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On the right path
Kaiser program provides kids with the knowledge they need to fight obesity

by Diana Reynolds Roome

The "before" and "after" picture set has become a banner for success in weight loss. Julianne Dean's certificate of achievement from the Kaiser Pediatric Weight Management Program first shows an overweight girl who is reluctant to face the camera. In the second picture, Julianne, 13, in a new peach-colored top with gold flowers at the neckline, is not dramatically thinner. Yet she looks self-possessed and bonny.

She's lost 35 pounds in six months, and she's proud of it.

"This kind of weight loss takes a dramatic change in the whole mental attitude, and that's what's important. It can't be summarized by a number on a scale," said Dr. Julie Kohl, who is Julianne's pediatrician at Kaiser Permanente in Mountain View.

"Losing weight is complicated, and needs to be done under medical supervision. The idea of an easy fix is seductive but not realistic. The important thing is keeping the weight off and establishing good habits for sustainable, long-term changes. We have to take a long view because this is a lifetime process."

Julianne's determination to slim down, and her will to approach eating and exercising differently, were bolstered by her family's enthusiastic support. The educational tools for transformation came from Kaiser's†well-designed program, which helps kids and their families change their behaviors for good.

Obesity in children and teenagers is one of the biggest health challenges facing the country today, according to several recent reports. Over the past 20 years it has more than tripled in adolescents and doubled in children from 6 to 11 years old. A widely distributed article published in the New England Journal of Medicine predicted that for the first time in two centuries, life expectancy is likely to decline instead of increase, and that today's youth, on average, may live less healthy and shorter lives than their parents.

"Once kids are overweight, they're at high risk for being overweight as adults, when they may have long-term issues with cardiovascular disease, heart attacks and stroke," Kohl said.

Even in childhood, a variety of serious health problems can result from carrying too much weight, including high blood pressure, joint and muscle pain, impaired mobility, asthma, and type-2 diabetes, which used to be rare in children.

Experts blame this situation on a raft of reasons, including heavy advertising of sweet, fatty and salty foods; "super sizing" of portions by fast food restaurants; cutting physical education from school schedules; snacking in front of the television, computer or video game console; and soda in school vending machines.

In response, schools are beginning to replace sodas and sweetened juices with less caloric drinks -- a smart move, since a 20 oz. soda has 17 teaspoons of sugar, empty calories that take the equivalent of four hours of hard bicycling to burn off. However, processed foods such as hot dogs and pizza, which are low in nutrition and high in cholesterol-boosting fats, still are easy to find on many school lunch menus.

Kaiser Permanente has taken on some of these challenges by coming up with imaginative approaches to weight management that put the emphasis not just on the child but on the family and the community. The HMO runs several programs that focus not on dieting but on activity, responsibility and forming new habits. Free solo classes help parents and kids to become savvier about eating and to decide on a "next step" action plan that they're eager to carry out. More intensive weekly sessions over several months lead to weight loss, lower heart rate and more energy.

Best of all, kids like Julianne start looking forward to going for long walks with the family and the dog, or playing tennis with dad when he gets off work.

"We encourage each other," said Julianne of her father, who lost 100 pounds last year and is helping Julianne to lose a similar amount of weight, "to get to a size where I know I'll be comfortable. Sometimes I do just feel I'm never going to get there. Then I say, why give up now when I've gone this far? I'm going for my goal."

Behind her all the way is Julianne's grandmother, Mary Picollo, who drove her to Kaiser's Pediatric Intensive Weight Management program weekly for almost five months without missing a meeting. Though she has been supportive, she knows that ultimately, Julianne's health is up to her.

"This is a lifelong plan she has to be responsible for. She needs to do it for herself and her own well-being, not for me, not for anybody else," said Picollo. Julianne's sister, 11-year-old Katie, accompanied them, and though she's never had a weight problem, she too learned a lot about making healthy decisions.

Meanwhile, Julianne's uncle and aunt bought her a pass to a gym, called to ask how she did at class, and took the girls swimming.

"It helps to have a supportive family. They know what I can and can't eat. They know I want to do this, and this is the time I need most support," said Julianne, who learned in class how to choose foods wisely, understand portion control, and build more active habits by going on group walks, playing soccer and taking part in relay races.

"The whole [Kaiser class] was going at the same pace as I was," she said, admitting that she didn't want to do P.E. at school, where teasing was hurtful. "At class, it was nice to see people going through the same thing as me."

Kids from age 8 to 17, of many ethnic backgrounds, attend Kaiser's weight management classes, and discover how different cultures face different kinds of challenges in maintaining a healthy weight.

All people have a different ideal weight, said Kohl, so comparing weight against height can be misleading. Furthermore, the standard charts are not based on a diverse ethnic population.

"Half of my patients are overweight and do not even know it until you show them their growth curve and BMI [body mass index]," said Dr. Wynnyee Tom, a pediatrician at Kaiser in Fremont. "They say, 'How come? I'm skinny compared to my relatives.' We're trying to change the perception of what overweight means."

Tom recently started an e-newsletter on children's fitness, which is available online at www.kp.org/pediatricsnewsletter. It's packed with ideas to help inspire families to eat better and exercise more.

"The best results are seen with programs that involve the whole family," said Kohl. "Julianne's family was really motivated. They came in and said, 'This is something we're ready to work on.'"

INFORMATION:

Kaiser Permanente HMO is located at 555 Castro Street, Mountain View, though the Pediatric Management programs are held in various other locations. For more information, contact (510) 784-4344.

HEALTHY HABITS:

Children are encouraged to play actively for at least an hour each day. Parents can help by:

* Being a role model. Go on hikes or long walks, ride bikes, play sports, or engage in any kind of physical activity.

* Limiting sedentary activities such as watching TV and playing computer and video games to one hour a day.

* Offering water when kids are thirsty. Cut down on sodas, juice and other sweet drinks to no more than one cup a day.

HEALTHY FOODS:

You don't have to throw out all the food in your refrigerator if you want to start eating healthier. There are many small, simple changes you can make that will drastically improve your diet. These changes don't take extra time or money, and they're easy to stick with:

* Make substitutions. Order brown rice instead of white rice, or buy whole wheat bread instead of white.

* Add healthy foods, rather than taking a favorite food out. Bring a snack of cut-up vegetables or some grapes in your lunch. You'll add a serving of vegetables or fruit to your diet and get the benefit of the vitamins and minerals it contains.

* Buy only nonfat or 1 percent milk, and low- or nonfat yogurt, sour cream, and other dairy products.

* Eat your fruits and vegetables first. You'll be less hungry by the time you get to your cheeseburger or dessert. This way you get the healthy foods in, leaving less appetite for the not-so-healthy foods. Also, the fiber in fruits and vegetables will make you feel fuller longer.

* Use a small amount of oil (olive, canola, or vegetable) for cooking (instead of butter, margarine, or lard).

* Use herbs, spices, and other low-sodium seasonings to flavor food.

* Eat two servings of fish a week.

* Buy low-sodium canned goods (soups, vegetables and beans).

Reviewed by: Alan Eshleman, MD and Sue Heikkinen, MS, RD, CDE