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Michelle Olsen, a Manchester clinical dietitian, was alarmed by what she was reading on social media.
It appeared that the respected American Academy of Pediatrics was recommending bariatric surgery for adolescents 13 and older with obesity. For even younger kids, AAP was suggesting weight-loss medication.
“I thought there has to be more to it,” said Olsen, a clinical dietitian at the Elliot Center for Advanced Nutrition Therapy and Diabetes Management.
So she read the AAP’s “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity,” published in the February medical journal Pediatrics. “And just as suspected, there is more to it,” she said.
The AAP recommends a wide range of treatments for obesity, including monitoring body mass index, diagnostic testing for other medical conditions, nutrition counseling, mental health screening and intensive, family-based behavior and lifestyle treatment. Only after all that is tried, and only in the most extreme cases, should pediatricians consider medication or surgery options for children with severe obesity.
Olsen was encouraged by what she read.
“What struck me is if anything, it’s hopefully going to get the pediatricians to maybe bring it up more, and not wait until someone is beyond the point where it’s going to be extremely challenging,” she said. “It’s easier to prevent weight gain than to treat it.”
“We’ve always known that literally you are what you eat,” Olsen said. “We’ve always known that nutrition plays a huge role in disease prevention.”
Olsen also was pleased with the AAP’s emphasis on a family-based approach to achieving healthy weight. “We want to work together for our kids,” she said. “We want to be on the same page for our kids’ health.”
The AAP guideline begins: “The current and long-term health of 14.4 million children and adolescents is affected by obesity, making it one of the most common pediatric chronic diseases. Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors.”
The Centers for Disease Control and Prevention defines obesity as a body mass index at or above the 95th percentile.
Cutting sugar, screen time
Erik Shessler, a Dartmouth Health pediatrician and president of the New Hampshire chapter of the AAP, said obesity has been recognized as a chronic disease for years, but this is the first comprehensive clinical guidance for treatment of children.
Shessler said to his knowledge no hospital in New Hampshire even offers bariatric surgery for youngsters. As for medication, that’s never the first approach, he said, considered only after lifestyle counseling, working with nutritionists and addressing mental health and other chronic diseases.
He expects the new guideline will ensure that providers are offering — and public and private insurers are covering — a broad array of treatments.
“It really does help level that playing field,” he said. “We have a road map we can follow.”
In his own Manchester practice, Shessler said he works with families on small changes that can make a big difference, such as getting little kids to drink water instead of sugar-sweetened soda or energy drinks.
“It’s thinking about eating with intention and how to keep ourselves healthy and how foods can help make us feel better,” he said. “We’re starting out with some general principles and then really meeting families where they are and listening to what their challenges are.”
One starting point is the “5-2-1-0” public health campaign, which recommends that children eat at least five servings of fruits and vegetables each day, limit screen time to no more than two hours, have one hour of physical activity and drink no sugar-sweetened beverages.
Pediatricians also can help parents set limits on screen time, Shessler said.
In his experience, parents appreciate the guidance and support. “These kids don’t come with instruction manuals,” he said.
Making most of less
The AAP guideline outlines a long list of factors that contribute to obesity in children, including marketing of unhealthy foods, consumption of fast food, and poverty, which can limit access to healthy foods and opportunities for physical activity. Screen time correlates with a greater risk of obesity; so do depression and emotional stress, AAP says.
Eileen Groll Liponis, executive director of the New Hampshire Food Bank, knows the many complicated reasons lower-income families may struggle with obesity.
“Access, affordability, transportation and time, those are all contributing,” she said. “Just one of them ticks away at the nutritional value you can put forward for your family if you’re pressed for money.”
“But people are quick to judge,” she said.
The Food Bank has focused on boosting nutrition from the start, Liponis said.
Its New Hampshire Feeding New Hampshire program enables its 400 member agencies to purchase produce, dairy and protein directly from more than 200 local farmers. When it comes to food, Liponis said, “The more local it is, the more nutrient-dense.”
The agency also offers Cooking Matters classes, teaching participants to prepare a healthy meal — and sending them home with the ingredients to make the same meal at home.
When Liponis talks with clients at mobile food pantries, she hears their stories of hardship and sacrifice. Some tell her they’ve given up protein because it’s too expensive; others say they’ve had to surrender beloved pets because they can no longer afford to feed them.
“Right now, it’s heat or eat,” she said.
She’s worried about families who will see their SNAP benefits drop next month, with the end of supplemental emergency allotments that were provided during the pandemic.
“People are going to be making harder and harder choices, and nutritious and fresh produce is not getting any cheaper,” she said. “It’s going to be harder for folks to battle obesity with the tools they have and all the odds against them.”
Education on Aisle 3
Marilyn Mills, a licensed dietitian and certified diabetes educator at Elliot Hospital, sees patients on an outpatient basis. But most days, her office is at the grocery store.
For 20 years, Elliot has contracted with Hannaford to provide dietitians at stores in the greater Manchester area, Mills said.
“We’re right on the store floor, we’re right in the aisles, and we’re interacting with customers and associates on a weekly basis,” she said.
“The supermarket is where everything happens,” she said. “That’s where people are going to come in and decide their beverage choices, meals and snacks.”
Mills teaches in-person and online nutrition classes and conducts in-store tours. She politely approaches families in the aisles to offer help and support. And in what she calls her “moveable classroom,” Mills offers kids healthy snacks (“snack pals”) and prizes, and talks with youngsters and parents about healthy eating.
“I’m there to provide an education and to provide it in a fun and nonthreatening, non-judgmental way for the whole family,” Mills said.
Elliot dietitian Olsen said in her practice, she typically asks three questions: what kids are drinking, what they are doing for movement and who is supporting them. “Are they drinking soda? Are they drinking juice? That might even be the first thing: Let’s switch to water or a sugar-free beverage,” she said.
She helps kids and teens come up with ideas for physical activity. She tells them that they’re in the driver’s seat: “This is something we can definitely get under control. It’s just making these changes,” she said.
“You don’t have to be part of a sports team, but our bodies are meant to move, and they’re meant to move on a daily basis,” Olsen said. “And kids just aren’t doing that these days. They come home and they’re just not moving.
“It can be as simple as getting a jump rope, or going for a walk with their family,” she said. “I don’t even talk about food sometimes.”
Reducing phone use can be tough for the younger generation. So Olsen encourages kids to use their phones as tools, for playing music while they’re walking, or measuring how many steps they take on a given day.
The AAP guideline urges providers to engage in “supportive and unbiased behavior,” including use of neutral words such as BMI or “excess weight,” rather than “fat” or “chubby.”
“Ongoing successful communication of support and empathy during obesity treatment is essential to reduce the effect of weight bias, because families will not continue to seek help if they experience stigma,” AAP says.
Dartmouth Health pediatrician Shessler said he was pleased to see that acknowledgement of the shame and stigma that accompanies obesity for both adults and children.
“We need to create a welcoming environment for families, and a supportive environment for families and children,” he said.
His message to families: “We’re going to be your allies.”
“For a lot of these things, we’re learning over time there are multiple factors, and there’s a genetic component to it,” he said. “It’s a big step to acknowledge it’s not simply willpower and totally under your control.”
In his experience, success is about “listening to the families and what their goals are and what their interests are — and celebrating the wins,” he said.
That may not mean an immediate change in a child’s weight but an improvement in overall health, Shessler said.
“If you’ve got yourself doing more walking, getting outside, getting fresh air, that fresh air is better for your mental health, better for your energy level, your sleep,” he said.
Dietitian Olsen said the key is to focus on lifelong health rather than body image. That’s what concerned some in her field when the AAP obesity guideline first came out, she said.
“We don’t want to do more damage, where we develop insecurity among kids,” she said.
She hopes the new clinical guidance will spur more pediatricians to refer young patients to dietitians such as herself.
“We would love to see the kids,” she said. “We want the best for them.
“We’re ready to take this on.”