ILLUSTRATION BY NISHAN AKGULIAN
To illustrate the importance of dialogue about childhood obesity in America, Dr. Greg Plemmons, assistant professor of pediatrics, whips out a pen and paper to draw a bell curve. The axis and bell form the easily recognizable “normal distribution” graph that describes the weight of children: few on the “very light” side to the left, and few on the “very heavy” side to the right, with most children falling in the middle.
Then Plemmons pens an extension onto the right side of the bell to indicate an increasing proportion of the heaviest children.
“The curve that shows weight distribution in children has lengthened to include an increasing number of heavier children … but it’s more than that.”
Plemmons pauses before sketching a whole second bell further down the “x” axis. “The whole bell has actually shifted to the right.”
It’s easy to see why Plemmons, who is director of the Pediatric Weight Management Clinic at the Monroe Carell Jr. Children’s Hospital at Vanderbilt, uses this illustration. The second bell curve looks menacingly like an encroaching wave. It represents wholesale change in the average weight of American children—an alarming and historic shift.
The average size of an American child has changed so much during the past two decades that in 2000, the Centers for Disease Control (CDC) retooled growth charts to include body mass index so health providers could better track obesity in young children. Four years later scientists from the National Institutes of Health warned that, for the first time, life expectancy in the United States will begin to decline again as heavier children grow up to have health problems linked with obesity, like heart disease, diabetes and stroke.
In Tennessee it’s estimated that more than two-thirds of adults are overweight, and more than 30 percent of them are obese. An incredible 36.5 percent of children ages 10 to 17 are overweight or obese; in some counties, it’s more than 50 percent. A mere 18 percent of children across the state get enough fruits and vegetables in their daily diets.
Failing Grades in Fitness
The figures for fitness are even worse. In the United States the standard for assessing students’ cardiovascular and respiratory fitness in schools is the mile run. During the 2007–08 school year, none of the grade levels in Tennessee (from two through 12) reached the national standard of the 50th percentile. Nor did they achieve the goal of running and/or walking a mile in the equivalent time it took their national peers.
That encroaching wave illustration can seem more like a tidal wave from the front lines. The weight management clinic that Plemmons directs has a five-month waiting list. He is considering prioritizing children who are so obese they already have high blood pressure or other health problems.
Addressing childhood obesity is central to Vanderbilt’s institution-wide focus on children’s health, says Jonathan Gitlin, assistant vice chancellor for maternal and child health and chair of pediatrics at Vanderbilt. He quotes Nelson Mandela: “There can be no keener revelation of a society’s soul than the way it treats its children.”
Nationally, success rates for weight-loss programs are only about 20 percent. Even at Vanderbilt, where rates are higher, about half of families never come back for their second visit.
The difficult question facing today’s obesity experts is where to spend precious time and dollars. No one doubts large-scale change is desperately needed at the state and national level, but for those working at ground level, individual children and families are the ones who need help right now to avoid becoming part of the grim statistics.
Families like the Genesys.
Cassandra Genesy has been determined for a long time to get her 10-year-old son, Ian, a referral to Plemmons’ clinic. “Both his father and the pediatrician have told me not to worry, that he’ll grow out of it,” Cassandra says with a tinge of frustration. “But I know this is important. Diabetes and heart disease run on both sides of my family.”
Cassandra Genesy worries about Ian’s future. The fifth-grader at Madison Middle School has a bright smile and gets good grades, but he weighs 143 pounds, his blood pressure is elevated, and he has a body mass index of 30.6—classifying him as morbidly obese.
Plemmons says despite Ian’s numbers, it’s really Cassandra who is the patient here.
“We could manage most obesity just by working with the parents,” Plemmons says. “The kids are fun to see, but it is the parents who have the power to effect change.”
Cassandra and Ian came to the Pediatric Weight Management Clinic in January for an intensive two-hour appointment. They talked with registered dietician Amy Freedman, pediatrician Kyle Brothers, and physical therapist Amy Darrow.
Together they went over challenges and strengths, then signed an action plan for simple changes, like getting the whole family to stop drinking sugary sodas. Cassandra was encouraged to have a simple start and a plan. But the odds are not great that Ian’s weight will turn around.
Predicting who will succeed in losing weight and who will fail is impossible, says Plemmons. Even socioeconomic status doesn’t seem to matter all that much. All in all, weight-loss clinics have low rates of success, and this is not lost on insurance companies. Obesity is not, in general, defined as a medical condition, so most insurance won’t reimburse the services offered at the Weight Management Clinic.
Too Much, Too Little, Too Late
While he believes help for obese individuals will increase, Plemmons worries the help might come too late for kids like Ian. “So much more is needed. Policymakers are not thinking yet about long-term complications,” Plemmons says. “When we see a dramatic change in heart disease and diabetes in 20- and 30-year-olds in 2020—that will get attention.”
Joan Randall, assistant professor of medical education and administration, is the administrative director of the Vanderbilt Institute for Obesity and Metabolism. “Experts now believe that we cannot go one-on-one to solve the obesity problem,” she says. “We need to focus on population-based changes to create an environment that is more conducive to making healthy choices.”
Randall also serves a much larger role in the statewide battle against obesity. As the newly elected chair of the Tennessee Obesity Task Force, it is her job to take a “bird’s-eye view” of anti-obesity efforts all over the state.
The task force is funded by the CDC to the tune of about a half-million dollars a year for five years. The goal: Work with the Department of Health and multiple statewide partners to create and implement a cohesive and comprehensive state plan to help turn the tide of obesity in Tennessee.
Vanderbilt is rich ground for such programs. In addition to the multidisciplinary weight management clinic at the Children’s Hospital, there is an effort led by Dr. Russell Rothman, assistant professor of medicine and pediatrics and director of the Vanderbilt Program on Effective Health Communication, to examine how simple changes in the way families are instructed about nutrition and activity can impact infant and toddler weight gain.
Policy and environmental change efforts led by Vanderbilt staff, faculty and students are under way in locations from schools to the Tennessee State Capitol.
Peabody College students majoring in human and organizational development help with a school-based project called “Live It! Go for the Red, White and Blue,” led by Vanderbilt Children’s Health Improvement and Prevention. One group of medical students is lobbying for soda tax money to be used to support anti-obesity policy, while another tends a community garden in an urban neighborhood. The “Veggie Project” brings mini-farmers markets to Boys and Girls Clubs locations around town. And the list goes on.
Kim Harrell, interim director of children’s health advocacy at Vanderbilt, says it’s important to work within the systems in which children live—schools, neighborhoods and the family—to create environments where it is easier for them to exercise and eat well. The Live It! Go for the Red, White and Blue program, based in Metropolitan Nashville Public Schools, strives to do just that.
“We pass out pedometers and have an online program for the children and teachers to track their steps and daily food intake,” Harrell says. “We work with teachers to give them tools and curriculum to help them help their students make better choices about nutrition and activity. And every year the effort results in more of an environmental shift or cultural change.”
She points to the Glencliff High School program, where groundbreaking is taking place on half an acre of the school’s land for a community garden, and the idea of adding a track around the school is being discussed.
“The Garden Club students are now learning about good dirt, how to test it, and how to amend it to grow healthy foods,” Harrell says. “Some of these kids have challenging lives. This gives them something good to share with others while cultivating what could become a lifelong interest in issues like food inequality and sustainable agriculture.”
Talks are under way to expand the Live It! project to help meet mandated goals established in 2006 by Coordinated School Health, a Tennessee Department of Education program designed to connect health with education. Harrell says Live It! is in a perfect position to help, especially because of its effective use of community partners and available resources.
But despite the past foresight of Tennessee lawmakers to fund Coordinated School Health, says Joan Randall, the economic downturn means funding for that program could be chopped. Advocates are fighting to avoid rollbacks on programs that appeared to be making headway.
More Scientific Evidence Needed
Perhaps the biggest challenge of all is the lack of scientific evidence to prove which of these programs works. Without the evidence, some programs are sure to be left behind.
“We must have research to guide policy,” Randall says. “We don’t have strong evidence now.” She is especially interested in another emerging Vanderbilt effort, the brainchild of Dr. Shari Barkin, division chief of general pediatrics in the Vanderbilt University School of Medicine’s Department of Pediatrics.
It’s called “The Nashville Collaborative.” A year and a half ago, this unique partnership was formed between Vanderbilt’s Department of Pediatrics and the Metro Nashville-Davidson County Department of Parks and Recreation. The Coleman Recreation Center, which serves one of the most culturally diverse communities in Davidson County, was selected as a prototype for a “community-based laboratory” to develop and test interventions that could halt pediatric obesity. The goal was to create rigorous research, based on an ecological model—one that would be sustainable and reproducible elsewhere.
“The goal is not just to stop childhood obesity, but to turn it around,” says Barkin, who is also a professor of pediatrics and the Marion Wright Edelman Chair of Pediatrics. “You cannot wait until children are already obese to intervene. Prevention is what will be critical to turn the tide.”
A clinical trial led by Barkin called “Salud con la Familia” (Health with the Family), which examined how to impact weight gain in preschoolers by working with Latino parents and children in their community, was one such research-creating intervention. The work was funded by the State of Tennessee and the Vanderbilt Institute for Clinical and Translational Research.
Some six papers are now in the works containing evidence from the project and The Nashville Collaborative. Local government agencies from around the country have taken a closer look at the program. Barkin says the science will reveal keys to success that include engagement of parents and preschool children together, beginning at an age of rapid growth when short-term intervention can have a significant impact, and better utilization of existing community services.
The means to expand this formula is already in place. A Robert Wood Johnson Foundation network has selected The Nashville Collaborative to be part of a nationwide effort called “Salud America!” That funding will allow Barkin and her colleagues to closely examine how the results that emerge from this kind of community-based research laboratory affects local programs and policies.
Barkin’s project is exciting, and Randall says she is watching other promising projects across the state. But Vanderbilt has yet another plan to pull its various experts together in ways that may bring large-scale change through new governmental policies.
Roger Cone, professor and chair of molecular physiology and biophysics and medical director of the Vanderbilt Institute for Obesity and Metabolism, has completed a proposal to make Vanderbilt one of 12 Nutrition Obesity Research Centers funded by the National Institute of Diabetes and Digestive and Kidney Diseases. The proposal was turned in last fall, and Vanderbilt should learn the outcome this spring.
The Goal: A Comprehensive National Center
If Cone wins the grant, that would position Vanderbilt as a comprehensive national center for the study of obesity—one that could bring support to a number of programs, including everything from the study of the genetics, molecular science and brain chemistry behind obesity to “ecological” research efforts like Barkin’s and projects like Live It!, and to clinical efforts like the Weight Management Clinic.
Plemmons says national and statewide programs with money to back them cannot come too soon. “This is our fifth year. At first we’d never seen a 200-pound 5-year-old,” he says, “but now we do, as well as a number of children who are very, very obese.”
Cassandra Genesy feels frustrated by a life that’s already difficult. Single and between jobs, Cassandra talks about challenges, such as the fact she lives on a busy street—a dangerous place for Ian and his younger brother to ride bikes or walk. She wonders if her efforts to help Ian lose weight just make things harder.
“Ian wants to eat because he’s bored, and I try to talk to him about it, but he literally cries that he wants something to eat,” she says. “It’s hard to keep saying no.”
Standing at ground level and going one-on-one with lives experienced in a society designed to encourage obesity can make a person feel hopeless. But, despite implications and evidence that children who are already obese probably won’t be helped, Plemmons believes reaching out to people like Cassandra and Ian is worth every second and every penny.
“The problem is formidable, but not to address it at this level would be ignoring the obvious,” Plemmons says. “We don’t just throw up our hands at leukemia because it’s hard. There is no cure for diabetes, but we want to help families manage it. Maybe obesity cannot be cured, but it can be controlled.”
“The goal is not just to stop childhood obesity, but to turn it around. You cannot wait until children are already obese to intervene.”
~ Dr. Shari Barkin
Ian is right at the top of that encroaching wave, sitting firmly on the expanding right side of the bell curve. He sits through his long appointment at the clinic, patiently playing Guitar Hero on his mother’s cell phone, but often flashing a bright smile as if to show he is paying attention. He has his own reasons for wanting to lose weight.
“Mostly I would like to be able to play more sports without getting an asthma attack,” he says.
His smile reminds everyone of his promise. Ian is the future and the reason parents like Cassandra are willing to try to overcome steep odds. He is the reason bright clinicians like Plemmons and his colleagues continue to work so hard—even to change one life. In families like the Genesys, Plemmons can see the tide turning.
“It matters when you see the beam on the kids’ faces when the numbers on the scale change,” says Plemmons. “The glass is half full because this problem didn’t happen overnight. This has been in the making for 30 years in this country and will not be solved quickly. These kids will grow up having learned something. It may take a generation, but hopefully they will pass it on.”