Online Health Chat with Dr. Naim Alkhouri

September 9, 2011

Introduction

Cleveland_Clinic_Host: Across the nation, Americans are increasingly worried about the rise in childhood obesity and are determined to fight it. A recent local study showed that 40 percent of 5th graders in suburbs across Cuyahoga County were overweight. In the past 30 years, this percentage has nearly doubled due in part to changes in children’s lifestyles, including inactivity and poor eating habits. Did you know that today’s average child spends nearly 24 hours per week watching television?

Healthy eating and physical activity habits are keys to your child’s well-being. Eating too much and exercising too little can lead to overweight and related health problems that can follow your child into his or her adult years. You can take an active role in helping your child and your whole family develop healthy eating and physical activity habits that last a lifetime.

Dr. Naim Alkhouri is board certified in internal medicine and pediatrics, and is a Staff Physician with Cleveland Clinic Children’s Hospital. He is Clinical Director of the Pediatric Cardiology and Metabolic Clinic, a multidisciplinary team of physicians, nurse practitioners, dieticians, exercise physiologists, and other health care professionals who take a comprehensive approach to preventing the onset/early progression of cardiovascular and metabolic conditions in high-risk pediatric patients. His specialty interests include nonalcoholic fatty liver disease, viral hepatitis, autoimmune liver disease, end stage liver disease, liver transplantation, and inflammatory bowel disease.

To make an appointment with Dr. Alkhouri or any of the expert pediatric specialists at Cleveland Clinic Children's Hospital, call 216.444.KIDS (5437) or visit us online at clevelandclinicchildrens.org/healthykids.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Naim Alkhouri, MD, gastroenterologist at Cleveland Clinic Children's Hospital. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.

Fatty Liver Disease

Peterson: What is 'fatty liver' in children? How is it diagnosed and treated?

Dr__Naim_Alkhouri: Fatty liver is a common complication of childhood obesity. It is estimated that 10 percent of children in the United States may have fatty liver, and the prevalence is as high as 50 percent to 70 percent in obese adolescents. The medical term for "fatty liver" is nonalcoholic fatty liver disease or NAFLD, which has a spectrum of disease that ranges from simple fat accumulation in the liver to inflammation and scarring of the liver. The most aggressive form is called nonalcoholic steatohepatitis or NASH, and this can progress to liver fibrosis and even cirrhosis during childhood.

NAFLD can present with abdominal pain, but it is asymptomatic in most children. Clinical clues for the presence of fatty liver include elevation in liver enzymes and the presence of fat on liver ultrasound. Sometimes, a liver biopsy is necessary to establish the diagnosis of the severe form of fatty liver (NASH).

Treatment should start with lifestyle modifications (diet and exercise). New clinical data demonstrated that vitamin E may be beneficial is some children with this condition.

Peterson: Who is most at risk for developing fatty liver disease? Is it gender based, certain ethnicities, etc.?

Dr__Naim_Alkhouri: There is a genetic component to fatty liver disease (e.g., the recently identified PNPLA3 polymorphism), and fatty liver runs in certain families. Hispanics are at higher risk; African Americans have lower risk. Boys are more likely than girls to develop fatty liver.

ssrangerthedog: Is NAFLD reversible?

Dr__Naim_Alkhouri: Absolutely. Fatty liver is reversible, especially when it is diagnosed in its early stages (before the development of inflammation and fibrosis). Even modest weight loss can have an impact on reversing fatty liver. This makes early identification of this problem an important public health issue.

jpendergast: Are there less invasive ways to diagnose NAFLD and do all obese children have NAFLD?

Dr__Naim_Alkhouri: Not all obese children will have fatty liver. Elevated liver enzymes and the presence of fat on liver ultrasound are considered non-invasive ways to diagnose fatty liver. Our research at the Cleveland Clinic has identified a few serum markers and clinical scores to diagnose the aggressive form of fatty liver or NASH without the need for a liver biopsy; however, these markers are not yet in clinical use.

Defining Obesity

david: How do you define obesity as it relates to children? Is it defined using BMI as it is in adults?

Dr__Naim_Alkhouri: The most common way to define obesity in children is by using the body mass index or BMI (weight in kg/ height in m2).

In adults, a BMI of 25 or more is overweight and a BMI of 30 or more is obesity.

In children, we use BMI percentiles. A BMI of > 85 percent for age is considered overweight; a BMI of >95 percent for age is considered obesity; and a BMI of > 99 percent is considered severe obesity.

There is a chart for children and BMI on the Center for Disease Control and Prevention (CDC) website at www.cdc.gov/

Healthy Weight Loss

grace: My 16-year-old son is overweight. What can I do to help him lose weight in a healthy way? He's quick to turn to fad diets/quick fix alternatives. The biggest struggle I've had is keeping him to a healthy meal plan. He's active, but only in spurts.

Dr__Naim_Alkhouri: Try to have three meals and one to two healthy snacks a day. Eating breakfast is important.

We use the following rule for our patients: Cleveland Clinic Children's Hospital 5 to GO!

• 5 a day fruits and veggies – for a healthy body, healthy life!
• 4 dairy or calcium servings a day – for strong bones!
• Give and get 3 compliments a day – to build self-esteem! We remember to criticize, but we need to remember to praise…
• 2 hours or less of TV/media/computer/screen time a day, not counting homework – for a healthy brain!
• 1 hour or more of exercise a day – for a healthy body!
• 0 fluids containing calories except for low fat milk!

5-4-3-2-1-0-GO!

helpout: My daughter is 16 and a vegetarian. She is overweight but active and healthy. She is bigger on bottom than on top. She wants to lose weight, but I don’t know how to help her, particularly because she is a vegetarian (she does eat fish though). What do you suggest? If she is active and healthy, is it still important for her to lose those extra pounds?

Dr__Naim_Alkhouri: Most vegetarians tend to have a diet rich in carbohydrates, and many of them are refined (that means they are not very filling), so vegetarians are often hungry throughout the day.

Encourage your daughter to consume low-fat dairy because it includes protein, which keeps her full. Also, make sure that for lunch and dinner half her plate is filled with non-starchy vegetables. Always focus on exercise and physical activity (one hour daily). Having a pear shaped body habitus is actually healthier than having central obesity (apple shaped).

Nutrition

Lauravas: We tend to think of processed foods as bad, since they have been altered from their natural state for safety reasons and convenience. Do you have any suggestions for "healthy food processing"?

Dr__Naim_Alkhouri: Food can have its nutrient value changed by the way it is processed, cooked, and stored. Food processing can destroy the water soluble B and C vitamins. However, processing and cooking food can also make it safer to store and eat.

Suggestions to retain the maximum nutrition in the foods you cook include:

• Store foods properly, such as sealing some foods in airtight containers.
• Try washing or scrubbing vegetables rather than peeling them.
• Use the outer leaves of vegetables such as cabbage or lettuce.
• Microwave, steam, roast, or grill vegetables rather than boiling them.

Lauravas: Snacking has gotten a bad rap over the past years. Mention the word "snack," and visions of sugary cookies, greasy chips, and fizzy sodas begin to dance through most moms’ heads. But snacking the right way is actually a good thing. What are your recommendations for healthy snacks?

Dr__Naim_Alkhouri: Healthy snacks include some proteins and whole grains for fiber. Examples include low-fat string cheese, Greek yogurt, low-fat popcorn, small portion of nuts, oatmeal, bean soup, and whole grain crackers.

dragonlady: My daughter is overweight and my son is very, very skinny. As the cook, how do I deal with the two of them, trying to keep them healthy?

Dr__Naim_Alkhouri: Your daughter (depending on her age) may need personal advice from a dietician regarding healthy eating and exercise habits. This way you can avoid conflict at home, and she can be held more accountable with regard to her own healthy habits and how they may affect her weight.

Frustration

livvy_s_momma: My 3-year-old daughter will not sit down for a meal, and when she does eat, she only wants chips. Mealtime is a constant struggle. She is a healthy weight, but I'm concerned that these bad eating habits will follow her into adolescence and affect her weight and overall health as she grows. What do you suggest?

Dr__Naim_Alkhouri: Make sure that you follow strict meal schedule with three meals and two snacks daily, no food or fluid with calories between meals or snacks (e.g., juice in their sippy cup). Your child needs to be hungry in order to try new foods. It's the parent’s job to determine what time and what is being offered, and the child's job to determine what to eat and how much. Chips are not a good option and should not be offered. Don't let your child mold you into their food preferences.

coolbeans: How do you motivate teenagers to eat better and exercise? They don’t want to listen to a thing I have to say. I cook healthy for them at home, but I know when they are away from home that they eat a lot of junk. I don’t keep too much in the house.

Dr__Naim_Alkhouri: Teenagers only care about what benefits them "now" and not in the future. Try setting up incentives for children to eat healthy and exercise, even starting at an early age. For example, keep track of when they eat healthy meals and offer small incentives at the end of the week -- maybe bigger incentives if they follow your goals for the whole month. Have the whole family participate and challenge each other.

Complications

momma: What problems do obese children face as children, and then later as they get older?

Dr__Naim_Alkhouri: Childhood obesity has many complications. Most concerning is that obese children have higher rates of premature death as adults (< 55 years). Other complications include obstructive sleep apnea, type 2 diabetes, fatty liver -- which can lead to liver cirrhosis -- joint problems, and vision problems, to name a few.

Prevention

mom_to_be: I'm a mom-to-be. What can I do right away to start my child on a healthy track?

Dr__Naim_Alkhouri: Breastfeeding for the first year of life is the best gift a mother can give to her newborn (exclusive breastfeeding for the first six months). Introduce a variety of foods on a continuous basis (start with fruits and vegetables). As your child gets older, don't let your food biases affect what you offer him or her.

jester: At what age do you begin to worry about a child’s weight? Also, at how much overweight do you begin to worry?

Dr__Naim_Alkhouri: After the age of 2 years, I would start to focus on prevention of childhood overweight/obesity by establishing healthy eating and exercise habits. Again, the goal is to prevent childhood obesity.

lmsalv: My child is 8 years old. Is that too young to have her start measure and counting calories for what she eats? She in 50 percent for height and 90 percent for weight. Most of it is belly fat.

Dr__Naim_Alkhouri: This is the perfect age to intervene. Growing children may not need to lose weight. Weight maintenance along with linear growth can lead to reversal of overweight. No need to count calories; simple lifestyle changes can make a big difference.

For example: Cleveland Clinic Children's Hospital 5 to GO!

• 5 a day fruits and veggies – for a healthy body, healthy life!
• 4 dairy or calcium servings a day – for strong bones!
• Give and get 3 compliments a day – to build self-esteem! We remember to criticize, but we need to remember to praise...
• 2 hours or less of TV/media/computer/screen time a day, not counting homework – for a healthy brain!
• 1 hour or more of exercise a day – for a healthy body!
• 0 fluids containing calories except for low fat milk!

5-4-3-2-1-0-GO!

General Questions

Ryan_j: Can you explain what biliary atresia is and does it predict or lead to liver disease later in life?

Dr__Naim_Alkhouri: Biliary atresia is a condition where a newborn has obliteration of his or her extrahepatic (outside the liver) bile ducts, which leads to liver cirrhosis during infancy. The Kasai operation is performed for this condition to establish drainage of bile; and if this fails, then a liver transplant may become necessary.

jpendergast: What types of programs are recommended for obese children between 5 and 10 years old?

Dr__Naim_Alkhouri: We have several programs at the Cleveland Clinic that can help your child.

I personally see children of all ages at the Preventive Metabolic Clinic on the main campus of the Cleveland Clinic. This is a multidisciplinary clinic targeted toward preventing/treating childhood obesity and its complications. We have a registered dietician and an exercise physiologist to help achieve our goals.

Dr__Naim_Alkhouri: For more information on this and other programs at Cleveland Clinic Children's Hospital, please visit: clevelandclinicchildrens.org/healthykids.

BabyB: Do you recommend surgery for children? If so, at what age and under what circumstances? Also, if so, what are the particular concerns for children having this type of surgery?

Dr__Naim_Alkhouri: Bariatric surgery (gastric bypass and gastric banding) can be considered in adolescents with severe obesity with other co-morbidities after failing at least six months trial of medical treatment.

Cleveland_Clinic_Host: To make an appointment with Dr. Alkhouri or any of the expert pediatric specialists or nutritionists at Cleveland Clinic Children's Hospital, call 216.444.KIDS (5437) or visit us online at clevelandclinicchildrens.org.

jpendergast: Realizing that obesity in children is a systemic issue, what sorts of policy changes would you like to see in afterschool programs?

Dr__Naim_Alkhouri: Vending machines with only healthy choices should be allowed. Increasing exercise requirements should be encouraged. There should be more emphasis on nutrition education electives in schools.

Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Naim Alkhouri, MD, is now over. Thank you again, for taking the time to answer our questions about Childhood Weight Management.

Dr__Naim_Alkhouri: Thank you very much for giving me the opportunity to answer your questions regarding childhood obesity.

More Information

Cleveland_Clinic_Host: To make an appointment with Dr. Alkhouri or any of the expert pediatric specialists or nutritionists at Cleveland Clinic Children's Hospital, call 216.444.KIDS (5437) or visit us online at www.clevelandclinicchildrens.org.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on 9/9/2011

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