Talking About Obesity in Children with Lina Alkhaled, MD

Podcast Transcript

John Horton:

Hey there, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Talking about weight makes people uncomfortable. Focus a weight conversation on kids, and the topic tends to get even more awkward. But it's an issue that needs to be discussed. Early obesity establishes a pattern that can lead to a lifetime of weight and health challenges. Kids who carry extra pounds are just more at risk of developing chronic life-altering medical conditions as they grow up. So today, we're going to talk about those long-term effects with Dr. Lina Alkhaled, a specialist on pediatric obesity. Dr. Alkhaled is one of the many experts at Cleveland Clinic who visit our weekly podcast to chat about important health issues. So let's take a look at the childhood obesity epidemic and, more importantly, how we can find a healthier path forward for our youngest generation. Welcome to the podcast, Dr. Alkhaled. Thanks for stopping by to chat.

Dr. Lina Alkhaled:

Absolutely. Thank you for having me. It's a pleasure being here with you guys. Thank you.

John Horton:

So when it comes to children with obesity, the trend seems pretty obvious. The CDC reports that nearly 1 in 5 children now qualify as having obesity, double what it was in the 1990s and four times what was seen in the 1970s. Given that, is it fair to call this an epidemic?

Dr. Lina Alkhaled:

Yes, absolutely. Actually, with these numbers that we've been seeing for the past few decades, pediatric obesity definitely has become this new epidemic. Unfortunately, it's actually, the pediatric overweight and obesity now, it affects more than 30% of our children. So this actually makes it the most common chronic disease of childhood.

John Horton:

Wow.

Dr. Lina Alkhaled:

So this is definitely an epidemic.

John Horton:

Well, and there's definitely a lot to discuss here. So I think, though, a good starting point might just be defining what qualifies as having obesity. Where is that line?

Dr. Lina Alkhaled:

Absolutely. So I'll just try by maybe defining obesity in adults, so that will be a little bit easier when we talk about obesity in pediatrics. So for adults, we all use the BMI, or the body mass index, which is an absolute number that we use with certain cutoffs to define overweight, obesity, different classes of obesity, et cetera. This is usually calculated based on your height and weight, and we use certain formulas to get this number. In pediatrics, we still use the BMI, so we still calculate the BMI. However, we do not use an absolute number, so do not have a number that defines obesity; however, we plot the BMI value on certain curves. We have BMI curves for males and females, and based on where that point actually lands on the curve, we can define obesity or overweight. So generally speaking, if the BMI is at the 85th percentile or more, this is considered overweight. If it's at the 95th percentile or more, this is considered obesity. And then, we have also different classes for class one, two and three obesity, but that will be more for the extended BMI curves.

John Horton:

I know a lot of times you hear, when parents maybe talk about their kids, they'll say, "Oh, they have big bones," or whatever, and I know that you hear about issues with BMI. Does that factor in, too?

Dr. Lina Alkhaled:

Whenever we evaluate kids or children with obesity, there are actually some syndromic or monogenic causes or genetic causes of obesity that can actually give you this “big bones.” So this might be 5%, 7% of all patients with obesity. The majority, I would say, and the majority of our patients, I would call them as just exogenous obesity, increase in weight. That's with no specific genetic problem. But generally, whenever we evaluate these kids, we want to make sure that this is actually not something going on, so there's no genetic cause of their weight gain, there's no hormonal cause of their weight gain.

John Horton:

As you mentioned, there are a lot of factors that go into leading to obesity. And given that this trend started a long time ago, why is it happening? Why are we seeing just weight tick up in children?

Dr. Lina Alkhaled:

So for the longest time, we used to think of obesity as something related to food intake and exercise. So we would always ask you to eat less and move more. There was a lot of blaming, there was a lot of shaming for weight gain. We would always attribute the weight gain to lack of willpower, per se. However, actually, what we've learned over the past few decades or so, obesity is actually a very complex disease. It's a complex chronic disease. And what I mean by complex, there are so many factors leading to why certain people gain weight compared to other people. So if we're starting actually … your risk for developing weight gain or developing obesity later on actually starts in the womb before even you were born. So just having a family history of obesity, so genetics, that would increase your risk of obesity later on in the future.

And it's actually not just the genetics, not just your buildup in DNA, it's actually … there are even more complicated factors, things we call epigenetics. So you can have the same DNA, so that same genes, but the way actually your genes manifest itself, it's kind of different just based on the environment that you live in. So of the environment that you live in promotes obesity, like there's a lot of junk food, there's lack of activity, et cetera, that would actually increase your scope of obesity. It's known now that babies who are born premature, or the babies who are very low birth weight, so they're very small when they're born, and usually, these kids, they're undernourished, I would say, in the womb, and when they come here, outside, we try to overfeed them so they can catch up. And usually, with this process, we're increasing their risk of obesity later on.

There is a lot of hypotheses about actually using antibiotics in children and mainly how many times you use antibiotics, if you use more stronger antibiotics, actually, that can cause weight gain. A lot of hypotheses about possibly tonsillectomy. Just actually having your tonsils removed can increase your risk of obesity in childhood. And I'll say that we all have these healthy bacteria in our gut, kind of usually helps us absorb nutrients. And it's found actually that patients who have a certain type of this bacteria have a higher risk of weight gain than compared to other people.

And nowadays, we're eating a lot of processed food and this processed food actually has altered our own bacteria, our own healthy bacteria. And actually, this also has changed the way we are metabolizing the food and has increased our risk of developing weight gain. Parents, actually as role models, we're using food as rewards. We're introducing food early [inaudible 00:07:31], I would say the solid food early on, maybe this high protein that we're giving the babies at a very, very young age, sometimes can play a role. Not sleeping well overnight, so not having a good sleep hygiene — that actually increases risk of childhood obesity.

I can go on and on for days about this, but basically, it's a lot. And actually, that's what I like people to know and our patients, I like to discuss with my patients — this is a very important point — that because of all of these factors, because of this complex disease, that even the environment actually can play a role and being exposed to certain viruses, chemicals, air pollutions — but all of these factors would play a role in the youth, in some people developing obesity. So this is why we say this is a complex disease. This is not a lack of willpower. This is not just something to be blamed or shamed for.

John Horton:

It's such a different thing because you're right, I think for a long time, people just assumed it was … you're eating too much and not exercising enough. And it does seem far, far more complex than that. And I can see why it's very interesting on your end to try to look at why somebody is in a certain spot.

So Dr. Alkhaled, what kind of health issues do you typically see in children that have obesity?

Dr. Lina Alkhaled:

There are many of them, many of these issues, and I would say mainly, I would start about with this main health issue that, unfortunately, a lot of times, actually, it gets overlooked by physicians and providers, which is the psychosocial aspect of it. And I would say that it was found that kids and children with obesity actually have a very poor quality of life. It's even poorer than kids with cancer. So it has a very negative impact on their mental health. There's a higher risk of depression in these kids that even carries over actually into their adulthood. So this is always something that we have to be very mindful of when we're discussing this very sensitive topic with these patients.

In addition to that, we have definitely, with increased weight … there's an increased risk of developing different aspects of the metabolic syndrome — so having higher risk of diabetes, higher blood pressure issues with cholesterol. Even actually with these kids who are growing, this extra weight on the joints, actually can affect their joints and they can have issues with their joints as well. There is a higher risk of having just acid reflux. There's a higher risk of developing even actually increased pressure in the brain. That can happen in certain cases, what we call — it's a condition called pseudo tumor cerebra, but it's actually a very serious condition that's a lot of times, actually just related to increased weight gain and obesity. And the list goes on and on.

John Horton:

And then, looking ahead with children with obesity as they become adults, I'm guessing a lot of those health issues tied to weight kind of follow them and may actually get worse.

Dr. Lina Alkhaled:

Absolutely, yes. So a lot of these health issues, as I said, they actually carry over into adulthood. As I said, depression actually can worsen even in adulthood. Diabetes that can actually become more severe to manage even in adulthood, high blood pressure, all of these complications, absolutely. Sleep apnea, which I did not mention, also a big one, that can happen and also continues in adulthood. So the majority of these complications, if we're not managing obesity, that will actually carry over into adulthood. And in the same token, I would actually say that children with obesity who attain a normal weight prior to adulthood, usually, they have outcomes similar to those adults who never suffered from obesity. And this kind of also is very important to let us know that we have to be, maybe a little bit more aggressive in managing obesity in childhood, so we're preventing these complications in the future.

John Horton:

How much of future heart disease cases can get traced back to obesity during childhood?

Dr. Lina Alkhaled:

So a lot of these, the heart diseases by itself, I would say it's related to so many factors. So you're developing diabetes along with obesity, that's very closely linked to obesity. Developing high blood pressure, developing issues with your cholesterol. And all of these factors also tie together, these actually would lead to increased risk of heart diseases in the future. So I would say, it's very closely linked, but also through developing maybe multiple steps of having other complications as well.

John Horton:

Because as we've always seen with healthcare, nothing is just one thing leads to another, there's always complications around it and variables. All of these potential long-term issues, they definitely are not something that you want for your child. So here's the big question: Can we reverse this trend and start bringing obesity numbers down? What can we do?

Dr. Lina Alkhaled:

Absolutely. So this is a good question and actually, I will say, we have to start now, we have to start very soon and we have to be aggressive. But generally speaking, because this is more of a generational problem and this happened over generations, just like knowing about genetics and epigenetics, we might need actually few generations until we reverse this. So this might take a longer time. Whenever I'm managing obesity, I'm trying to talk to my patients, we talk definitely about lifestyle. So there are a lot of things that we have to optimize and make sure that we're taking care of. Screen time that's less than two hours per day. Stopping or discontinuing all the sugary beverages, so no juices at all. This actually has been proven that will decrease your risk of obesity and actually causes weight loss in pediatrics.

Sleep hygiene, so sleeping a good amount of time overnight and not having kids staying up all night, sleeping in all day long. This is actually not healthy and not helpful also for weight maintenance and weight loss. Trying to eat the least amount of processed food. I know this is very hard and challenging in this day and age because almost everything's processed at this point. So what I would tell my patients is try to do the least processed versus ultra-processed. So if you can't really tell what are the ingredients in the food that you're eating, maybe this is too processed, it's ultra-processed. Also, just having the parents as role models. So if we can all exercise together, we're all eating healthier together, this definitely helps actually with the weight management.

John Horton:

How would you recommend that parents address talking to their children about having obesity or having overweight to kind of avoid those feelings of fat shaming that you were talking about earlier?

Dr. Lina Alkhaled:

Absolutely. So this is actually, it's a very sensitive topic, and a lot of times, we actually do a little harm unknowingly and it was just based on the language that we're using with the kids. So I usually recommend to address that from a health standpoint, that this is not something that we have to blame the kids for. So this is maybe the first thing. We're not blaming, we're not shaming. We know that this is a chronic condition, it's a chronic disease. It's the same way you manage diabetes or high blood pressure. It's one of these diseases, one of these chronic diseases. So we have to address that from a health standpoint. That we are trying to be more healthy. We're trying to actually just to implement healthier stuff so you feel more energized, you do actually have a better sleep, prevent the future complications, which is, make sure that they're not developing any heart diseases in the future, as you said, or diabetes or other chronic conditions.

So I would usually like to address it from a health standpoint, not just the weight number standpoint. And at least, I would say, at the Cleveland Clinic, we're actually blessed to have a lot of our psychologists who are also specialized and obesity. Because we can actually have a lot of kids, they develop obesity with eating disorders. So you can have eating disorders, you can actually have body dysmorphia with obesity. So during my evaluation for these patients, I always try, whenever I actually hear that maybe there's some concern about eating disorder or maybe something else going on, I would always try to have one of our colleagues just also talk to these patients and assess them, just to help them reshape or change the way we're thinking about weight gain so there's no blaming or shaming.

John Horton:

It's a very sensitive issue for people and it's a tough topic for adults, and I'd imagine it can be even tougher for children.

Dr. Lina Alkhaled:

Yes. And that's actually not just at home, it's actually at school. And I can tell you, kids can be very mean. So I hear a lot of stories about other kids bullying, teasing, physical fights just because of the weight, which is unfortunate. So I feel like this is something we have to be very mindful of. Even just talking to teachers, principals, just at school, that these kids — actually even they can hear comments from other kids. And unfortunately, some of these comments are really, really mean. So it's something that needs to be addressed on so many levels.

John Horton:

So Dr. Alkhaled, you mentioned a bunch of kind of actionable tips that people could do to help with this and stuff, like making sure you get enough sleep, getting a little more exercise or activity, watching what you eat, eating more, you said, natural foods as opposed to the processed ones. If you do a lot of these things, can you undo the damage that maybe was caused by having some extra weight and maybe avoid those negative health issues during childhood and later in life?

Dr. Lina Alkhaled:

Yes, absolutely. So as I said before, being aggressive and trying to address these issues early on — a lot of these kids with obesity who were able to attain this normal weight prior to adulthood, usually they have a similar outcome to adults who never suffered from obesity. So basically, we're able to reverse or at least hold this progression of these diseases. And I would say it's because we now actually believe, or actually, we understand, that this is a complex disease.

A lot of times, maybe this is something I would like to share here, is that lifestyle can help a little bit, but a lot of times, if I see that the patients are still not responding, and I know because you know that there are so many factors causing this weight gain, there are so many medications that are approved to manage childhood obesity, and there's actually now approved for ages 12 and above, which is going to be a different topic. But basically, I would say using medications for management of obesity also would be something very helpful and beneficial in reversing these side effects or holding the progression of these complications of obesity later on. These medications, usually a lifelong treatment. So this is what I like to make sure that my patients are aware of. And the reason for that, for the use of medications in this population, all of these factors that I actually just mentioned, they change our hunger and fullness hormone, the balance between the hunger and the fullness hormone. So children with obesity have maybe a higher amount of the hunger hormone, less amount of the fullness hormone, or maybe they're more resistant to the fullness hormone, I would say. But basically, these medications can now reverse or can now restore the balance of the hunger and fullness hormone. So this is something also I would offer to my patients who actually I feel like they're qualified and they've tried a lot of lifestyle changes and they're just kind of hitting a dead end.

John Horton:

If parents are worried about their child's weight, how do you recommend that they approach that with their child's pediatrician? How do you start that discussion?

Dr. Lina Alkhaled:

Generally, it's the reverse. So usually, I see these patients after being seen by their pediatricians. So the pediatrician usually is the one who would refer these patients to me. So I would say, maybe on the second step. However, I would like maybe for all physicians, all pediatricians, just try to keep in mind when assessing these patients, again, know that this is a complex disease — a lot of these factors we cannot really control when we're managing obesity. So try to be more mindful and sensitive when discussing this disease. A lot of parents feel a lot of guilt because they feel they failed their children, they cannot make them lose this weight. So trying just to explain this to parents and talk to the patients so there's no sense of guilt or shaming when we're discussing this disease. And just letting them know that we have, now, options for management of obesity, we have very effective options to manage obesity. And this is a chronic condition that needs chronic treatment, so I'd like to make sure that parents or patients do not get discouraged. It's a journey and we're here to help them and support them.

John Horton:

We've covered a lot of information here today, Dr. Alkhaled. So before we say our goodbyes, is there anything else you'd like to add regarding obesity in children?

Dr. Lina Alkhaled:

I feel like I said this multiple times and I would say one last time, as I said one more time, again, please think of it as a disease — treat the way you treat other diseases, thyroid issues, the way you treat high blood pressure or cholesterol. And I think we should not withhold medications if patients are not following lifestyle. Again, this is a chronic disease. And just keep in mind that this kid's quality of life is so poor, just be mindful of this and try to address this because this is, I would say, the most significant thing that I really deal with on a daily basis with these kids.

John Horton:

I think that makes the point perfectly, Dr. Alkhaled. So thank you very much for taking some time with us today and I look forward to having you back on the podcast.

Dr. Lina Alkhaled:

Yeah, my pleasure. Thank you so much for having me.

John Horton:

There's no question that childhood obesity is a major health concern and reversing this trend won't be easy. It will require lifestyle changes, tough choices and a significant commitment. It's worth the effort, though. Consider it an investment in a child growing up to live a long and healthy life. If you like what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Till next time, be well.

Speaker 3:

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