I can remember the call a few months ago. I was finishing up at work and my wife called on her drive home from the pediatrician’s office. I asked her if all went well and she hesitated a bit. She said in a quiet voice that the nurse practitioner had told her our 3-year-old son was overweight!
I immediately denied the fact that our son could ever be considered overweight. I then got a bit angry, because I immediately began thinking about negative connotations associated with obesity and about the long-term health implications. What his nurse had actually said, I found out later, was that my son’s weight was above target range for his height. She had actually refrained from calling him obese or overweight. However, when I saw the charts that she sent home with him, there was no denying it. He was breaking out of a normal growth pattern.
As an adult cardiologist, I spend most of my time with patients suffering from coronary heart disease, arrhythmias and congestive heart failure. As it turns out, I spend significant time counseling patients about their weight because most of my patients are obese. For some patients, excess weight puts increased stress on the heart and can increase morbidity from coronary heart disease. Obesity also puts patients at risk for hypertension and diabetes; independent risk factors for heart disease.
Childhood obesity, like adult obesity, is at or near an epidemic. The association of cardiovascular disease with obesity is clear and we are seeing additional associations of childhood obesity with traditional cardiovascular risk factors (e.g. diabetes). My opinion has been that improvements in weight must start in the kitchen with a close examination of the foods we eat. Modest changes in the eating habits of both adults and children can result in significant advances.
I have counseled my patients that they must look closely at the caloric contents of the foods they are eating. They must watch portion sizes based on calories per serving and must balance that against their daily caloric burn-rate or basal metabolic rate (BMR).
1) BMR Man: 1,800-2,500 calories
2) BMR Woman: 1,500-2,250 calories
I wanted to put this evaluation process in place for our son, to see if there were any simple changes to his diet we could make or any problem areas we could identify. We found that we were able to substitute lower calorie items for higher calorie items in many instances. We are also doing a better job of enforcing that he eat more vegetables and fruit. We have also significantly reduced his fried food (French fry) intake.
The identification of excesses in dietary intake is an important first step in making a plan for improved eating habits. I have recommended the following strategy to many of my obese cardiac patients:
1) Keep a diary for one week of all foods eaten with calories calculated and corrected for serving size.
2) Calculate total calories eaten for the week.
3) Calculate caloric savings of changing any food to similar lower calorie item (Whole milk to skim milk; regular soda to diet soda, etc.)
Aim to continue to change foods or reduce portion sizes until caloric intake for a week is less than weekly caloric burn rate. At that time, for adults, it is time to consider an exercise program, as even modest increases in exercise (translation = increased caloric burn rate) will pay big dividends.
Because exercise tends to make patients hungry, I usually request that patients get used to the lower caloric intake for a month or two before beginning any formal exercise program. Anyone who is starting an exercise program should discuss it first with their physician. Once approved by your physician, I would recommend the following:
1) Start a brisk walking program 30-45 min daily; or
2) If you belong to a gym, discuss your goals with a trainer who can design a cardiovascular workout program for you.
3) Increase intensity of walking or total exercise time by 5 to 10 percent every two weeks.
In this fashion, significant gains can be made. It is recommended that children stay active for at least 60 minutes a day. For my son, who is already quite active, the small changes in his diet and improved communication have resulted in stabilization of his weight while he has grown a bit taller, which helps his position on the growth curve.
I have wanted to thank his nurse practitioner for the wake-up call. For children, parents are the only ones who can intervene and make these critical changes. The growth curves don’t lie, and the longer a child is allowed to drift off-course, the more difficult it is to bring weight back in line and correct ingrained eating behaviors.
For adults, eating is very much related to habit. My patients continue to eat large portions and clear their plate, habits which are often developed in childhood. Many of my obese cardiac patients that feel tired do not often attribute their symptoms to overeating, weight or associated de-conditioning. They are often more concerned that there has been a change in their coronary disease.
The challenge posed to physicians is to continue to push patients to improve eating habits. We need to establish reasonable short-term goals (e.g. ‘You should lose five pounds in the next two months’ rather than ‘You need to lose 100 pounds’) and continue to remind patients of the associations between their eating and health problems, especially cardiovascular disease.
One of the lessons we can all take away is that no matter how young or old we might be, we can all benefit from practicing good eating and exercise habits. With a little focus and effort, you will be amazed at the difference you can see and be truly pleased with the results that will come over time. Give it a try, stick with it and you will be rewarded for your hard work!
Chester Hedgepeth, MD, PhD, is executive chief of cardiology at Kent Hospital and director of the Brigham and Women’s Cardiovascular Associates at Kent Hospital. If you are interested in learning more or would like to schedule an appointment with one of our cardiologists, email us at firstname.lastname@example.org, log on to kentri.org/bwcardio or call 681-4996.