too Fat?

Two Bergen County pediatricians discuss how they deal with childhood obesity - even as society's influence makes it tough.

 

If you’re the parent of a child who is too heavy, you’re torn between two selves. “My child must shed those extra pounds to protect future health!” one says, while the other counters: “Don’t let anyone shame or stigmatize my child, whatever his or her body type!”

Nobody says it’s a slam-dunk, pleasing both consciences at once. According to the Centers for Disease Control and Prevention (CDC), in 2017–2020 obesity affected 19.7 percent of America’s kids, more than three times its prevalence in the 1970s. While the rate of increase had been slowing, then came the pandemic, bringing greater social isolation and, research shows, reduced physical activity. And childhood obesity threatens to trigger Type II diabetes, high blood pressure and high cholesterol, all of which heighten the future danger of heart attack and stroke.

The issue sparks controversy. This January, when the American Academy of Pediatrics (AAP) released tough new guidelines for treating childhood obesity, newsletter author Virginia Sole-Smith complained in The New York Times about the guidelines’ focus on weight loss. She claimed that it risks teaching kids that “the bullies are right—that a fat body is just a problem to solve.”

What’s a parent to do? Pediatricians try to help, but they don’t pretend the problem’s easy—not in a media world that promotes an unrealistic supermodel-thin ideal on one hand and a parade of tempting fast foods and salt- and sugar-laden snacks on the other. “You can’t come down too hard on a child— you don’t want to shame them,” says Robert Jawetz, M.D., of Tenafly Pediatrics. “But you can’t ignore the problem because it does have long-term health consequences. Finding that middle road is admittedly very difficult—I can imagine how difficult it can be for a parent.”

Reversing a pattern of overweight in a child or adolescent takes a family commitment, says Janet Lazieh, M.D., of Holy Name Pediatrics in Teaneck. It often requires new family shopping habits and a disciplined effort by the child. But Dr. Lazieh insists: “It is doable.”

The two doctors joined BERGEN in a Zoom conversation.

BERGEN: What’s your philosophy for treating a child who’s obese or at risk for obesity?
DR. LAZIEH: It’s a major problem, and we’ve been seeing increased prevalence. It’s really the family—I can’t blame the kid. We ask the child: “Do you really want to do something about your weight?” We really need to be on the same page. It’s not a punishment. Then I bring the parents into the conversation, because they’re the ones who do the grocery shopping.

DR. JAWETZ: There has to be buy-in from the entire family. Usually Mom and Dad will both be on board. Although if parents live in different households, there can be differences in what the child is eating. Also generational differences, where the parents work during the day and a grandparent insists that the child eat a full meal on coming home, then he eats a second dinner later on when the parents are home.

BERGEN: You’ve both stressed the parents’ role. What happens when a parent is doing more harm than good?
DR. LAZIEH: Sometimes a parent will approach me or the medical assistant and request that I not mention weight loss to the patient because they “will really melt down.” We approach it smoothly by asking: “What do you think about your weight?” But if I’ve known the patient long enough, sometimes I have to be frank and say, “We have a problem. And we really have to do something about it.”

DR. JAWETZ: I’ve had the same experience, being firmly instructed before I even walk into the exam room, “Do not mention what the scale said.” I will honor that request. But at the very least I’ll say, “Your weight is not appropriate for your height, and that’s something we need to work on.” Obviously there are varying degrees of severity. If the parent doesn’t want to talk about it and the child is in the category the AAP terms “overweight,” with a body mass index (BMI) between the 85th and 95th percentiles, I’m not necessarily going to pursue that aggressively. But when the BMI is above the 95th percentile, the child is at risk for significant health problems—Type II diabetes, significant cardiovascular disease later on. So I feel I have to say something. The new AAP guidelines stress the need, every two years, to check labs on children in the obese category, to check their lipid profile, to check their liver profiles to make sure they’re not developing what’s called nonalcoholic fatty liver disease, and to check their hemoglobin A1C to watch for Type II diabetes.

DR. LAZIEH: With divorced parents, it can be a blaming game, with the kid caught in the middle. Sometimes I put both parents on a FaceTime and say: “Listen, we have to make a plan.”

BERGEN: Dr. Jawetz, do you use that tactic—both parents on FaceTime?
DR. JAWETZ: Sometimes, when I need to discuss something that affects both. Or I’ll get one parent on the phone if they can’t be in the room at the same time. Because when you have two separate conversations, it takes double the time and you get accusations back and forth or things start to get lost in translation.

DR. LAZIEH: Sometimes a child will ask, “What should my weight be?” It can be overwhelming or scary to discuss weight-loss goals of up to 50 pounds. Instead, I try to focus conversations on SMART goals— specific, measurable, achievable, realistic, timely. I may say, “Let’s make a deal. Five pounds in the next two months.” If that’s not achievable, I’ll do blood work, and sometimes I show them signs of change on their body. There’s something called acanthosis nigricans, where dark skin on the neck is a sign of metabolic syndrome. I tell them, “This is your body telling you you have insulin resistance and may develop diabetes.”

BERGEN: Tell me about a child who won the battle against obesity.
DR. JAWETZ: I had a long talk with one teen about his weight being mismatched for his height and how this was unhealthy. He and his mom asked what they could do to improve his health, so we did a deep dive into what he had been eating to discuss what needed to be changed, and we brainstormed about what forms of exercise he might like. When I walked into the exam room to see the young man the next year he had a big smile on his face and said, “Doc, are you proud of me?” He had managed to lose 20 pounds while growing 2 inches. I told him I was indeed proud of him, and I was. He has continued to maintain a healthy weight.

DR. LAZIEH: Those who were intentional about losing weight engaged in sports, adopted regular exercise schedules and limited their diets. Most used calorie- and portion-restricted diets and some went as far as using programs like Weight Watchers.

BERGEN: The op-ed piece in The Times implied a range of opinion: extreme vigilance against the slightest excess in BMI on one end, resolute rejection of “fat-shaming” on the other. Where should parents be on this continuum?
DR. JAWETZ: I think the author misinterpreted what the AAP guidelines are saying. They’re not trying to shame anyone for how they look, or recommending an automatic jump to medicalizing the treatment of obesity. They’re saying we need to make an increased effort to work with families to help these children lose weight—primarily through intensive lifestyle management and intervention. Unfortunately, in the medical system as it exists, it’s very hard to do that because functionally what they’re recommending as intensive lifestyle modification would require 26 visits over a year, which in a general pediatrics practice is virtually impossible, both for the physician and for the family—and probably wouldn’t be covered by insurance. Some plans do cover a nutritionist, and there may be a chance to work with a nutritionist and a personal trainer. But that assumes a family has the resources to do this, because it’s expensive. For families who don’t have the resources, that kind of lifestyle modification is unfortunately very difficult.

BERGEN: Do you have patients who have been bullied and “fat-shamed” by peers?
DR. LAZIEH: Absolutely. We see anxiety levels increasing, and there can be a lot of embarrassment tied to body image. This is true for both boys and girls. Unfortunately, we sometimes also encounter resistance to lifestyle changes. “I tried all that,” they’ll say. “It’s not working. I’m not going to bother.” But the motivation really has to come from the child. If they are not convinced to change their habits, there is little benefit to lecturing.

DR. JAWETZ: To go back to BMI, my attitude has evolved over time. When I started in practice I went more by “the letter of the law.” I was more apt to bring it up with a child who had a BMI over, say, the 85th percentile, the AAP’s boundary of “normal.” But as I’ve gained more experience as a pediatrician and read more studies, it has become obvious to me that the BMI is nowhere near a perfect tool.

BERGEN: Bariatric weight-loss surgery is described as an option, but it seems an extreme remedy for kids.
DR. LAZIEH: They’re saying it can start at age 13, and I respect the AAP guideline. But honestly, I feel that we should really push for the conventional way before discussing surgery and drastic, irreversible changes. At 13, children are still growing.

DR. JAWETZ: I don’t think I’ve ever had a patient who’s actually had bariatric surgery. I think it should be a last option when everything else has failed. If a parent and child were interested, would I discuss it and refer them to a place that did it? Absolutely— especially because all the expert organizations seem to endorse it. But I wouldn’t push it.

BERGEN: They say it’s no substitute for a changed lifestyle, because you have to do that anyway.
DR. JAWETZ: Correct.

DR. LAZIEH: Exactly. Patients post-bariatric surgery still need to follow balanced diets.

BERGEN: It sounds like you’re both in about the same place there, philosophically. How about medications?
DR. JAWETZ: There’s been a lot of publicity about Ozempic and Wegovy, recently approved for children as young as 12. And some of the older medications are probably underused. Unfortunately, the newer medications are expensive and often not covered by insurance, which again leaves you in the same situation of, what do you do?

DR. LAZIEH: We also have access to Osymia and other oral medications, which I haven’t prescribed yet. I do sometimes send a child to a pediatric endocrinologist, who may prescribe the diabetes medication metformin.

BERGEN: They say the family sit-down dinner is in decline, and kids often make up the nutritional difference with fast food and snacks.
DR. LAZIEH: Yes. Besides educating families, we need to aim our efforts at the food industry. Even taking a stroll around the mall with your child you will be bombarded with several fast-food options, some with a zillion calories. It’s really not easy.

BERGEN: Isn’t it true that genetics helps determine which kids are heavier than others, and that a genetically heavier-than-average body type isn’t necessarily unhealthy?
DR. LAZIEH: Yes. Bone structure, muscle structure and fat distribution throughout the body can vary based on each individual’s genetic makeup. But we still need to pay attention to children’s eating habits and make sure we keep the percentage of body fat within an acceptable range for their body type.

DR. JAWETZ: If the child is stocky like the parents and has a weight on the high end of normal, or perhaps even falls into the “at risk for overweight” range, I probably won’t be too concerned—assuming he or she has a healthy diet and lifestyle with lots of physical activity.

BERGEN: Speaking of activity, we hear that kids are less active today, sitting in front of screens instead of playing in the neighborhood, and that COVID made it worse.
DR. JAWETZ: No question, exercise is an issue. We need to find ways to get moving, even if it’s just going for a walk after dinner. But exercise is a smaller component of the problem. More important is what and how kids eat. I think our food is, for the most part, unhealthy. There’s too much processed food. Those foods are designed to make us want to eat more. They’re easy to make and easy to prepare.

DR. LAZIEH: And cheap! As a parent myself, I know how hard it is to avoid high-calorie foods and snacking.

DR. JAWETZ: I tell parents, if it comes in a box or a bag it’s probably not super-healthy— except frozen steamed vegetables.

BERGEN: Any final thoughts?
DR. JAWETZ: Incremental change works. Kids don’t necessarily have to go out for the football team or swim 300 yards. Every little positive change is useful. But we can’t just throw our hands in the air and do nothing, because then the game’s already over.

DR. LAZIEH: I agree. We’re not going to give up. I have seen success with families who followed the right steps and didn’t give up.