Home Blog The wolf at the door

The wolf at the door

July 2008

Finally, we are taking a long, hard look at the bloated elephant in the room: Kids are fat.

We knew that. All you have to do is go to your nearest playground–although actually, the kids out on the playground probably aren’t fat.

Go to the mall. Go to the video store, or the electronic game store or McDonald’s. There they are, ogling the latest Wii and PlayStation games, wondering if the secret password to level 15 is hidden in the latest issue of “Gaming for Teens” magazine.

Look at their fingers. Those calluses are not from working outside or throwing balls, but from hours spent sitting at home, staring at a TV screen, moving their hands across a game controller with the skills of a pianist or a telegrapher. Sitting, just sitting.

Obesity is a major health problem in this country. We knew that. We’ve seen the many studies showing that fast food and television viewing (among other factors) have contributed to the fattening of children in this country.

We are encouraging kids to move, to get off the couch and play. Even cartoons and kid shows try to promote physical activity–although ads that promote physical activity are followed by the latest ad for Happy Meals!.

But the problem continues. To make things worse, some of these kids will need cholesterol-lowering drugs to reduce their risk of future atherosclerotic cardiovascular heart disease.

In the July 2008 issue of Pediatrics, a report outlined recommendations for routine screening of children at risk of dyslipidemia and cardiovascular disease. The authors recommended drawing a fasting lipid profile in children older than age 2 but no later than age 10. For children age 8 and older with an LDL above a certain level, “pharmacological intervention should be considered.”

I can already see it now: pitches for statins on yogurt cartons; ads for “Zocor, now in bubble-gum flavor!” on Nickelodeon; “side effects may include bloating, tummy ache, boo-boos, and other unmentionable things that go bump in the night …”

Can we hire Little Red Riding Hood as spokesperson? That tale is all about obesity: the girl trying to fatten her grandmother with sweets; grandma in bed, probably with diabetic ulcers and post-MI weakness, waiting to sneak a treat before her next insulin dose; the wolf who just wants to eat everyone, without monitoring his cholesterol or his BMI.

The moral of the story? Food kills!

The article recommends screening every three to five years for children whose initial tests are within the normal range. It also recommends weight management as the “primary treatment” for obese or overweight kids who have high triglycerides or low HDL levels. So now we have to worry whether children have dyslipidemia, whether their LDL is elevated, whether they have metabolic syndrome. Aren’t all syndromes “metabolic” in some way?

In my first posted blog entry, I wrote that, “Children are not small adults … but sometimes they are.” Now, more accurately, we can say, “Children are not small adults, but sometimes we must treat them as such so they become healthy adults”.

As pediatric hospitalists, we need to take the lead in addressing this issue with our patients. Just as we have become efficient at discharge planning and at establishing care plans for illnesses like asthma, we must tackle the issue of obesity in the inpatient unit.

Our patients are a captive audience. (We can actually turn off the TV or the PlayStation without getting moans and groans.) We have the time, which primary care doctors may not have, to discuss diet and exercise. We can enable nurses and techs to begin the conversation on childhood obesity on admission and allow them to participate in the development of initiatives to educate patients and families on the risks of childhood obesity.

Most hospitals have nutritionists, physical therapists and/or child-life experts willing and able to help establish lifelong goals for children and family members, and start them on diet and exercise programs prior to discharge. Inpatient units should include nutritional assessment and intervention as part of intake and discharge. Let’s calculate the BMI of older children, preadolescents and teenagers. Let’s figure out their diet and recommend changes. Let’s take away the in-room entertainment (PSP be gone!) and encourage patients to walk around the unit, if they can).

And let’s meet with “The Cafeteria Committee”. Seriously, how can we begin the conversation on diet and exercise when we offer our patients “cheesy” scrambled eggs and bacon for breakfast, and burgers, chicken tenders and French fries for lunch? Hospital medicine can be preventive medicine … but only if we chose to push prevention.

Food for thought. (Sorry, I couldn’t help it.)