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PEDIATRIC PERSPECTIVE

Doctors can't do much to help kids weight

The adolescent Navajo boy had velvety black skin on the back of his neck, a condition, called acanthosis nigricans, that used to occur primarily in obese adults on the verge of developing diabetes. It is now common in children on the reservation near Gallup, N.M., where I worked with one of the most overweight populations in the country.

The 14-year-old boy tipped the scale at 200 pounds. After a physical, I counseled him about his diet, made him an appointment with a nutritionist, and outlined an exercise program to the boy and his mother.

When he returned to the clinic two months later, he got on the scale. Though he said he'd been following the new regimen, he'd gained another few pounds. His mother cried.

The sad truth was that despite our best medical efforts, we were no match for the forces promoting obesity. A pediatrician might help a little -- by counseling patients to watch under two hours of televi-

sion daily, limit soda and juice, eat more fruits and vegetables, etc. -- but if a child is already obese, a family is largely on its own. Like many pediatricians, I believe that a child's personal responsibility is crucial to weight loss, but I was frustrated by my own inability to offer more help.

Parental limit-setting is by far more effective, particularly at helping kids avoid getting fat in the first place. Children must be taught to eat appropriately because the skill isn't inborn.

Many nutritional advisers still promote the now discredited theory that kids know when they're hungry and when they're full. In fact, most have lost that ability by the time they reach kindergarten. For example, in one Pennsylvania State University study, 5-year-olds ate everything on a plate, regardless of portion size.

Studies also show that parents must introduce some healthy foods, like broccoli, many times before children learn to enjoy them. Teaching young children to eat healthily may prevent future obesity.

To be sure, some parents of healthy children go overboard and police every calorie, influenced by a culture that idealizes thinness. But many of the kids who need the eat-right-and-exercise message the most -- often from families who are poor or of color -- aren't getting it. Although 20 percent of all American adults and 15 percent of children are obese, rates are significantly higher among the poor and underserved.

What about children who are already overweight? Studies of obesity among the meticulously researched Arizona Pima Indians span 13 yards of shelf space in the National Institutes of Health library, but not a single one explains how to help them lose weight successfully. The American Academy of Pediatrics statement on obesity has, among others, sections about "Risk Factors" and "Advocacy," but conspicuously absent is any area titled "Treatment."

Though some programs might help some obese kids, these are limited, demanding, and often part of research protocols. There's simply no easy way to lose weight. Thus, people turn to fads. The latest are low-carb diets, which 11 percent of Americans currently follow. But last year the New England Journal of Medicine reported that, although 300-pound patients eating a low-carb diet vs. a low-calorie one lost 8 extra pounds after six months, the difference was gone by a year. That's not counting the 40 percent of people who dropped out of the study.

On the Navajo reservation, children from poor households -- like my patient -- frequently ate large portions of cheap fast food. My wife, a high school teacher, observed that the most common breakfast was Coke and Cheetos bought at school vending machines. In their oversized clothes, students generally opted out of physical education programs.

At the current rate of increase, Massachusetts' kids could catch up to the Navajo's 50 percent obesity levels by 2050. Legislatures, advertisers and schools need to step up to the plate.

In February, after lobbying from the American Heart Association, the US Senate approved $420 million for the Safe Routes to School program to promote walking and biking to school. In Massachusetts, Rep. Peter J. Koutoujian (D-Newton) is introducing House Bill 3519, a plan to improve school nutrition and physical education.

Although the American Academy of Pediatrics recommends banning soda dispensers in schools, many cafeterias -- even in wealthy suburbs -- have turned to vending machines or chain-branded food sales to balance food service budgets.

Many other options, like voluntarily limiting high-calorie food advertisements on television, better federal standards for portion sizes, and safer public playgrounds, await serious consideration.

Last week, the Kaiser Family Foundation delivered a blistering indictment of junk food marketing to children, citing items like SpongeBob Cheez-Its. Hopefully, publicly shaming the purveyors will discourage them. House Speaker Thomas M. Finneran's call for universal preschool could create opportunities to teach healthy habits from a young age.

And in their offices, pediatricians should consider treating severe obesity the same way they treat other behavioral disorders, such as anorexia, with comprehensive counseling and as-needed hospitalization for intensive treatment. Insurance reimbursement for obesity treatment should adequately cover the followup that may be needed.

My Navajo patient didn't lose weight over the two years I counseled him and, after moving to Boston, I lost touch with his family. Perhaps his children one day will live healthier than he did -- if legislators, health advocates, marketers, parents, and doctors partner to do the right thing.

Dr. Darshak Sanghavi is a clinical fellow at Children's Hospital and Harvard Medical School. His e-mail address is darshak.sanghavi@childrens.harvard.edu.

Copyright 2004 The New York Times Company