A few weeks ago, a young man, a child psychiatrist, called saying that he had read the first Weighty Issues column and that he agreed that psychiatrists should be actively involved in the weight loss arena.
He shared that he had several children in his practice whose body-mass indices were over 40 and that he was frustrated that the pediatricians he had spoken with seemed to be only watching and waiting for the children to grow taller. I told him what he already knew: Pediatricians have in place a very specific protocol to follow regarding the treatment of overweight and obesity in children.
I had the impression from him that he was not exactly sure that the protocol was being followed and that he was absolutely sure that the pediatricians had no appreciation of the emotional aspects of these children’s weights. He said he was so fired up about this that he was going to pursue American Board of Obesity Medicine diplomate status himself. In addition to his background in child psychiatry, he also had studied public health, and his parents had worked in the area of disease prevention.
I was thrilled by his call because he got it! Overweight and obesity are a public health menace. Every day, psychiatrists see patients with these maladies, and we should be more knowledgeable about them or armed to get the treatment started ourselves. Although this child psychiatrist continues to intervene with his patients’ pediatricians and embarks on his own ABOM studies, he can, as he sees his patients and their families, write prescriptions for exercise and play time for the family, limited screen time (TV and computer) for the youngsters, no sweetened beverages, fewer simple carbohydrates, and more plain water. These interventions all are consistent with routine lifestyle recommendations for children (and adults), and they also can promote improved well-being for children and family members.
A recent report indicated that about a quarter of 2- to 5-year-olds and one-third of school-aged children (6-18 years) are overweight or obese in the United States (JAMA. 2014 Feb 26;311:306-14). By convention, body-mass index, a measure of relative body fat, is used to indicate underweight, normal weight, overweight, and obesity. It is derived from a formula: weight in kilograms divided by height in meters squared. In adults, normal is 18.5-24.9, overweight is 25-29.9, and obese is greater than or equal to 30 (National Institutes of Health/World Health Organization guidelines for BMI). For children, one calculates the BMI and then plots this on a graph in comparison to other children of the same age and sex to derive a percentile scale number. Percentile scale numbers from 58-94 indicate overweight, and percentiles greater than or equal to 95 indicate obesity in children aged 2-18 years. For children aged 0-2, a weight for length above the 95th percentile indicates overweight.
Childhood obesity is a major risk factor for overweight and obesity in adulthood, and for depression and cardiovascular disease in childhood and adulthood. It also sets one up for potential trouble in the areas of self-esteem, body image, body protection, poor school performance, and relationship issues with peers. These are areas of importance for psychiatrists, child and adult, as we assess, plan for, and treat our patients day to day. Furthermore, childhood overweight puts children at risk for type 2 diabetes, metabolic syndrome, high cholesterol and high blood pressure, asthma, sleep disorders, early puberty or menstruation, Blount’s disease (progressive turning of the lower leg, resembling bowleg), and nonalcoholic fatty liver disease. Obesity in adulthood leads to high blood pressure, strokes, type 2 diabetes, dementia, osteoarthritis, sleep apnea, obesity hypoventilation syndrome, reproductive problems, gallstones, and some cancers (esophagus, pancreas, colon, rectum, breast-after menopause, endometrium, kidney, thyroid, and gallbladder).
The late Dr. Hilde Bruch, one of my mentors in the 1970s, was an early thought leader in childhood obesity. She did research in this area starting in 1937 while practicing pediatrics before she became a psychiatrist in 1943. She said that she was struck by the number of overweight and obese children she observed in the United States, compared with what she had observed in Germany and England. (She died in 1984 at the age of 80 and would be greatly saddened that childhood obesity is now a global issue.) In her 1973 book, “Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within,” she grappled with the taking in of calories, and, speaking of hunger, said that “it is not innate, but something that contains important elements of learning.”
As an analyst, she thought of feeding learning as coming primarily from early mother-child interactions, but we now know that this learning can come through any repeated interaction and that genetic, social, cultural and environmental, and biological factors also apply.
The psychiatrist or anyone else working with children and families must endeavor to reduce self-blame, explore influences, and instill hope in the process toward normal weight and/or adequate management of weight. The psychiatrist and anyone else working with the child and family will appreciate that, if energy intake and physical activity output are manipulated consistently, the tendency for the child will be increasing height and decreasing BMI. The Prevention and Management of Obesity for Children and Adolescents Guideline is very clear about when to refer to a tertiary special weight management program for children. The guideline also speaks to use of weight-loss medication (orlistat for children 12 years and older, sibutramine for children 16 years and older). Bariatric surgery is recommended for children who have finished growing up (by growth plate evidence) and face imminent serious health issues if their weight cannot be brought under control. These children, after surgery, will need to radically restrain their eating, take supplements, and be followed for the rest of their lives to forestall complications and return to overweight and obesity. I believe that child and adult psychiatrists can be of tremendous use here in helping sort out both the physical and course-of-life issues that could threaten successful continued weight loss, whether the weight loss comes through lifestyle change, lifestyle change and medications, or bariatric surgery and subsequent lifestyle change.
I would like to thank that young child psychiatrist who called, because he spurred me to continue our “Weighty Issues” journey by looking at childhood and overweight and obesity and how it can affect our work as physicians and psychiatrists. Parental physical condition at conception at gestation and genetics may set the stage, and then interaction with the family, the culture, the society, and the environment all interplay in the child’s development to produce an outcome of an overweight or obese child. We still are trying to discover why some but not all children in the same family, neighborhood, socioeconomic strata, culture, etc., are burdened by overweight. The reasons may be found through biological inquiry, but it may just as well in found in psychiatric/psychological inquiry.
Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics, and the interface between general medicine and psychiatry.