ER: To provide practical information to primary care service providers on how to identify children who are overweight or obese and how to intervene with those children and their families. The program is going to cover the prevalence of overweight and obesity in children and adolescents and what kinds of problems practitioners will be seeing in the primary care setting.

ER: Obesity in general, and particularly in children, is really a problem that transcends medical models. Obviously, children who are overweight or obese often have medical conditions that have be treated in a medical care setting – for example, some have complications such as Type 2 Diabetes, some have elements of the metabolic syndrome – and those disorders need to be treated in a medical setting. But there isn’t a medicine, a pill or a prescription that you can give to help manage childhood overweight or obesity because the underlying causes are related to factors in the environment that militate against physical activity and appropriate nutrition. Many of the affected kids come from areas where it may not be safe to play outdoors, for example. They may attend schools where physical activity is not mandatory or physical education classes may have been cut for budgetary reasons. They may not have an opportunity to walk to school or to be physically active during the school day and, when they come home, it may not be feasible for them to go out and play because their parents may work or there may not be a place for them to go.

ER: It’s an enormous problem. National statistics indicate that more than 15 percent of children are already obese. Local statistics indicate that the numbers are much higher. What comes along with childhood overweight and obesity is a very strong likelihood that those children will remain obese throughout their lives. Obesity tracks into adulthood and the accompanying disorders can cause a great deal of suffering and loss of productivity. National Health and Nutrition Survey data for 1999 to 2000 indicated that about 30 percent of US adolescents already had elements of the metabolic syndrome: many had abnormal blood lipids, elevated blood pressure or abnormalities of glucose metabolism. Those are all precursors or risk factors of cardiovascular disease including left ventricular hypertrophy, stroke, and myocardial infarction. Those children are also at risk of developing Type 22 Diabetes. Some years ago, when I was in my pediatric endocrinology training, we didn’t see Type 2 Diabetes in children; we saw Type 1 diabetes. Type 2 has now been observed in children and adolescents for the last 10 or 15 years and has become a serious problem. Most of those children are overweight or obese and in many ways more difficult to manage than children with Type 1 Diabetes. Often, they come from families where Type 2 Diabetes, heart disease and high blood pressure occur in many of the adults. This constellation of disorders that starts with overweight and obesity is a family problem and needs to be managed quite differently from "more ordinary" disorders in children.

ER: Fundamentally, we can interrupt chronic disease expression at its origin by recognizing that there are certain risk factors for diseases in adulthood. If we can identify risk factors such as overweight and poor physical fitness, which are associated with abnormal blood lipids, hypertension, and abnormal glucose metabolism, we can prevent the later development of more serious and overt conditions such as cardiac disease, renal damage, and stroke . We now understand that these risk factors occur in childhood – that the beginnings of adult disease occur in childhood – and we need to manage children’s growth and development in order to minimize that.

I think it’s going to require that physicians provide counseling on nutrition and on physical activity, and I think those things are relatively unfamiliar to physicians. We know that interventions to promote physical activity and improve nutrition can actually prevent the development of Type 2 Diabetes in adults. So, in theory, those kinds of interventions in children should work. We don’t yet know what the best way is to do that, and in the office setting that’s a challenge because physicians don’t often have a great deal of time to devote to those kinds of interventions. But there are some simple things physicians can do by way of recommending approaches to patients and their families. The easiest is actually one that’s used in the city Health Department program, called "GO-215" – the Philadelphia area code. The two stands for less than two hours of television or screen time per day, the one stands for one hour of vigorous physical activity and the five stands for five servings of fruits and vegetables. There should be great emphasis on breast feeding for infants and babies, and avoidance of sugar-sweetened juices and sodas for children. Physicians should improve their identification of children who are overweight or obese. Growth charts accessible from the Centers for Disease Control website (cdc.gov). These growth charts can be used for simple, inexpensive screening to identify abnormalities of growth and development, such as overweight and obesity. Ideally, every child should have height, weight and body mass index obtained and plotted on charts at every visit, so physicians can follow those pieces of information longitudinally and identify children who are gaining weight too rapidly.

ER: I think the major obstacles to addressing obesity outside the medical care environment have to do with lifestyle and the environment in which our children are growing up, which fosters sedentary activities. There are many toys that entice them to sit still, sit in front of the computer screen, or to play with games that do not involve physical activity. There are many children growing up in environments that are not conducive to playing outdoors, not conducive to vigorous activity. These children may also live in environments where available foods are high in calories, high in simple sugars. They have limited access to fresh fruits and vegetables. I think those factors are major barriers to addressing this obesity epidemic, which has occurred over the last 25 years. The changes that have occurred during that time are largely environmental changes. Genetics haven’t changed.

ER: Locally, the Philadelphia Health Department has programs. The Health Promotion Council of Southeastern Pennsylvania is one of the sponsors of the upcoming conference and has set up a physical activity program in West Philadelphia. There’s an organization called Pennsylvania Association for Nutrition and Activity (PANA) that has given advice and is setting up interventions in the Philadelphia area. The Food Trust, another local organization has collaborated with community groups to improve nutrition and the schools and to develop regulations that would prevent sale of soft drinks in school vending machines in Philadelphia and. The Childhood Origins of Diseases of Adults (CODA) consortium is a group of health professionals from the Philadelphia, nearby areas in New Jersey and the Wilmington, Delaware area who share an interest in the childhood precursors of adult disease. This group began several years ago to meet on a monthly basis as a study group to share ideas, collaborate on writing articles on the subject and to learning from each other. From early 2003 through the beginning of 2004, I served as Program Director for CODA. I continue to be an active participant in CODA. As I am also a member of the Board of the Health Promotion Council, I have served as a liaison between HPC and CODA and have participated actively in planning October conference. CODA members are particularly interested in doing research and education, and in developing, evaluating, and implementing models of clinical care that will be effective in preventing the childhood origins of adult disease. The first CME program that CODA put together occurred last January at the DuPont Hospital for Children in Wilmington. CODA subsequently undertook a collaboration with the Health Promotion Council of Southeastern Pennsylvania. The conference planned for Philadelphia on Oct. 22 is focused not only on primary care physicians but other primary care practitioners, such as nutritionists and advanced nurse practitioners, who are in contact with children who are either at risk for developing overweight or who are already overweight or obese.

ER: Sure. CODA is wide open. We meet once a month as an interest group and the meetings alternate between Thomas Jefferson University and DuPont Hospital. Anyone is welcome to come, it’s not a membership-type of organization. CODA has not moved into advocacy activities, and I don’t think plans to do so right now. We are not funded. We are really a study group where people come together to help each other learn and to develop collaborations.We now have some students who are being mentored by our members on research projects.