Friday, September 8, 2017

lamentations of a community pediatrician

I am tired of hot cheetos. I am tired of juice and kool-aid for toddlers. I am tired of pizza or and wings from the local takeout. I am tired of 1 month olds being given 4 ounces of formula with cereal in it to “help them sleep” and the school aged children drinking milk or chocolate milk with every school meal even though they don’t really like the taste of it. I am beginning to see more and more 200 pound 12 year olds and 80 pound 6 year olds.

It is Well Child Check season in the land of pediatric primary care. As a private practice Pediatrician in Washington, DC I don’t actually eat those foods myself or feed them to my child (though I do love pizza and wings once a month) almost every single patient I see with elevated body mass index or abnormal increased weight gain has had or currently has some part of this in their diet.

I am beginning to worry every day I am in my office about all of the premature heart disease we are going to see in 20 year olds because I now have seen close to 10 school aged children with abnormal lipid panels due solely to their poor diet, I have seen more than my share of toddlers and school aged children with developing Blounts Disease (this is a disorder kind of like deforming kiddie-arthritis where the bones in a part of one or both knees begins breaking down due to excess weight, causing deformity of the knee), I have seen countless young women with metabolic disorder and polycystic ovarian syndrome (think bad cystic acne, hirsutism, abnormal and often heavy periods). I have seen more than my share of rotting teeth due to prolonged bottle use, inadequate teeth brushing, and poor diet high in sugar-laden beverages.

Every day I say or type in my instructions to countless children and parents “no juice, soda, sweet tea, or koolaid, it’s bad for your child’s teeth and behavior” and I cannot tell you the number of children and parents who argue that juice must be good because “WIC (Women, Infants and Childrens Program) gives it to me”. Or the kids that say “I don’t even like milk, but school gives it to me at breakfast and lunch so I just drink it”. Ohhhhh WIC and schools! If only we could divest ourselves of the sugar and milk lobby and give these kids what they need - gasp, WATER! Water, the only drink that other countries, with much lower rates of childhood obesity than the United States I might add, allow in their schools. It literally takes me a several minutes in most visits to share with parents that no juice is definitely not healthy even though it has “vitamins and minerals” and that no it’s not the same as eating a piece of fruit. And no, if your child doesn’t like milk they don’t actually have to drink it and they can just drink water and get their calcium from things like yogurt or cheese. And no, chocolate or strawberry flavored milk isn’t needed because if your kid doesn’t like milk he/ she really doesn’t have to drink it. And yes, the sugar in juice and chocolate milk is just as bad in it as the sugar in soda is and nope I don’t allow my 6 year old to drink juice, soda, sweet tea, or koolaid (except at the random birthday party or when he is with my family who simply won’t listen to me) and nope my 6 year old doesn’t drink cow’s milk. Seriously, I can recite these points in my sleep because I say them every day countless times.

My heart hurts. The ICD 10 codes: abnormal weight gain, childhood obesity, pediatric BMI greater than 95%ile dot the majority of my notes. Cutting out the “juice, soda, sweet tea, and koolaid”, cutting back on the take out, increasing the time outside or dancing and playing, and cutting out the cow’s milk would be enough in most cases to curb this trend.

We had a new neighbor in his mid-30s die of heart disease this summer. His obituary showed a child who has struggled with his weight since early childhood and multiple relatives with obesity. His story includes hypertension and pre-diabetes in his 30s. This story is going to be more frequent if there isn’t major policy and cultural change in America.

Thankfully I have had a handful of success stories and they keep me inspired to share healthy diet and exercise with all because honestly so many of my patients just don’t know. The toddlers who I have done intensive intervention with in my office and referred to our local childhood obesity program whose entire families have adjusted their diets and their weight gain has slowed and can run and play more. The adolescents who have lost weight since their last visit who walk in with their parents who are looking mighty healthy too and tell me about the weight they lost and how they no longer drink sweet tea every day and do take out much less. The mothers who breastfed for a few more months even though it was hard. The families who stopped giving their 2 month olds rice cereal in their formula (of note, the current recommendation is exclusive breastfeeding until 6 months old unless medically contraindicated. No supplemental foods - that includes rice/oatmeal cereal until the kiddo can sit up on his/her own usually between 4-6 months).

So while I lament, I press on because there is so so so much work to do. Now off to find a healthy early morning and I can’t sleep blogging snack for this 4 month old growing fetus of mine.

21 comments:

  1. Are kids really not supposed to drink milk anymore? That's a new one for me.

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    1. Yeah, seems a bit.... extreme. I'm a pediatric specialist and my kids are on the thinner side and love milk. We limit it to meals only and non-flavored but actually make sure it's whole milk only since they are kind of skinny. Their PCP seems to think this is a good idea. However, they both HATE soda so they've never even had that

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    2. I don't completely restrict milk in kids, but as the post said in kids who 1. don't like milk, I suggest their parents cut it out and give them calcium in other ways and 2. in kids who are obese and drinking too much milk I tell them to cut it back or completely cut it out. This post was mostly about children who are obese and have poor dietary habits, not average children.

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  2. Hear, hear! Keep up the good fight. I'm surprised it is that bad in DC. From a community FP.

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    1. The obesity epidemic is bad everywhere. In a city like DC with severe food swamps (this is what our local health alliance calls it, when you have tons of takeout, 1-2 poorly stocked grocery stores) like the community I work in, it's disproportionately bad.

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  3. I hear ya. In my case often the parents want me to cure their child's "hormone problem" when it's 100% lifestyle driven.
    It's really depressing and frustrating.

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    1. The dreaded hormone problem!!! I follow the AAP guidelines and obtain the screening lipid panel for obese children and by age. In some with signs of metabolic derangement I do screening thyroid but it literally is NEVER the thyroid.

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  4. Tell me more about no milk. I'm a dentist married to a physician and we have no plans to give our baby sweet tea, juice or flavored milk ever but milk at meals only. Water for any time in-between...

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    1. See comments above - milk with meals is TOTALLY FINE! I suggest only up to 4 ounces at each sitting. And yes, I agree completely with water for in between times. However, I can't tell you the number of kiddos I see who just don't like the taste of milk, but are being forced/ coerced to drink the milk either with flavoring or with a bottle (2 and 3 year olds).

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  5. I have this conversation with my adult patients all the time. I should just tattoo "Stop drinking juice" on my forehead.

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    1. Here here! I'm with you. Maybe we could just do henna temporary tats - me during Well Child Check season.

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  6. One of my gastric bypass surgeons told me every year they are consulting younger patients to be approved for the procedure because early liver disease (non alcoholic steatohepatitis) is so devastating.

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  7. With regard to milk -- I think the main thing is to drink WHOLE milk (>1yr). Not skim or 2%. Those just have replaced the fat with sugar, and fat is good for developing brains and satiety. Added sugar is terrible. Whole milk in its natural state (in moderation, of course!) I think is fine :)

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    1. This comment has been removed by the author.

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    2. Messed up my comment on my phone, here goes my second attempt. Please provide some sources that discuss whole versus 2% and skim milk. I had NO idea that the way this is done is by adding sugar! I can't wait to read more about this - it would be a game changer for me and many practicing pediatricians who don't know. Thanks for shedding light on a topic I had no clue about. Can't wait to read more about it.

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    3. From my super quick 5 minute review online it is really hard to find this information. a few sources disagree with you and say that fat is removed and nothing else is added. Looking forward to reading your sources.

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    4. A quick check on the milk in my fridge shows the same content of sugar b/w whole and 1% with just lower fat content.

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  8. OB here...I'm seeing 350 lb teenagers with "irregular cycles" and every parent insists she exercises regularly & eats healthily.

    No one likes the diet/exercise bit. Sometimes I can convince them to take metformin...but they hate the GI s.e. so they just stop after a few weeks. I just want to scream that if your teen's BMI is higher than my age (I'm in my mid 40s), there is a major problem.

    I'm old enough to remember when a pt weighing 225 lbs was a BFD...now I see at least 1 an hr.

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    1. So sad. Question did the pediatrician who referred them attempt dietary modification? Not per patient report but based on the records you received?

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  9. THIS!!!! I used to be a regular reader of this blog when I was in still in med school 6-7 yrs ago, but things have been busy and I occasionally peek in now (cannot even remember what account I used to chime in with a rare comment back then). BUT THIS!!! On this Tuesday, as I am gearing up to face yet another full schedule with an average BMI of 31, and making a list of all the A1c's that need to be repeated, knowing that I will be spending half of every visit disabusing each patient of their misguided ideas about food, feeling like Sisyphus, and realizing that you cannot undo decades of institutionalized abominable food programming in a day or a month or even a year... THIS was both heartbreaking and reassuring! I am so glad to know (well, I knew, but to actually read a personal account today) that I/we (IM/primary care) are not alone in these trenches. This will sound too dramatic, but I feel like it is the medical equivalent of being a Soviet soldier on the Eastern front in WW2 and realizing that the Allies have joined forces with you and have launched an offensive on the Western front. If only this war could be won in under 5 years!

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