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Melanie: Childhood obesity is now one of the most important public health problems facing children today. There's no handbook for your child's health, but we do have a podcast, featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels.

Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole. And today, we're examining childhood obesity. Joining me in this round table panel is Dr. Marisa Censani. She's the Director of the Pediatric Obesity Program at Weill Cornell Medicine and New York Presbyterian Komansky Children's Hospital and an Associate Professor of Clinical Pediatrics at Weill Cornell Medicine and an Associate Attending Pediatrician at New York Presbyterian Weill Cornell Medical Center; and Isabel Reckson, she's a registered dietician and Certified Diabetes Educator in Pediatrics at Weill Cornell Medicine.

Ladies, I'm so glad to have you with us. And as we were talking before this podcast, we know the passion that we all share. And I share it with you. So Dr. Censani, as we're getting into this topic, tell us a little bit about the current state of childhood obesity today. We're calling this really an epidemic, yeah? So tell us about what you see on a daily basis.

Marisa Censani: Thank you so much for inviting us to speak on this important topic with you today, Melanie. September is National Childhood Obesity Awareness Month, and this is a really important time where we can learn about the ways to prevent obesity and to promote physical and mental health in our children.

So this is really important, because the childhood obesity rate has more than tripled over the past 30 years, and obesity is now affecting 19% or almost one in five children and adolescents, between the ages of two and 19 in the United States. And in fact, this is most important because pediatric overweight and obesity now affects more than 30% of our children. And it is the most common chronic disease of childhood.

Melanie: Wow. It's really fascinating what we've seen as a change. So as we're defining what obesity is, tell us how you measure it. And is it different for adults and children? Tell us how you calculate it and really how we know.

Marisa Censani: So during childhood and adolescence, body mass index percentiles are based on the height and weight and the age of males and females. And we use this to determine BMI status in the children. So BMI percentiles are very important in childhood obesity management. So when I see a child and family coming to me for an initial consultation, I always review these BMI percentiles and growth charts with the family. And so we discuss that a body mass index percentile between the 5th and 85th percentiles, it's considered a normal BMI status. A child's BMI in the 85th to 95th percentile meets criteria for overweight. And if you have a BMI that's equal to or above the 95th percentile, this meets criteria for obesity.

And so there are CDC growth charts that are available to pediatric providers in clinical practice that I do review with my patients. And in addition, there are also online resources, applications, and calculators that provide this BMI information for families, so families can actually use them to calculate their child's own BMI percentile.

Melanie: So Isabel, what a complicated issue that we have here. There's so many causes that can hinder a healthy situation for kids. Tell us a little bit about why you think this is such a big problem and getting worse. I mean, we're seeing schools cutting some recess and gym. And now in COVID time, of course, a lot of this is exacerbated by kids not moving around as much. What about communities and the built environment and what you've seen? Tell us a little bit about this complex issue.

Isabel Reckson: Yes. So first, Melanie, thank you again for having us today. And just as you said, we have really seen increased rates nationally. In our own practice, Dr. Censani and I, we've seen more kids during COVID come in with excessive weight gain and such.

And so causes are really multifold. Directly, we think about nutrition and physical activity and how that affects childhood obesity. But really, we know that societal and policy changes are largely to blame, which includes a big shift towards more convenient foods and ultraprocessed foods, and just overall less opportunities for movement.

The pandemic, as you mentioned, cut out school gym, cut out recess, opportunities for kids to move regularly and increased screen time. But additionally, even just the infrastructure of our cities, the way our cities are built, do all communities have access to sidewalks? To safe places for kids to move around? To bike lanes and such like that? I think it's really important when we address this topic to really look at the inequity in our food systems, and to know and understand that obesity does disproportionately affect children and families of lower socioeconomic status. And one of the big contributors of that is really food insecurity, which is lack of access to safe and nutritious foods. And that on its own can cause serious stress, anxiety, and depression, which has been shown in some studies to actually further increase rates of obesity. So it's a cycle there.

On the community effort, we know that community intervention can be really successful whether it be on a more local scale or national scale. Starting with places to move around for kids as mentioned, we need to safe places such as parks and playgrounds and bike paths. City resources, so here in New York city, there's New York city parks. They have something called Shape Up NYC and they offer free workout and exercise classes. After school programs are really key to get kids moving, community centers and even nonprofits, something like Harlem Children's Zone, which does offer exercise opportunities for kids.

Nutrition education from myself, coming as a dietician, I think is crucial. I personally feel that nutrition education should be in school curriculum, though that's on a more broad scale level there. Otherwise, I do think dietician visits should be normalized into doctor's office visits and that's something that Dr. Censani and I work together to really try to promote is if a child does come to us for obesity or excessive weight gain, having a whole approach that does include both of us, the medical and the nutrition aspect, as well as additional resources.

And then just lastly, one other thing to mention, as I said before, is it is really important that we do have access to safe and healthful foods. Just specifically in New York city, that could be through supermarkets, farmer's markets or even community gardens, like Grow NYC where families do have that access and are able to get the food that their families really need.

Melanie: Dr. Censani, and thank you, Isabel, for that comprehensive answer, such a complex problem that we're discussing here today. And Dr. Censani, when we talk about treatment options and as a pediatrician, do you discuss this with families? Are they hesitant? Do they acknowledge that their children have this issue? Do you see it running around in families? When they come to you, what are some of the treatment options available? How does the whole process work? Because it's very sensitive. And as I've learned in the field, we have to, as parents, be very careful how we ourselves are role models. Exercise, eating healthy, but also how we speak to ourselves. And especially our girls, hearing us look in the mirror and say, "Oh, you know, I'm so fat" or, "Oh, should you be eating that?" I mean, there's so much involved, right? So when they come to you, how is it that you work with them? It's a pretty sensitive topic.

Marisa Censani: Right. So this is a great question. So typically, when pediatricians are approaching families, it's really important for us to assess the medical risk of our patients in addition to family concern and motivation. We assess birth history. We assess, you know, past weight gain or loss, growth patterns, nutrition, physical activity, sedentary behavior. We review the parental obesity. We review family history, of course, of any of the complications that can be related to obesity, including hypertension, cardiovascular disease, obstructive sleep apnea.

Now for children with obesity, our focus is really on intervention. So there is actually a four-stage approach to managing obesity and this is recommended by the American Academy of Pediatrics. Stage one typically involves general recommendations for healthy habits, which we discuss with our families. We talk about incorporating at least five servings of fruits and vegetables daily. We encourage more physical activity. Stage two, then moves on to more structured weight management to approach patients, focusing on more targeted goals. We develop daily eating plans that are created by a dietician. We really emphasize an hour of supervised physical activity daily.

And typically, we progress in these stages and that if there's no success in three to six months, a patient is then advanced to a more stage three comprehensive multidisciplinary intervention. And this involves a pediatric weight management specialist with intensive lifestyle interventions. This includes a structural behavioral modification program. We do food and activity monitoring, short-term diet and physical activity goals with a multidisciplinary team, which is something that we really focus on at Cornell with our behavioral specialist, our nutritionist, the medical team. It's really this variety of people that are involved the management care. There's increased frequency of visits, and this could be from monthly to weekly. There's planned meals, food logging. Parent participation is so vital in the behavioral modification with families. And this helps to work on improving the home environment. Group visits at this stage have also been shown to be having a really therapeutic effect, which we have our own program, our Kids and Teens Healthy Weight Program as well as commercial weight loss programs are considered at that stage.

And then finally, stage four is the last stage, and this is more of a tertiary care intervention. And this involves potential pharmacological intervention, also consideration for eligibility for bariatric surgery. So as you can see, there's a variety of ways to approach the management and treatment of pediatric obesity. And it's really specific to each family and we work together with the families with this multidisciplinary care.

Isabel Reckson: Yes. And I just love to add to what you said, Dr. Censani, just about our whole family approach that we use in our practice. We really do emphasize and encourage family involvement and the importance of social support, whether it is from family or even friends. In terms of family involvement, that could be family meals together. It could be bringing the child grocery shopping and looking up recipes together to promote change in dietary habits.

But also, as you said, Melanie, it's really important to be mindful of the language we use and our attitudes surrounding food. But we've seen situations where kids have been told to eat a certain way. Parents might say, "This food is bad for you" or something like, "This food might make you fat." And what happens is that often leads children to seek food outside of the home and might create guilt with certain food choices. So our goal is to foster a healthy relationship with food and teach kids balanced nutrition in a way that's also going to support their overall mental and physical health.

Marisa Censani: I agree, Isabel. I think the key is for families to support dietary changes for their children, incorporate these changes for the entire family. Maintaining this balanced diet is really key in promoting healthy weight in general and encouraging and supporting children as they try new foods and they help to prepare meals, gives them a healthier approach to their dietary choices, but also really emphasizing the physical activity and being involved in what your child is doing. I think that's really key as well for families. The whole family-based approach, I think, is very vital.

Melanie: And Isabel, expanding on that for just a second and before we wrap up, I'd like to give you each a final thought. But Isabel, when you're working with families, culture can be involved. There are cultural issues with the type of food that people eat and, you mentioned earlier, even food insecurity, which is really this obesity paradox in some of these underserved areas as well. So speak about how your program uses the multidisciplinary approach that Dr. Censani mentioned and how you work with these families all together.

Isabel Reckson: We have different kinds of interventions in our program, as Dr. Censani mentioned. I might do one-on-one nutrition counseling, or we do have the kids and teens healthy weight program, which is more of a group approach. But either way, we really do promote family involvement. And I think one of the really important things is that a lot of times families come to us looking for an exact plan, but I really like to let the families take the control. And people come from different backgrounds and different foods. And rather than saying, "This is the way you have to eat," you know, finding a way that we can make nutritious choices with the foods that they culturally have in their everyday lives.

So putting the child in the hot seat, putting the family there to sort of say, "What are changes you're open to making?" How can we improve upon your child's health with some of the staples that you're ready to include in your life is just really so important. So I try to practice using motivational interviewing techniques and creating realistic goals that are sustainable, rather than necessarily putting children on a diet or following a specific meal plan. Because I think it is really important to see what a family is open to doing differently and how we can include things that are already part of their lives into their dietary and activity changes there.

Marisa Censani: I agree. And our goal really is to address obesity and its co-morbidities during childhood, screen these children to find those at increased risk. It's incredibly rewarding to provide this comprehensive obesity care to children and adolescents and guide families through their medical journey to healthy weight, which is so vital to start early on in childhood. If we can intervene early on and prevent these future health complications, we're really helping to give these children a healthy future.

Melanie: And Dr. Censani, first last word to you. What do you want families to know if they're looking at their children or if they're obese as a family, where do they turn to help? What is the first step? Is this something the pediatrician will identify with them? Where do they turn? What do you want them to know?

Marisa Censani: Absolutely. So it's very key. There's certain risk factors for childhood obesity. I think that's something as pediatricians that we are often screening for our children. These include the sedentary lifestyle, the poor diet, the minimal exercise. These are certainly things as I discussed that families can work on and improve.

You know, as a pediatric endocrinologist and obesity medicine specialist, that is something that's really important for me, is to be an advocate for the health of our patients. And we are there to help parents and guide them through this process. Sometimes it's just making these small changes and even just focusing on whole grains, fresh foods with fibers, limiting high-calorie sugary drinks, processed foods, having more fiber fruits and getting them involved in physical activity, but also just kind of giving them the guidance and the support they need. And we do do that through a variety of different mechanisms as we were discussing with Isabel. We do have our Kids and Teens Healthy Weight Program. These are interactive small group sessions. They focus on healthy eating and important food and nutrition concepts.

We meet with families individually. I meet with my families, Isabel meets with them. We have a behavioral specialist that meets with them. We have a variety of individuals that are there, and then we provide these additional educational group sessions, which they're very hands on, cooking demonstrations, label reading, supermarket shopping, restaurant dining. And we're just really exposing the children to different foods, different activities, different resources, things that they weren't aware of previously. And it's really rewarding to see when they're trying a new food for their first time. They're preparing a recipe in a different way. And then they have that social support and that structure. And so I think there's a variety of ways to approach families. But I think if families know that they are supported, they can come to their providers, and we can kind of guide them in their journey to healthy weight. I think that that is most important, to provide that structure and really help with the future health of our patients.

Melanie: Well, it's certainly such an important topic. And Isabel, last word to you. As you're working with food and cooking and this whole multidisciplinary approach, what would you like families to know about the program at Weill Cornell Medicine? How you can help their families from everything, from teaching them to cook, to learning to be good role models, all of it? Offer up your best advice, please.

Isabel Reckson: So I think it's really important to remember that nutritional needs for each child and each family are so individualized and we see so much stuff online in the media. You know, the diet industry that says, "This is the best for everybody, and this is the best thing." And it really doesn't take into account an individual child's needs. So as Dr. Censani said, we're really here help you and see what are the needs of your child and your family and how we can work to make positive change. And so I really think that individual needs-based assessment is just so key.

And something else, just to really notice that this is really hard. And the pandemic has been really hard for children and mental health is just so important to address. And we're here to try to offer services. We have, as Dr. Censani said, a behavioral psychiatrist on staff who does help with promoting behavioral change. And there's a lot of weight stigma out there and things that make it really difficult for children along with regular mental health concerns of COVID. So children with obesity have another level of possible contributors to anxiety and depression and disordered eating. So, obesity is really multifactorial. It's not one thing. So there's so many different things to consider. And that's what we're here for is to try to help our kids find the best approach for them and be here to really support our families.

Melanie: I want to thank you both for joining us today and discussing this very complex and sometimes heartbreaking issue. It's really multifactorial as you said, and there's so much that we can do. And listeners, please share this show with your family and friends on your social channels, because we are learning from the experts at Weill Cornell Medicine together.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Kids HealthCast. We'd like to invite our audience to download, subscribe, rate, and review Kids HealthCast on Apple Podcast, Spotify and Google Podcast. For more health tips, go to weillcornell.org and search podcasts. And don't forget to check out our Back To Health. I'm Melanie Cole.

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