Every specialty has its burden, and pediatric endocrinology’s is obesity. Primary care providers refer because they or the child’s parents suspect the cause is hormonal. It almost never is. The overly adipose child invariably has, using older terminology, exogenous obesity.
Traditionally, this has implied excessive calorie intake and inadequate expenditure (the “overactive fork and underactive foot”), arising from sloth and gluttony. I don’t share this belief. Over the years, I have studied this issue extensively and once had my weight loss program. I want to share my understanding and experience.
Firstly, I believe obesity begins with a “scavenger” metabolism that is ruthless at extracting calories from carbohydrates (CHO) and storing them as fat, something that had survival value prior to agriculture but is now disadvantageous with the “western diet” (WD). This diet is characterized by “foodstuffs”; calorie-dense, highly processed, and adulterated products containing unnatural combinations of salt, fat, sugar, and high glycemic index (GI) carbohydrates that overwhelm natural satiety mechanisms. The scavenger metabolism itself causes overconsumption. If your daily calorie expenditure is 2,000 calories, but your diet and metabolism oblige you to lock away 500 calories daily as fat, you need consume 2,500 calories to survive.
Why is the WD so obesogenic? It is certainly not calorie content alone; the same strain rats fed isocaloric diets of varied macro content will differ in their fat storage. Many believe that high GI CHO is the problem, causing excessive fat storage, especially in those having the scavenger metabolism. Evolution has designed us to operate principally in the fasting state. We are not adapted to the almost continuous intake of high-GI foodstuffs, and those with this metabolism suffer most.
The child with obesity must eat a different diet. It almost doesn’t matter what that is; low fat, low CHO, low GI, DASH, Mediterranean, Atkins, South Beach, Paleo, Ketogenic, Diogenes, etc., anything but the WD. I believe that the best alternative is the low-calorie, high-fat (LCHF) diet, first popularized in 1863 by William Banting, whose short account of his experience, “A Letter on Corpulence, Addressed to the Public,” started the first mass dieting craze.
Amongst contemporary ketogenic diets, the “Banting diet” of Dr. Noakes, Professor Emeritus at Cape Town University, ranks highly in my opinion. The British Journal of Sports Medicine paper “Evidence that supports the prescription of low-carbohydrate high-fat diets: a narrative review” outlines his position, and his recommendations can be found in the book, The Banting Pocket Guide.
I explain to the parents of the child with obesity that his/her metabolism is too efficient at turning CHO into fat and that the solution is to either remove all CHO from the diet (Banting) or at least restrict it (low GI). I provide the parents with food lists and direct them to books and online resources.
The American Academy of Pediatrics (AAP) has issued its first-ever guidelines on childhood obesity. Disappointingly, they don’t recommend any specific diet, just the usual “healthy eating” (presumably meaning the USDA’s MyPlate recommendations, which is actually high CHO, especially as high GI grains). Their solution is intensive lifestyle and behavior modification programs with frequent “motivational interviewing,” along with medications and bariatric surgery for some. They acknowledge that these recommendations are unrealistic but say it is the best evidence they have for weight loss.
In the real world, the best diet is one the child will actually stick with. In my experience, whichever is prescribed (including “healthy eating”) will not be implemented for more than a few days at best. There are various reasons for this. One is a true addiction to the WD, so discontinuation produces withdrawal symptoms that the family cannot handle. Another is that the child (and dad!) cannot face the prospect of a future bereft of pizza and fries.
I have never found sending the child to a dietician or nutritionist effective, but if you have access to an academic weight loss program, by all means, refer there, though nearly all studies have shown the lost weight to be regained within a couple of years. Instead, you could offer the family the Banting or low GI diet, but do anticipate they will not follow up, as they are unlikely to have adopted the diet.
Unfortunately, as it stands, the excessively adipose child is likely to remain that way into adulthood. We need to find other ways to help.
