A FORWARD-THINKING U OF M TEAM TRIES A NEW APPROACH IN THE FIGHT AGAINST CHILDHOOD OBESITY
Aaron Kelly and Claudia Fox knew they were failing.
The faculty members in the University of Minnesota Medical School’s Department of Pediatrics were frustrated they couldn’t do more to help kids who have severe obesity, a condition that affects 80,000 children and adolescents in Minnesota and 4 to 5 million nationally.
For years, the popular consensus—both in the eyes of the public and in the medical community—was to prescribe what Kelly calls run-of-the-mill solutions: more exercise, less junk food, more fruits and vegetables. Although diet and exercise are important, those obvious lifestyle modifications were proving to be ineffective for kids whose body mass index (a measurement of body fat based on height and weight) is in the highest 1 or 2 percent.
“These are the kids who need our help the most,” Fox says. “So, if lifestyle changes aren’t working, what else can we do?”
To answer that question, Kelly and Fox realized they needed to start thinking about obesity differently.
“We said, ‘We need to think of obesity as a disease and we need to treat it as such,’” Kelly says. “You don’t just tell someone with diabetes to try harder or someone with depression to cheer up. These are diseases with underlying causes. And obesity is no different.”
Nearly a decade after their initial conversations, the two are now co-directors of the U’s new Center for Pediatric Obesity Medicine, a comprehensive program funded in part by Minnesota Masonic Charities that unites innovative research, compassionate care, education, and public advocacy to help kids with severe obesity.
“We want to improve their quality of life,” Fox says.
UNDERSTANDING THE PROBLEM
Severe obesity can cause an array of health problems in kids, including a build-up of plaque in the arteries, high blood pressure and cholesterol, and increased risk for heart disease and diabetes—health concerns that typically don’t surface until adulthood. And the psychological effects caused by weight-related bullying—such as anxiety and depression—are also very real.
Part of that stems from a cultural stigma surrounding obesity: most people see the condition as a behavioral choice rather than a real disease.
“I have 7-year-old patients who get bullied in the bathroom because they’re big,” Fox says. “But it goes all the way up to adults who have obesity whose doctors think that every problem is automatically related to the extra weight, rather than really hearing what the patient has to say. It’s pervasive.”
The idea that severe obesity can be overcome by hard work and better choices has led to a dearth of evidence-based approaches to treat the condition, Kelly says. When he came to the U in 2008, little was known about severe obesity other than that it was on the rise. On the other hand, moderate obesity—defined as children and teens whose BMI is higher than 85 to 95 percent of their peers—was leveling off.
Around that same time, Kelly and his research team enrolled 20 teens with severe obesity in an intensive 12-week lifestyle modification program. Their weekly visits included diet counseling, physical activities such as tennis, swimming, and walking, and free gym memberships. In other words, it was a prescription of what everyone thought would work.
The results? “We didn’t see a change in weight or BMI,” he says. “It was a sea change for us. We quickly realized that we were in the dark ages of obesity medicine and that we needed to start thinking differently about how we were approaching this group of teens.”
The first step, Fox says, was embracing the idea that severe obesity cannot be treated with one-size-fits-all behavioral changes, because the disease itself is influenced by far more than a person’s behavior. In fact, she says, 40 to 70 percent of a person’s BMI is determined by genetics, which means no matter how much a person wants to gain or lose weight, it’s not entirely up to them.
“Severe obesity is a disorder of energy regulation—that’s all it is,” Fox says. “It’s not from eating too many cookies or watching too much TV. It’s a dysfunction of how the body operates.”
Kelly recalls one of Fox’s patients who, despite limiting herself to 1,400 calories per day, was unable to lose weight. “The knee-jerk reaction was that she was not complying with the dietary advice,” he says. “But we found that her body was burning half as many calories as it should have been. In order to lose weight, she would’ve needed to limit herself to just 800 calories a day.” That’s the equivalent of approximately one bagel with cream cheese.
Kelly says the lack of medical evidence for treating severe obesity in young people—combined with society’s preconceived notions about people who are overweight—underscores why new approaches are so necessary.
“It’s easy to judge,” he says. “But how would you do eating just one bagel per day? We need to come up with good treatments that will always be there, and we will continue to try things outside of the box. We can and must do better.”
The Center for Pediatric Obesity Medicine prides itself on that outside-of-the-box thinking, Kelly says, including one idea that might not seem unique at all: treating kids and teens who have severe obesity with medication.
Medications for adults are widely available, but the options for children are limited. Kelly says the discrepancy stems from the idea that obesity in kids should be controlled by behavioral changes.
It’s an exasperating double standard, says Megan Oberle, a pediatrician and researcher at the center, especially because existing medications could have life-changing benefits for people younger than 18.
“It’s frustrating as a pediatrician to see these medications for adults but not be able to use them in kids,” she says. “So you wait until they turn 18 to try these interventions, and by that time the person has gained more weight and gotten much sicker.”
That’s why the center’s work to examine the effectiveness of obesity medication in children and adolescents is so important. “I think this is the beginning of a new mindset for pediatrics,” Oberle says.
One of the center’s current studies involves an existing diabetes drug called exenatide, which has a side effect of weight loss. When combined with diet and lifestyle modifications, exenatide led to significant weight and BMI reductions in a small group of participants in a pilot study. Today, Kelly and his team are working to recruit a large group of teens to enroll in a more expansive study of the drug.
Health in a box
Megan Oberle, a member of the U’s pediatrics faculty and recipient of the Masonic Early Investigator Award, tested a meal kit subscription program—similar to commercial offerings like Blue Apron or Hello Fresh—at the U’s pediatric weight management clinic and found the program was both feasible and popular with patients and their families.
During their regularly scheduled clinic visits, 20 families received a dietitian-approved meal kit, which included recipes and nonperishable items to make two healthful dinners. Oberle says families were surprised by how easy it was to cook simple, healthful meals and wanted more guidance on this in the clinic.
“And they were surprised by the portion sizes,” she says. “We had several parents say that it was eye-opening to give their child a smaller portion but have them feel full and not ask for more. We think this type of tool can be a foundation for other interventions.”
Meanwhile, Fox is leading a clinical trial that asks two foundational questions: At what point should children with severe obesity start taking medication, and what medication should they take? She is trying to create a treatment algorithm for kids by using two drugs—one that was developed to treat seizures and migraines, but has shown promise for treating obesity in adults, and another that’s used as an appetite suppressant in adults.
“We’re looking at when is the best time to start obesity medication if a kid does not lose weight with diet and exercise alone,” she says. “And if a kid doesn’t respond to one medication, should we switch to a different one? Or should we combine it with a second medication? These are questions that are asked whenever you establish how a disease is treated, but we don’t really have that information.”
That study takes a personalized approach to treating obesity by taking into account each child’s unique characteristics—factors like genetics, hormonal response to treatment, and medical history.
“Obesity is a very different condition for each person,” Fox says. “A given treatment strategy might work really great for one kid, but not so great for another, and we want to figure out why that is. It’s about finding the right treatment for the right patient at the right time.”
The group is also pursuing additional ideas that may show promise for kids with severe obesity. For example, they’re exploring gut microbes that may affect how the body uses calories as well as whether magnetic resonance imaging (MRI) can identify areas in the brain related to eating behaviors and obesity.
Kelly says several of these studies, which are supported by Minnesota Masonic Charities, are the first of their kind. “We’re trying big ideas,” he says. “It allows us to collect that preliminary data and say, ‘This isn’t worth our time’ or say, ‘Hey, this is a really good idea. Let’s make it a bigger study.’”
DRIVEN TO DO MORE
In addition to exploring new treatments , Kelly and Fox want to be advocates for the kids they’re helping.
For Kelly, that meant meeting with Minnesota lawmakers earlier this year to drum up support to expand the Best Pharmaceuticals for Children Act to include obesity as a priority disease. The 2012 law encourages the pharmaceutical industry to conduct research that could extend the use of existing drugs to treat childhood diseases. It was his first foray into political advocacy, but Kelly says it won’t be his last.
“Childhood obesity is the most prevalent chronic disease that we see, and it leads to so many other health concerns,” he says. “The more we can do to further research into treating the disease, the better.”
The center has also created a fellowship in pediatric obesity medicine—one of the first of its kind in the country—with the goal of training the next generation of doctors in state-of-the-art medical care for kids with obesity. Fox says getting more physicians interested in this field is part of the center’s long-term mission to create a supportive, positive culture around obesity care.
Ultimately, Fox and her colleagues want to eliminate the stigma around childhood obesity and change the way people think about the disease.
“I don’t think people understand what it’s like to live with severe obesity, especially as a child,” she says. “Many are not happy. They’re ostracized, they don’t fit in at school, they can’t keep up with their peers. And they can’t hide, because obesity is such a visible disease. The clock is ticking, and we need to be here to meet the needs of these kids.”
Justin Harris is a contributor to Legacy magazine.