Kidzie: Thanks so much for taking the time to answer some of our questions! What is obesity and “overweight”? How do we define it for parents and children in a way that is easy to understand?
Dr. Flanders: The body is composed of different tissue types such as fat, muscle, bone, and water. Though children come in a variety of shapes and sizes, generally speaking, the average healthy child has a body composed of approximately 20% - 25% fat. When a child has a proportion of body fat that is much too low - for example 10% body fat - then that child is considered underweight. If a child’s body fat composition is too high - for example over 35% - then that child would be considered obese. Overweight falls somewhere in a range between normal and obese. Children in the overweight category are not obese but are considered to be ‘at risk’ for developing obesity.
Most primary health care providers do not have the equipment or expertise to measure body composition so they use body mass index (BMI - a measure of weight relative to height) as an estimate of body fat composition instead. Children with a BMI higher than 85% of their peers are considered overweight and those with a BMI higher than 95% of their peers are considered obese.
It is really important to keep in mind that obesity does not necessarily equal poor health. Although obesity is a risk factor for poor health, many children are obese based on clinical measures but are perfectly healthy in reality. Conversely, there are nutritionally unhealthy children whose weights would be classified as normal. So one must always be careful to look beyond just the clinical numbers when assessing children for obesity. This would be best done in conjunction with a properly credentialed health care provider.
Kidzie: Why do you think obesity and overweight has become such a huge problem today? Is it simply an issue of poor food choices, or is the problem much deeper? Is there a genetic component?
Dr. Flanders: No one knows for sure why obesity rates are surging globally but there is no question that as a population, we are eating far more daily calories than we did a few decades ago. There are a number of proposed explanations for this, probably many of which are simultaneously at play:
- The nature and quality of the food we eat is changing. The degree of food processing (which strips foods of nutrients) has increased, the caloric density of foods has increased, and the amount of salt, fat, and sugar added to foods has increased.
- The way we eat is changing. Portion sizes have dramatically increased. The frequency with which families eat out or take out is increasing. The number of home-cooked meals (usually smaller portions with far less calories, fat, sugar, or salt) eaten as a family around the family table has decreased. Our tendency to drink sugar-sweetened beverages (such as soda, juice, and sports drinks) has increased.
- The marketing of our food is changing. Food manufacturers and retailers are developing ever-more powerful marketing strategies convincing us to routinely buy and consume their 'latest and greatest' food products. These aggressively marketed foods are typically ultra-processed, low-quality and highly caloric. Worse yet, many marketing campaigns imply, or explicitly lead consumers to believe, that their products are healthful. In reality most are not.
- Have our genes changed? There is no doubt that genetics plays a role in determining whether or not any given child will suffer from obesity. A better understanding of the genetics of obesity will hopefully one day inform the process of finding a solution. On the other hand, it is hard to use genetics, at least as we understand it today, to explain the sudden surge in global obesity rates over the past 2 decades. Based on our understanding of genetics, gene mutations happen slowly and over multiple generations, not rapid-fire over a few years or decades. It is hard to imagine that a person born in the 1990s would have different genes coding for lesser willpower to make healthful choices than someone born 25 years later. Much more likely is that over 25 years our environment has evolved to render otherwise equivalent people less able to make healthful choices.
Kidzie: As a pediatrician, you and your team undoubtedly care for many children that may have challenges with their weight. What is a common question you get around healthy weight management? Where do you usually start from a management or counselling point of view?
Dr. Flanders: The most common questions, indeed, are around weight. The challenge, however, is that focusing treatment and counselling on a child’s weight alone seldom helps and may actually make things worse.
I consider obesity to be the consequence of a problem, not the problem itself. For example, a fever is usually the consequence of an infection; treating the fever without addressing the infection will get one no closer to resolution. Similarly, obesity is typically the consequence of leading an unhealthy lifestyle, which is a collection of behaviors that, over time, gradually degrades one’s overall health. Focusing on weight reduction alone will not help. If one can identify and improve the underlying unhealthy lifestyle behaviors, then the obesity gradually resolves.
So, in clinic, we guide the focus of discussion away from ‘weight’ and towards permanent lifestyle-enhancing behavior change.
After a thorough assessment, we generally start treatment by establishing a care plan with the family. For younger children, this process tends to be negotiated between the care team and the parents, not the child; young children should not have to feel any burden of responsibility for their health. For older children, the parents and the child usually share these responsibilities in an individualized and developmentally appropriate manner. Usually we counsel around health-promoting behaviour change in three spheres: nutrition (e.g. how to cut down on sugar intake), movement (e.g. how to add more exercise to one’s day), and wellness (e.g. strategies to deal with low self-esteem and bullying). We define short-, medium-, and long-term goals for each sphere, and then we begin by tackling goals, one or two at a time.
Kidzie: What are some things that your clinic is involved in that are innovative.
Dr. Flanders: Over the course of my career, I have developed an ever-growing concern about not only the medical/physical predispositions and adverse outcomes of obesity, but the mental health ones as well.
Obese children are more at risk of suffering from social stigma, bullying, depression, low-self esteem, emotional eating, and discrimination. Not only does obesity predispose to these, but many of these conditions are well known to cause or worsen obesity. There will be little, if any, success treating obesity if the mental health piece is not adequately addressed.
This Fall, our Kindercare Pediatrics Nutrition and Healthy Lifestyle program will be piloting a new treatment program that will strive to address not only the physiological, but equally the psychological aspects of our patients’ obesity experience.
Kidzie: What are some common barriers to attaining a healthy weight?
Dr. Flanders: The biggest barrier is that our current environment stacks the odds highly against success when it comes to enabling children to lead healthier lifestyles. Children and their parents are overwhelmed, day-in and day-out, by relentless incentives to eat poorly and live unhealthily. Until our politicians and public health organizations initiate meaningful change in this regard, I am not optimistic that these barriers will be surmountable.
Kidzie: If there is one piece of advice that parents can follow with respect to preventing overweight and obesity, what might that be?
Dr. Flanders: The most important thing that parents can do is to ‘keep a healthy home’. Although many environmental factors are leading to health erosion in our communities, your home can be a safe-haven from this. In a healthy home, the cabinets, pantries and refrigerators are filled with high quality foods like fresh/unprocessed fruits, vegetables, meats, dairy, whole grain breads/cereals etc. Absent are poor quality ultra-processed foods laden with added salt, sugar and fats. This isn’t to say that kids should never eat items such as cake, cookies, candy, or chocolate, but ideally these items are kept out of the daily meal and snack rotations; they are served less often, for special occasions, and ideally out of the home. Keeping a healthy home also means preparing foods ‘from scratch’ and eating together as a family at the family table more often than not. Keeping a healthy home also means limiting screen time, cutting down on sedentary behaviours and jumping on multiple opportunities to be physically active. Finally, a home can only be healthy if those living in it feel safe, free from bullying and stigmatization no matter their weight, shape or size.
Kidzie: Thanks so much Dr. Flanders!