Transcript

Ask the Doctors
February 6, 2003

Host: Tom Endres (TE)
Guests: Vernaliza Cassidy (VC), pediatrician
Diane Grove (DG), dietician
Gary Borlace (GB), supervisor health and fitness program

ANNCR:
Welcome to Ask the Doctors the program that gives you the opportunity to ask your questions to a panel of area physicians. Your host is Tom Endres.

TE:
Welcome to Ask the Doctors, a special program tonight. We’re going to be focusing on children and their eating habits. Let me first of all introduce our guests. The phone number will be on the screen as always, but let me introduce our guest panelists first of all. Joining us from the Mid Michigan Physicians group in Clare is Vernaliza Cassidy, a pediatrician. Welcome to the show. Vernaliza’s clinic is up in the Harrison area and her practice is out of Mid Michigan Hospital in Clare. Welcome to the show. Next to Vernaliza is Diane Grove. Diane is a registered dietician with the Mid Michigan Medical Center in Clare. Welcome to Ask the Doctors.

DG:
Thank you.

TE:
And our third guest today is Gary Borlace. He’s the supervisor of the employee health and fitness department at the Mid Michigan Medical Center in Midland. Gary, welcome to Ask the Doctors.

GB:
Thank you.

TE:
Gary, let’s start with you. Tell us a little bit about what kind of health and fitness programs are run at the Mid Michigan Medical Center.

GB:
Well the employees have this program, the wellness program that’s run, it’s primarily for the employees. Our goal is to offer discount services. We do cholesterol screening, blood pressure screening, and smoking cessation. We have an 8000 square foot gym facility that’s open to the employees. We have full time fitness professionals on staff supervising all their work out regimens, and designing programs. We offer wellness programs for employees that are not members of the fitness center. Basically our goal is to keep everybody healthy.

TE:
Terrific, well our goal tonight is to talk about childhood obesity. We’ve been working with community partners around the state to look into this area and see what we can do to maybe try and correct it. We have a grant for a Sound Partners project for community health from the Benton Foundation through the Robert Wood Johnson Foundation, and we thank them for their help. Let me ask you, Dr Cassidy, a pediatrician. What kind of treatments would you look for to treat youngsters that are obese?

VC:
Well mainly the treatment is diet, behavior modification, and increase in physical activity. We don’t recommend any forms of medication for children. There is no medication that is FDA approved for children to lose weight. And basically those three are the main things.

TE:
What if you’ve got a child, who is two or three years old, and they’re getting a little chubby? What kind of help is available by talking to their pediatrician?

VC:
Well if a mother comes in and she’s getting worried whether her child is getting obese or not, of course the first thing I would want to do is determine if the child is really overweight or not. And what we do is we get the weight and the height and from the weight and the height we compute the body mass index. And line the child’s BMI in a growth chart, and depending on where the child is, it will help us determine whether the child is obese or not. If the child is overweight, but there are no complications of obesity than I don’t really recommend weight reduction. I just tell the parents to maintain the weight and maybe give tips to the parents in terms of healthy choices for food and give tips to the parents on how to promote better eating habits for the child. I also encourage the parent to have the child in more physical activity, engage in any kind of sports activity.

TE:
Diane, from Wolverine a call comes in, “What types of dieting or what kinds of eating programs are safe for children?

DG:
As a rule you kind of try not to encourage a real strict program with a small child. Like Dr Cassidy said really the idea is to have them maintain their weight and let them grow into it. What I encourage is better food choices, and what I mean by that is I try to encourage lower fat choices as a rule, more what we call nutrient dense choices. And a food is nutrient dense when it provides a lot of nutrients other than just calories. So, let’s say something. For example, like yogurt, which can be fairly high in calories, but it provides calcium and other nutrients, is a nutrient dense food. That would be something I would encourage as opposed to something like Jello that has a lot of calories, but not any of those other nutrients. The other thing we try to look at is portion control, and reasonable portion control. A lot of times when I’m working with anybody on weight management I encourage them to pre-portion foods. That way if the item we are talking about is animal crackers, to put a child size portion in a baggie so that way when a child is asking you know you’re getting the right amount, and it’s helping teach them a little bit about portion control and how much is appropriate.

TE:
Ok, what other kinds of foods, is there anything specifically children should avoid, any kind of foods?

DG:
That’s a really good question. We try to stay away from really doing good and bad foods. I think everything has a place in the diet, and in anyone’s diet it’s how much, how often. So there are going to be better choices and less better choices, so to speak. We’ll take a classic junk food, so to speak, like a bag of potato chips. Should my child never eat potato chips? Well, that’s probably more a little restrictive than we need to be. Should they be a very once in a while very small portion food? Yes, there’s really nothing that I think you need to avoid entirely, but a lot of things I think you need to be reasonable about how much.

TE:
Let’s talk about how often.

DG:
Ok.

TE:
For a three, four, five-year-old child, how many times should they be eating a day?

DG:
Six is not unreasonable. Usually they eat a meal, snack, lunch, snack, dinner, and snack. This is not an unreasonable amount. They have very small stomachs and reasonably high calorie needs so they can’t eat just three meals and get their calorie needs met. Still you know you want to encourage snacking, but you need to be reasonable with the how much and even I know that with my own kids I’ve had to set limits and set specific snack times to keep them from grazing all day. And I think that’s a reasonable step to make, that snack time will be at this time, and from there we’ll decide what we’re gonna eat.

TE:
Ok, Gary, Are there any specific kinds of exercise programs for young children?

GB:
Well, there are a lot of different activities and things and different programs available for children. There’s a lot of programs that are offered through local YMCAs, YWCAs, community centers and so forth, but as far as specific programs it’s really directly dependent on each person, and each individual. But activity for children, for the most part, just needs to be fun. If it’s not something that is fun, generally they won’t enjoy doing it, and if they don’t enjoy doing it, generally they won’t continue to participate. A lot of it comes from the parents, as well it has to be influence from the parents. Parents that are active tend to have more active children.

TE:
So it has to be play?

GB:
Exactly.

TE:
So, outside playing games, throwing the ball around in summer, doing stuff with water balloons, or swimming, these kind of things?

GB:
Exactly, generally the younger the child the more fun the activity should be. Children should be around the ages of eight to ten before they should start entering into team sports. There are developmental issues with that. Issues as far as physical issues in regards to strength, capability of handling a lot of the different activities, as well as understanding it. The younger the child if they’re in a more strict program the more difficult it’s going to be for them to comprehend. And if they don’t once again enjoy the activity they won’t stick with it.

TE:
There are a number of questions here and I just love this question. At what age should children start exercising?

GB:
There’s no question about that one. At anytime, as soon as the child is walking it’s exercise. And basically a lot of that is just walking, bouncing, following around. I read an interesting quote and it said, “how many people know inactive 3-5 year olds?” And generally the activity is not the problem. They’re bouncing around the room like little bouncing balls, but its finding activities that are fun that the whole family can do that reinforce healthy behaviors.

TE:
Dr Cassidy, from Mt Pleasant a person wants to know. Is it ok from a medical standpoint for young children to be vegetarians? And Diane you may want to step in there as well.

VC:
I think they just have to be aware that there has to be a balance. There are different nutrients a child needs. They have to make sure that the child gets the protein and they get the appropriate vitamins. It’s just a matter of being aware of what the child is eating. They can be vegetarians of course, just to make sure that child is getting all of the requirements and there is balance.

DG:
And part of that is too, I would usually encourage for a young child to be a latose-ovo-vegetarian. Where they would have dairy products and possibly eggs as a source of protein just to be sure they’re getting enough protein for one thing, but it takes some knowledge of exactly which kinds of foods need to be presented for them to be getting the right nutrients.

TE:
Can they come see you at the hospital?

DG:
Sure, of course they can.

TE:
You would help them out with meal planning and there must be books available, and web site information?

DG:
Definitely, yeah.

TE:
It’s interesting because Dr Cassidy just before this show you did a seminar this evening. This one has to do with what percentage of body fat would a child have before puberty? You just did a seminar on puberty. Do kids, just before puberty, do they begin to put on a little extra weight?

VC:
Before puberty? Not really, actually it’s after puberty that they actually gain a little more weight. It’s actually during puberty that they would have the growth acceleration both in height and weight. So actually during puberty is when a child who is thin in going to be gaining more bulk and a child who is stocky is going to be a little bit leaner during puberty.

TE:
In a very young child, a two, three or four-year-old, how do you define obesity? When would you say, that’s an obese child? How much over a standard height and weight for their age?

VC:
Ok, it’s different for different age groups and its different for the gender. We define obesity if it’s above the 95th percentile for weight for age or weight for height. Sometimes it can depend on the age, sometimes it can depend on the height. But, These are very general, its’ not a very specific, or good measurement for obesity. What is a good, more specific measure for obesity is actually the body mass index. And anything above the 95th percentile for a child for the body mass index is considered an obese child. The 85th-95th percentile is high risk for obesity.

TE:
Ok, Gary talk about the amount of exercise and the benefits that an active child has.

GB:
Time frame, generally on average 20-30 minutes a day is what is recommended. That’s the difficult part for most families, is getting the 20-30 minutes a day involved into the activities. And as far as the benefits are concerned, it not only improves the heart and lungs functioning on capacity, it also improves muscle strength. Exercise and activity does a lot more than just improve strength. It also helps children learn how to share, helps make friends, and also helps build their self-esteem. Generally, it’s about thirty minutes of physical activity on a daily basis.

TE:
From Harrison tonight a call comes in, would one of you talk about how much one might avoid fast food and fast food restaurants especially for really young children about 2-5 years old?

DG:
Certainly once a week would be the maximum I guess I would consider reasonable. Ideally a couple times a month would be more reasonable. Fast foods are notoriously high fat and high calories. The average kids fast food meal is gonna run depending on a couple choices you make around 800 calories. That’s a big chunk-- .

TE:
How many calories a day would be reasonable for a three or four-year-old’s diet?

DG:
It depends a little bit on size certainly they’re at a place growth wise where their needs are per pound much higher than an adult. Somewhere around a ballpark though would be about 1500 calories of a diet is not unreasonable.

TE:
But if we’re talking about three meals and three snacks---

DG:
And one meal at 800 calories—is that really going to be half of what they are going to eat for the day. That’s really unlikely. They’re likely to eat much more than that. So you can see where you can very easily put that calorie limit and get them way over. Over 100 calories a day is enough to gain 10 pounds in a year. So by just overeating 100 calories a day you can make a big difference when someone only weighs 30 or 40 pounds.

TE:
Yeah that’s a big percentage of their body weight. Talk about sweets if you will. A call comes in from Mt. Pleasant tonight-how much candy is ok? A child seems to have a sweet tooth, is that a learned thing?

DG:
Actually sweet is one of the inborn things we enjoy. We learn to like salt, we’re born liking sweet so that’s kind of an innate sense. What’s reasonable? I think you need to look at your child’s overall picture. I wouldn’t say never allow your child to have candy because that seems to have really bad effects because what happens is then when they have that opportunity they run with it. Set reasonable limits. Does it seem reasonable to me that when my child asks for a candy I allow him two small pieces? Yes. That seems to be kind of a reasonable limit. An occasional candy bar is a reasonable limit, on a daily basis, not so much.

TE:
Dr. Cassidy, a question from Houghton Lake tonight. A person wants to know about the use of vitamins, especially if they’re trying to limit caloric intake because of an obese child.

VC:
Oh yes, I certainly recommend vitamins. Actually I recommend to my parents after a year of age when the babies stop their meal formulas and start eating a regular meal, kids tend to be picky. So I just tell them it will be safe for them to give their children multivitamins on a daily basis especially if they think they’re not getting all the vitamins from the diet. It would not hurt the child.

TE:
Talk a little bit about medical complications that are caused by obesity in children.

VC:
There are a lot of complications. Probably the top on the list is high cholesterol. Even children can have high cholesterol. Number two complication is probably diabetes In fact there is an increase in the incidence in this country of type 2 diabetes, the non insulin type diabetes. They have been seeing a lot of increase in the adult onset. There can be problems with the bones because your child is heavier they will have problems with joint pains and heart problems, as an adult is a problem. Coronary arthritis is a complication. Maybe not as a child, but when they grow to be an adult it is one of the complications, and a lot of other things. Maybe not immediately, but later into adult life.

TE:
From Atlanta a call comes in wondering if there are any camps for young children that are obese that either the child or the child and a parent would attend. Let’s say a week day camp or something like that to learn how to eat smart and get out and do that exercise. Are you aware of any of those kinds of opportunities?

GB:
Opportunities like that have been far and few between. But the Mid Michigan Medical Center has just finished up a program called a “Game Plan for Family Food and Fitness” where we’re trying to tackle the area’s problems of that nature. We just finished up with the four week program for families to learn proper nutrition and proper exercise. What we did is had a two hour block set for four weeks, four nights and talked about proper food portion sizes and exercises that they can do at home with the family. But unfortunately programs like that are far and few between.

TE:
If the parents are obese, what is the likelihood that their child will also be obese? Does it run in families?

DG
: If at least one parent is obese the likelihood that that child will be an obese adult increases significantly. That’s not to say that if parents aren’t obese children can’t be obese either. There are some factors there. But it significantly increases the likelihood, it’s better than a 50% jump.

TE:
From Elk Rapids tonight, there’s a question from someone whose daughter has Cushions disease. Could you tell me more about Cushion’s disease and is it related to obesity?

VC:
Yes. Cushions disease is actually one of the disease patterns that obesity is one of the parts of that disease. It’s a metabolic disorder and usually in children they are obese, but they are of short stature, so they are not tall. They grow out instead of up. Like I told you it’s a metabolic disorder and usually it’s associated with obesity. They’re body is gaining weight, but their arms and legs stay thin. So there is a certain type of a face for Cushions disease.

TE:
And what kind of treatment, is there any treatment?

VC:
Oh yes, there’s a treatment for it. For diagnosis they have to draw blood and measure the cortisone level.

TE:
From Mesick tonight. Diane, talk a little bit about the amount of protein a child should have in their diet. High protein, low protein? How much protein do kids need?

DG:
Actually surprisingly little. The basis we use for the amount of protein somebody needs is based on his or her weight. It’s usually so many grams per kilogram or per pound. When you have somebody who only weighs 40 pounds then 30 grams of protein is more than enough. You’re looking at somewhere between 1 and 1.3 grams per kilogram and there’s 2.5 pounds in a kilogram so at 40 pounds roughly cut it in half, you’ve got about 20. Twenty grams of protein is sufficient.

TE:
Ok, what if you’ve got a picky eater, they only like to eat macaroni and cheese or peanut butter sandwiches?

DG:
Kids will always, I shouldn’t say always, but frequently do food jags. They usually get over it. Usually after a few weeks of only macaroni and cheese they’re ready to move on. Really kind of interesting little fact I ran into a couple years ago, it can take up to 10-20 times of offering a new food before a kid will eat it. That surprised me too.

TE:
That’s a lot.

DG:
That is a lot.

TE:
How do you introduce a child to new food? You’ve got a two or three year old who has never had, maybe, brussel sprouts? How do you do that and have the child have a good experience with it?

DG:
Ok, be very patient. That’s really the key. To introduce the food realize that they may not even the first few times you put it on their plate, they may do no more than maybe touch it. Putting it in their mouth may not even be part of that experience. Maybe the next two times putting it in their mouth and not chewing it or swallowing it will be part of that experience. Do it slow, it takes kids some time to warm up to new things. You just need to be patient. If you’ve offered it several times and they’re clearly indicating they don’t like it. They don’t like it and just move on. But, give them some time and patience in letting them experience it at that age. Part of the whole experience of how does it feel in my mouth? And does it roll across my plate? That is part of that whole thing for them.

TE:
Ok, we’ve not had a lot of snow but have had a very cold winter. What kind of exercise can we do inside?

GB:
I do a lot of presentations and that question is asked a lot. When I generally refer to the 20-30 minutes is, depending on how much TV they watch, which I generally recommend an hour or less of TV a day, but if a person does watch more TV I always make the comment that during an hour TV program there’s generally four commercial blocks each which are about five minutes a piece. If a person has any stairs in the house, go up and down the stairs a couple times, get on the floor do some push ups, maybe some crunches, jumping jacks, walk in place, there’s always house cleaning. House cleaning, believe it or not is exercise. There’s just many things to do during the commercial break, just five minutes at a time. It doesn’t necessarily have to be 2-30 minutes at one time. You can break it up and accumulate at least thirty minutes in a day.

TE:
Okay, well believe it or not, now our time is about up. I want to thank our guests. Dr Vernalize Cassidy with the Mid Michigan Physicians group, thank you so much for being with us after your busy day. Diane Grove a registered dietician with Mid Michigan Medical Center in Clare, thank you for providing your information. Also, we want to thank Gary Borlace, Supervisor of Employee Health and Fitness at the Mid Michigan Medical Center, In Midland. I also want to remind you that we will be doing a number of programs throughout the year on childhood obesity. It’s a big issue in the state of Michigan and we have applied for and received a grant for a Sound Partners Project for Community Health from the Benton Foundation and the Robert Woods Johnson Foundation and we thank them very much for their support. We’ll be hearing more about his issue throughout the year. Thanks so much for calling in this evening on Ask the Doctors. And don’t forget to check our website it’s www.wcmu.org where you can find out all the latest information about our programs on WCMU pubic television on public radio. Thank you and good night.

ANNCR:
Thank you for watching Ask the Doctors. Tune in this time next week for Ask the Meteorologist on CMU Public Television.

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