You ride the elevator, clutching your son’s soft hand. Beyond a marbled expanse, the Dr. Bernstein Health & Diet Clinic comes into view. A slim but weary-looking nurse offers you an information package as you and your son wait for the doctor. If you go for it, your not-so-little guy will get three B-vitamin shots a week, between 950 and 1,300 calories a day, and no carrots, bananas or grapes because even the slightest deviation from the restricted food list may be detrimental to his success.
“His weight is off the charts,” his paediatrician had said, offering only a referral to a registered dietitian. You’ve done everything you could think of, saying no to the potato-chip pleas and trying — mostly in vain — to replace Nintendo with kneeling push-ups. At eight years old, your son is too young for Weight Watchers (it accepts members over 10 with a doctor’s involvement). The sole paediatric obesity clinic in your city treats only kids at risk for type 2 diabetes. And so here you are, in the peachy-beige gloom of the Dr. B Clinic, because you saw on its website that one boy lost 52 pounds in 3½ months. (The 60-clinic commercial operation — which guarantees a medically supervised weight loss of up to 20 pounds a month — has been targeting kids in Canadian newspaper ads too.) I just want my son to be healthy, you think to yourself, but why does the only option seem so extreme?
Geoff Ball, director of the Pediatric Centre for Weight and Health at Stollery Children’s Hospital in Edmonton, says he’s an optimist. But with fewer than 20 non-profit paediatric obesity treatment centres nationally, it’s not easy. “We know that there are about 1.6 million overweight children in Canada, yet these clinics maybe see a thousand kids who get referred for weight management.”
So what about the other 1,599,000 kids? There are registered dietitians, for families with money, insurance or access to a funded clinic. Some family doctors provide guidance on weight, but researchers say the majority don’t. Health Canada provides downloadable copies of Canada’s Food Guide and other resources at its website, hc-sc.gc.ca. There’s a new federal Children’s Fitness Tax Credit that allows parents to claim up to $500 of eligible expenses for each child under 16, says Claude Rocan, director-general of the Centre for Health Promotion at the Public Health Agency of Canada (PHAC). But while these initiatives may help prevent obesity, are they enough to assist the 26 percent of Canadian kids already tipping the scales?
Consider Sandy Alvarez* in Fredericton. “I knew I had a problem with Mike,” she says of her then 75-pound five-year-old. “He wanted food all the time.” Her family doctor outlawed snacks. A paediatrician told her Mike was fat and always would be. “I felt stunned and helpless,” she says. “I live in a small city — there were no other places for me to go.” A registered dietitian told Alvarez what she already knew. “We already ate three balanced meals a day, including whole wheat products; we drank only skim milk, water and 100-percent juices.” Luckily, Mike was accepted into a fledgling childhood obesity treatment initiative, the Learning, Eating, Activity Programme (LEAP!), at the University of New Brunswick. “A nurse, a dietitian, a leisure specialist and a sports therapist all worked with Mike at each appointment,” says Alvarez, who’s proud of her now health-conscious nine-year-old.
LEAP! only has the capacity to help 30 families a year due to limited funds and part-time or volunteer staffing, but at least Fredericton families have that. In Saskatchewan, for example, no such integrated obesity clinic exists for children. “Some jurisdictions haven’t identified it as a problem or don’t have the resources,” says Ball, an assistant professor of paediatrics at the University of Alberta. “It takes people, money, space and time — it’s difficult to go to a children’s hospital and say, ‘We need two million dollars to make an obesity clinic for kids.’”
*Names changed by request.
Given that obesity costs Canada about $2 billion annually, surely this would be money well spent. Prevention initiatives may provide the biggest bang for the buck, concedes Ball. “But you’re talking about overweight kids at risk for diabetes and heart disease — what do you do for these kids?” PHAC’s Rocan doesn’t have an answer. Treatment issues are a provincial responsibility, he says, adding, “we definitely want to be part of the conversation because we think it’s an important issue.” In the meantime, discouraged parents are understandably drawn to quick-fix diet solutions that can take a toll not just on their finances, but also on their children’s health.
Back at the Dr. Bernstein Clinic, the diet program is available half-price to kids eight years old and up. That rings in at about $300 a month, but the clinics try to accommodate financial stresses. Yet the true costs may be much greater. The Dietitians of Canada and every doctor we spoke to (other than Stanley Bernstein himself) agree that restricted-calorie diets aren’t appropriate for children and may curb development or growth. Better to exercise and get the recommended daily calories (around 1,800 for an average eight-year-old) from healthy foods than to go down as low as 950 calories a day, for example. Bernstein argues that patients also get calories released from fat cells, but experts dispute that. Plus, rapid weight loss of four to five pounds a week decreases the metabolic rate, making regain more likely.
Experts also worry about the emotional effects of getting kicked out of overly restrictive programs. The Bernstein Clinics offer guidance and support, but will stop the program of clients who flout the guidelines. “I shudder to think what that does to kids’ self-esteem,” says Liann Meloff, a psychologist and director of the multidisciplinary Pediatric Obesity Clinic in Calgary. The Bernstein program does have some positives. “There’s a weight-loss maintenance plan, medical supervision and vitamin supplementation, which is important with low-calorie diets — although many kids won’t want the shots,” says Gary Goldfield, a psychologist specializing in obesity at the Children’s Hospital of Eastern Ontario in Ottawa. Still, experts who looked at the Bernstein diet would prefer to see more emphasis on behaviour modification as well as physical activity.
So if low-calorie diets aren’t appropriate for overweight children, what is? The 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children recommend a nutritious eating plan developed by a registered dietitian, increased recreational activity and less sedentary or screen time. The recommendations say families should be assessed for barriers to change, such as difficulty paying for fresh fruits and vegetables, and offered family-oriented behaviour therapy, such as teaching parents how to plan healthy leisure activities or combat emotional eating as a family (see 11 healthy-weight tips). LEAP! and the Pediatric Obesity Clinic in Calgary follow this type of multi-faceted approach.
The middling results of such programs are tough to swallow, however. “Even in the most successful weight management program for kids…the success rate is 30 percent,” says Ball. “And in the real world, there’s a variety of cultures, mental-health issues, family issues like divorce — you have to have very modest goals.” That said, isn’t 30 percent better than zero? And isn’t it better for a child to lose 10 pounds and keep it off, rather than lose 50 and regain it? Meloff agrees that long-term changes are what count. “Kids who have been educated to make healthy lifestyle changes — now that’s success.”
Still, paediatric obesity researchers hunger to know more. Currently, little long-term research exists on effective weight-loss techniques for kids, and most of it focuses on prevention, not treatment. Rocan says the Canadian Institutes of Health Research have earmarked $10 million to study childhood obesity. The hope is that better evidence of reliable methods might convince the federal and provincial governments to allocate more money toward treatment.
Healthy living in our screen-addicted, supersized society is hard. It’s a huge education process for busy parents to learn how to say no and buy healthier foods on a tight budget. Emotional healing is required too. “I knew a weight-loss clinic would need a scale, a blood pressure cuff — I didn’t know you’d also need a box of Kleenex,” says Peter Nieman, a paediatrician with the Pediatric Obesity Clinic in Calgary. “These kids have been bullied, rejected and demeaned.” (A recent Yale University study determined that even overweight children as young as three are more likely to be considered ugly, sloppy, mean or stupid.) Given all of the obstacles to healthy, long-term weight loss, it’s no wonder that overweight kids and their parents feel doomed to failure.
Desperate parents turn to books, the Internet, commercial programs — anything that can offer results. Bookstores brim with weight-loss tomes that vary hugely in quality and practicality. (To see paediatrician Peter Nieman’s review of seven popular diet books for kids, read our article, Seven Diet Books for Kids.) Web-based diets also exist, such as TrimKids from ediets.com and books available from pariplan.com and slimkids.com. But without a health professional’s supervision to help execute these programs, you’re taking your chances. In light of funding challenges, even professionals like Gary Goldfield are trying to offer some Internet services to selected screened applicants, though he knows they won’t be as effective as face-to-face sessions.
On the commercial front, Weight Watchers (WW) is developing a 12-week family program in which coaches and local paediatricians teach parents (not kids) about healthy foods, boosting activity and behaviour modification. The focus is less on weight loss than on growing into a healthy weight. Ball and others say the parental focus is similar to their programs and shows promise. Although no diets or exercise regimens are prescribed, a study of the pilot program found that 23 of 33 children lost weight and kept it off for nine months. There’s no word on when Weight Watchers Family might launch in Canada, but the central tenets of the program are outlined in its currently available book, Weight Watchers Family Power: 5 Simple Rules for a Healthy-Weight Home.
In the meantime, WW does not encourage children to join adult meetings. Still, 14-year-old Cathy MacKinnon* can’t say enough about the program that helped her drop 58 pounds. The Ottawa teen talks a mile a minute: “I had tried, like, tons of stuff — going to a dietitian, trying to eat healthy — but it never lasted.” Research into other diets proved daunting. “Certain ones you had to buy certain foods, or were so strict I didn’t think it was livable.” Then 13, she went to WW and bonded with university students and 50-year-olds alike as she lost the weight. MacKinnon is the first to admit that she was extraordinarily motivated and worked out every single day.
Better would be more awareness among family physicians and more provincially funded, multidisciplinary treatment centres. While parents wait, they need to stay strong, holding the line on junk food and insisting on daily physical activity. “For parents who claim to have ‘tried everything else’ — I still question whether they’ve truly tried healthy, active living, versus commercial diets,” says Gabriela Tymowski, director of LEAP! and a professor in the faculty of kinesiology at the University of New Brunswick. That said, she adds, parents need support from their schools, physicians and communities to encourage free play and healthier food choices. The Canadian Medical Association, for one, has called on school boards to provide 30 minutes of activity per day and healthy cafeteria foods, and on governments to improve labelling and restrict junk-food advertising. The Ontario government has mandated a minimum of 20 minutes of daily physical activity for all elementary students. But these suggestions will take considerable time and political will to implement nationally.
Meanwhile, the clock is ticking for obese kids at risk of type 2 diabetes, depression, cardiovascular problems and even certain cancers, and who have about a 50 percent chance of becoming obese adults. The lack of resources bewilders parents, who oscillate between apathy and anger. And even the most dedicated physicians are becoming discouraged at the lack of attention to childhood obesity treatment. “The [Ontario] Ministry of Health loved our proposal for a family-based paediatric weight-control program, but of course didn’t fund it because of a lack of cash,” says Goldfield. “Obese children are probably the most under-serviced patient population in North America.”
*Names changed by request.
Gabriela Tymowski, director of LEAP!, a program which treats childhood obesity at the University of New Brunswick in Fredericton, suggests these tips to help families keep excess pounds at bay:
1. Play outside every day (kids need at least 30 minutes of daily activity).
2. Walk or ride bikes whenever possible.
3. Remove TVs, computers and video games from bedrooms, restrict screen time to less than two hours a day and encourage other pursuits such as reading.
4. Keep consistent bedtimes. Well-rested kids are more likely to make good food choices.
5. Keep washed and sliced fruits and vegetables, lean proteins and low-fat, whole-grain foods readily available.
6. Avoid diet drinks and foods. Preliminary results from a University of Alberta study found these can trick the body into overeating.
7. Share family meals at the dinner table as often as possible; homemade meals are typically lower in calories, fat, sugar and sodium than those in restaurants.
8. Get children to help make packed lunches and dinners at home (they’re more likely to eat what they prepare).
9. Pass up sweetened juices and pops. Harvard University researchers estimated that the average daily difference between calories consumed and energy expended, which has led to today’s childhood obesity rates, is between 110 and 165 calories — about equal to one pop.
10. Don’t wait to talk to a health professional — even obese three-year-olds have a 25-percent increased risk of adult obesity.
11. Be encouraging without pushing and never put overweight kids down, adds Cathy MacKinnon,* an Ottawa-based 14-year-old who recently lost 58 pounds.
*Names changed by request.