With a young patient, Lutherville, Md., pediatrician Alan Lake.

In pediatrician Alan Lake’s mind, a recent longitudinal study showing children who are overweight or obese by fifth grade have a high risk of becoming or remaining overweight or obese in their teen years makes his case (PediatricsDec. 1, 2014).

“The major lessons we learn from these studies is we can’t wait to intervene,” says the Lutherville, Md., pediatrician. “The educational programming for families has to be done very early, probably with the child still in utero.”

Lake was referring to the Barker hypothesis and the role of intrauterine nutrition in programming a person’s metabolism for later life. Poor nutrition in pregnancy and after birth, Lake explains, predisposes the child to overweight/obesity and co-morbid conditions like cardiovascular disease and diabetes later on in life: “And if the child gains weight excessively `the first couple of years of life, it becomes very difficult to get rid of it.”

This wasn’t always pediatricians’ perception, says Lake. Three decades ago, when he was in training, pediatricians tended to anticipate that the overweight child would slim down after puberty—a belief Lake now calls “completely bogus.” Indeed, he points to studies denoting a new classification of obesity—severe obesity—for patients with a BMI above the 99^th percentile. Nearly 6 percent of children are severely obese, he notes, and at greater cardio-metabolic risk than children with less severe obesity. Lake adds that they represent the fastest growing category of obesity, underscoring the need for early intervention (JAMA Pediatr. 2014;168(6):561-566).

Pediatricians today, he says, are much more aware of the pace and complications of childhood obesity and the importance of working with parents and prescribing healthy nutrition and physical activity for their young overweight and obese patients. But many pediatricians continue to face frustration in battling childhood obesity—finding successful therapies and achieving good outcomes is very difficult. While programs like Weigh Smart at Mt. Washington Pediatric Hospital in Maryland have proven to be effective, such resources are limited.

So, what can pediatricians do to be more effective in fighting—and even preventing—childhood obesity? Lake, who has been at the forefront of proactive approaches both in the state of Maryland and across the country, recommends that pediatricians—

• Do not avoid the issue: There are many barriers in treating the overweight or obese child, notes Lake, including the reluctance by some pediatricians to address the issue for fear of antagonizing the family. “Do we tell the family your child is significantly overweight?” says Lake. “My philosophy is there has to be an awareness both for the fitness of the child and the recognition that the fitter the child the better he or she will do in school, independent of the long-term ramifications, which are enormous.”
• Identify and manage patients early: Pediatricians have the unique capacity to bond and work with families from the beginning, to recognize the family’s history of obesity, to educate them about the complications of obesity, and to intervene early and steer them to the right resources. “Early identification of those children who will most likely benefit is critical,” says Lake.
• Motivate parents: Teach parents the importance of being role models for active, healthy lifestyles? “It doesn’t do any good to tell the kid what to eat if the family doesn’t prepare it at home,” Lake says. “If you eat at a fast food restaurant you’ll take in 200 more calories than you would at home.”
• Consider behavioral interventions: The key to an effective behavioral intervention, notes Lake, is the motivational interview originally developed for smoking cessation. By reviewing the child’s growth chart with parents and asking them for their thoughts on any concerning trends, Lake says, “Pediatricians can prompt parents to come back with the observation that we’d better start doing something about this. The earlier we can achieve that, the more options we can give families to succeed.”
• Manage complications: With co-morbid conditions showing up earlier and earlier, Lake encourages pediatricians to keep a keen eye on obesity related conditions like hypertension and type 2 diabetes and refer, when appropriate, to resources like the Pediatric Obesity Hypertension Clinic at Johns Hopkins. “Pediatricians are aware of the complications,” Lake says, “but they may not be aware of how early they can occur.”
• Partner with schools: “‘There’s nothing more I can do. I can’t limit his diet any more, I can’t keep him more active, and I can’t afford to join a gym.’ Parents cite all sorts of barriers, but by incorporating appropriate education and programs in the schools, where the kids are captive, we can clearly help,” says Lake, pointing to a pre-school wellness program he helped institute in Maryland in collaboration with the state education and health departments. Lake also encourages pediatricians to join a school board or council to help establish wellness programs in pre-schools, elementary and secondary schools. As co-chair of the Baltimore County School Health Council, Lake led efforts to remove fried foods from school menus while introducing whole grain breads and low-fat milk products.
• Advocate healthy nutrition for kids: Through working with the American Academy of Pediatrics, amusement parks and fast-food outlets, pediatricians can effectively advocate healthy nutrition for children. For example, through serving on the nutrition advisory board for the Disney Foundation, Lake guided Disney to replace ice cream dots and candy with fruits and vegetables on its food carts, remove French Fries from touch screen ordering systems for children, and reduce food portion sizes. “We cut the caloric content of adult meals by 120 calories and by 60 to 100 calories for children,” Lake says.
• Grow a garden: To cultivate an organic appreciation for healthy foods, Lake led efforts to establish a vegetable garden in 26 county preschools by March 2015. “The kids will plant and harvest their garden, and eat what they grow,” Lake says. “As part of the project, they’ll have access to a demonstration kitchen to learn how to prepare the food to be eaten.”
• Advocate physical activity: Lake was appalled to learn that only one-third of schools nationwide hold recess for more than 30 minutes each day, and that 180 public schools in Maryland have no gymnasium. In response, among other initiatives, Lake designed a program in which pediatricians identify and refer to school nurses and physical education teachers children who are severely obese and who have poor fitness performance. The nurses and teachers, in turn, are enrolling these children in an increased physical activity program. To date, 30 Baltimore County elementary school children have enrolled in the program, which he plans to expand to neighboring counties.
• Conduct outcomes research: Ongoing outcome research is essential, Lake says, to illuminate the needs and demonstrate what programs make a difference: “Fitness for girls 9 to 19 declined 80 percent over the past ten years. By doing the research and recognizing the trends, we can see what we need to do to do better.”
• Talk the talk: Noting that he and Maryland pediatrician Dan Levy have presented some 33 grand rounds on childhood obesity in the state of Maryland, Lake encourages other pediatricians to do the same to raise awareness of related health problems and prevention strategies.
• Join a posse: Lake is the first to admit that any successes he’s made against childhood obesity are due to collaborations with members of his so-called “posse”—pediatricians, educators and policy makers in the state of Maryland: “Yes, I am passionate about this, but I have a posse of equally passionate people committed to making sure options are there for obese children.”

##