Transcription of Dr. Michael Dedekian for the show Connecting Kids with Food, #77
Dr. Lisa Anybody who’s been paying attention to the news knows that this national epidemic of obesity and being overweight is something that we’ve been concerned about for quite a while. We’re especially concerned because we’re heading down into the younger years. An individual here in Maine, who spends a lot of time thinking about what this means, obesity and being overweight in children is Dr. Michael Dedekian, who is a pediatric endocrinologist right here in our lovely city of Portland. Thanks for coming in.
Dr. Mike: Thanks for having me.
Dr. Lisa: Dr. Mike, first tell us, what’s a pediatric endocrinologist?
Dr. Mike: Great question. A pediatric endocrinologist is someone who helps children with growth and any other hormone problems they might have that includes diabetes and a full spectrum of other diseases like thyroid problems and problems with puberty, those kinds of issues.
Dr. Lisa: It’s pretty specialized. Why did you become interested in this?
Dr. Mike: That’s a great question too. I became interested in endocrinology because I think it’s a terrific blend of science and being able to help care for patients. I have a basic science background from research laboratory experience. The kind of science that we use in endocrinology directly takes what we have learned at the bench top to bedside where we can help children be well and grow.
Dr. Lisa: Having spent time working with children and parents through my own medical practice, I know that it takes us certain special ability to communicate that we develop I think through pediatric training. Is this what you found to be so?
Dr. Mike: That’s true. I think no matter what kind of doctor you are, communication is the essential feature. There’s no doubt about it. Sometimes things in endocrinology can be complicated. We do our best to boil things down to their essential elements. One of the things that inspires me about the field is that endocrinology is very observational, meaning that we have learned from science what the body does naturally and are trying to restore that balance to our patients. That usually a pretty easy concept to understand.
Dr. Lisa: It is an imbalance that we’re talking about now when it comes to children being overweight and obese. What has happened that causes the imbalance to occur in such a widespread manner?
Dr. Mike: That’s the essential question. I think you really hit it on the head there. We don’t know of the answers to that question. Some people argue that our genetics have not changed that much in the past few hundred years. Therefore, it must be mostly environmental influences that are the root of this problem. It’s probably a little more complicated than that because as our understanding of genes and genetics has changed over the years, we’re learning that genes are malleable, that their expression is dependent on certain things in the environment.
Even though the DNA code may not have changes how our genes are being expressed and used in the body may be something that’s changing over time. That’s a complex constellation of environmental influences, societal influences and many other different issues. I always like to say in the beginning that the epidemic of obesity that we see in children and adults has no single trigger. It’s a multifactorial issue.
I gave a couple examples already. Food supply would be another one. The way our food supply has changed, the way portion size has changed, the way our behaviors have changed, the way parenting has changed, all these things play a role. Socioeconomic is another huge factor as well and that has changed. There’s no one single issue. I think there is a popular misconception that obesity is a personal choice and it is not a personal choice.
I think if you ask anyone who’s overweight, if they have chosen to be overweight, they would not say that they have chosen to do that. Certainly any child who is overweight has not chosen that for themselves. It is not a personal choice. It’s not something completely under our control. I don’t mean to absolve us of personal responsibility because that’s obviously very important. What we put into our bodies and how much we move our bodies is important. There are many other factors like genetics and family history and environment that are not under our control and we need to think very broadly about this issue.
Dr. Lisa: What about the possibility of endocrine disruptors that has been brought up in the last say 20, 30 years?
Dr. Mike: That’s another great issue and an important one and one that we’re really in the very early phases of understanding. The field of endocrine disruptors has not been around for very long. The term was not coined out long ago. We work with some leaders in the field. If anyone is interested, they can look up on the Colby College website lecture that I gave as part of the day-long symposium with Dr. Bruce Bloomberg who’s from California, who has spent some really pioneering work in this field and shown that yes, the chemicals in our environment are concerning. We need to take them seriously.
I think we’re still waiting for more science and more evidence to point us in the right direction in terms of what should we be telling our patients, what kinds of chemicals and toxins in the environment should we prioritize as ones to avoid. We’re still learning but it’s clear that these chemicals absolutely can push us down a path of altered metabolism and for children, altered growth, altered puberty.
We’re not sure exactly how it all works yet but there’s enough scientific evidence to show that it is concerning. I think of endocrine-disrupting chemicals as an important piece of the puzzle to not the only thing but an important piece to keep an eye as we move ahead.
Dr. Lisa: I like the idea that you put right out there at the very beginning that this is not a choice. That the children are not choosing to be obese and even really adults are not choosing to be obese. For me, it comes back to the time I’ve spent with patients in my own practice and the compassion that’s really required to deal with people who are in this difficult situation that’s hard to make challenge changes in. I find that challenging. How have you dealt with that?
Dr. Mike: It is very challenging and it’s because there are usually many issues to tackle for something that is maybe a knowledge gap. I think that we all have some knowledge gap when it comes to understanding nutrition because it’s so confusing. I learned something about nutrition from my dietician every day I’m in clinic. Sometimes it’s a problem with socioeconomics as I mentioned. That maybe the family needs more social support. That’s why we work with a social worker in our clinic who’s a really essential element.
Sometimes there may be mental health issues. Sometimes there may be issues within the family that need to be addressed as well. It is very complicated and we have to deal with it I feel like in a very multidisciplinary kind of way. I should say too that a physician working on this in a clinic seeing one patient after another is nice for individual families but it’s not going to be the solution.
The solution has to be much broader and has to involve cultural forces. It’s going to take a little bit of courage on behalf of governments and administrations to deal with this issue. Any meaningful long-term change has to come from a societal level in some way.
Dr. Lisa: We’ve seen examples of the society starting to wake up and take notice and make changes. What are some of your favorite things that Maine has engaged in to try to decrease the problems of obesity?
Dr. Mike: That’s another great question and it leads us right into talking a little bit about Let’s Go! What’s great about Maine is that we really lead the way in many areas and our model for many other centers and communities throughout the country. As you know, I’m involved with and part of my time is supported by the Let’s Go! Program which was started by Dr. Tory Rogers here in Portland. Let’s Go! is a multidisciplinary effort that crosses many different sectors of the community and society to prevent obesity.
When it is put in action for kids and families, it’s not advertised as obesity prevention. It’s advertised and promoted as healthy living, which I think is the right way to go. We don’t want kids to be overly focused on a number of their weight. We want them to be thinking with their families about healthy habits. The mantra of Let’s Go!, the essential message of Let’s Go! is 5210 which hopefully many of your listeners have heard of.
It helps remind us about how to be healthy. It’s a healthy living prescription for five fruits and vegetables a day, two hours or less of recreational screen time, one hour of physical activity everyday and really putting a limit on sugary beverages and juice. That’s the zero, zero sugary drinks and juice. It’s a healthy living prescription. Kids in Maine and other states in New England and really around the country, there are places far away as Hawaii that are doing Let’s Go! in their communities.
Kids in these communities see Let’s Go! messaging all over the place. They may see it at school. They may see it at their church. They may see it a Boys and Girls club or YMCA. They may have parents who are encountering it at their place of work and then at their physician’s office as well, they’ll be seeing this messaging, this kind of messaging that helps promote healthy living.
Dr. Lisa: How has Let’s Go! been able to work with the physician offices to put these messages into place?
Dr. Mike: Dr. Rogers has a well-oiled machine and a small army of people who help physicians in their office achieve this goal. It involves some simple steps but important steps including making a connection to the community which we help offices do, including using a health habit survey with families at well-child checks which we also help with and make it easy for physician offices to achieve and prioritizing proper weighing and measuring of children so that BMI can be calculated.
This might be a good time to talk about Body Mass Index a little bit. If your listeners don’t know, that is a measure of weight for height. You use weight and height to make that calculation. It is not a perfect measure of how obese you are. It is a measure that we find useful on the medical side to predict risk. In other words, if a child’s body mass index is far, far above the normal range for age, we know that over time that child is going to continue to struggle. It may help the pediatrician or family medicine doctor prioritize certain interventions for that family.
I often encourage my patients as I eluded to earlier not focus on that BMI. I don’t think it’s right for example for schools to be calculating BMI and then sending that information home with the child unless it’s in the right context. We use that measure that’s an important measure in the Let’s Go! Program for healthcare professionals. I think as our awareness of this, not only here in Maine at Let’s Go! but as a nation involves and how this issue should be best communicated to families in the most healthy way. We’re starting to rethink how to communicate these numbers to families.
Dr. Lisa: What is the scope of the obesity and overweight problem in children in Maine? Is it different from the nation?
Dr. Mike: It largely follows national trends so between 30 and 40% of all kids in Maine and around the country have a weight that is outside the normal range for age.
Dr. Lisa: How does this impact children’s health? We know that long-term there’s an impact on adult health and longevity and ability to live a healthy life. How does impact the life of a child?
Dr. Mike: It can impact the life of a child in many ways. I think I should say first that most children are healthy no matter what their weight is. Adult-type diseases are still relatively uncommon in childhood. However, we’re starting to see an increase in these diseases in a way that is far beyond what we would have predicted even a few years ago. I always tell people that I got into pediatrics because children usually have one or two medical issues that need to be worked on and usually they’re fixable and solvable. You can fix a broken leg or an infection and send kids on their way and they’ll be healthy for 90 more years.
What we’re starting to see especially in my clinic where I see kids who are struggling the most towards this few population. What I see is a list of what we call comorbid conditions or medical issues stemming from weight that really look like an adult-type medical problem list. Things like pre-diabetes and outright type two diabetes, hyperlipidemia, meaning high cholesterol; children who need medical therapy for elevated cholesterol levels.
Young women and young teenagers who are having problems going through puberty and having irregular menstrual cycle is an issue. Obstructive sleep apnea, something you may usually only think of as in adult population is much more common in the children that I see. Then the social comorbidities I think are important to mention as well. Not every kid who has a weight issue struggle socially but many do.
Quality of life by various psychosocial measures is often lower in children who are really struggling with their weight. That’s a major issue as well and something that we really emphasize and focus on also. The medical issues really run the full gamete. Anything that an adult can have because of a weight issue, a child can have too. Usually it’s in the early phases but we love to get involved early; the earlier the better. Often we can prevent those issues from really becoming a problem.
Dr. Lisa: How do you usually begin working with a family on this issue? It does go beyond the child. In fact sometimes just focusing on the child can be very stigmatizing. What’s the approach?
Dr. Mike: The approach we use in our clinic is first to say some of the things that I said earlier in this interview which is to take away blame and to point out that there are many issues that can cause weight problem. We emphasize that we want kids to feel comfortable in their own bodies no matter what those bodies look like. We start from there and I feel that that really helps.
We also emphasize that we don’t have a particular weight goal in mind or a particular number in mind. Many families are relieved to hear that. Once we break down some of those barriers, we can then open up the discussion a bit more. We really try to let families lead the way. We like to find out what families see as the greatest barriers to better health in their family and work on those issues first. We’ll help guide them and give suggestions of course but we really try to let families be in the driver seat.
We have several themes that we emphasize in the clinic. One of them is that families need to work together that rule within the family around food should be the same for everyone. You shouldn’t have a different list for different members of the family. If something is expected of the child, we expect it at the whole family as well. That’s something that’s very important. We see where families are. We have themes in mind to work with them on but we really let them lead the way.
Dr. Lisa: How has all of this impacted the way that you’ve parented your own children? You have a one-year-old and a four-year-old and I can’t imagine that you can separate that easily.
Dr. Mike: That’s a great question. I think there’s no doubt that I’m healthier personally because of the work that I do. That’s probably just the nature of medicine and being around a great team including a great dietician and social worker and other physicians who are always teaching me something new about this. It’s helped me. It’s helped parent for sure. I think it’s given me a little bit of courage too to take certain things out of the house.
For example, I always tell my patients that if something is there, it’s much easier to eat. If it’s not there, then you won’t eat it. I always sort of poke fun at my staff in the hospital. If they bring me donuts or if they bring donuts to share with everyone, guess what? I eat them. I don’t let them go to waste. I think that’s true of anyone. If those donuts or that ice cream isn’t there in your home, then it’s not going to be as a barrier to better health.
I usually tell families, “Go out once a week and have ice cream instead. Give yourself a special treat once a week but don’t have it in the house. That way, it’s a measured portion. You’ve had a good week. You’re giving yourself a little bit of reward for it. That way, kids don’t feel they’re completely deprived of things which we want to avoid also.
I definitely practice what I preach. I like to be able to tell my parents that in a very honest way. I think we do a good job. I think my kids are growing up in a very positive environment. I don’t think they’re hyperaware of food or have some anxiety about food. I think it’s a very healthy.
The other thing I’ve been able to witness is in my daughter’s day school, they were not doing the Let’s Go! program when we first started there a few years ago. This is the Trinity Day School in Portland. They did a wonderful job bringing the Let’s Go! program to the day school. I saw how they cleaned up snacks. They now offer healthy food and vegetable to all the children at snack time even if they don’t have it in their own lunch that they bring.
There’s no juice anymore in the whole daycare which was a little bit of a shock to the system, to some parents but the kids adjusted and are totally fine now with it. They have healthy celebrations meaning that for birthday parties and holidays. There are healthy snacks and treats offered instead of cookies and cupcakes which really has cut down dramatically, right?
If you think about it in a class with 40 kids, there’s a birthday every week. There’s some sugary something every week. When we rolled out this idea of healthy celebrations, it was a real relief to the childcare staff and also to the parents that the kids were going to be having healthy foods instead of sugary things all the time.
I’ve seen how it works on a parent level. I like the kinds of things that it does with my own family. We’re educating our family and grandparents are keeping an eye on what’s going on too. That’s always a tricky one. I think we’re doing well.
Dr. Lisa: Are you originally from Maine?
Dr. Mike: Spent a lot of time growing up in Maine so it feels very much like home and was very thankful that my parents decided to retire here and we came along for the ride.
Dr. Lisa: Is there something about Maine and the ability to go into the outdoors and be active and have an active lifestyle that drew you here?
Dr. Mike: Yes, absolutely. I mean, Maine I think has one of the greatest quality of life existences you can live. It’s just the right kind of place for me. We do love to be outside. We love nature and all its seasons. I always tell kids in my clinic who say there’s nothing to do or there’s nowhere to go outside to play. There may be some kids who live in neighborhoods that are a little tougher than others. Maine has a lot of space. There’s plenty of snow to shovel. There are plenty of leaves to rake and places outside to go.
I’m always trying to encourage my families to take advantage of the great resources that we have here in Maine. It is such a wonderful place to be and a great place to raise a family and tremendous opportunity to be healthy if you know what to do and where to go.
Dr. Lisa: Your kids are one and four so I don’t know that you’ve experienced this personally but do you have any thoughts on the way that we’ve developed this kids sports institutional … I don’t know, megolith of it now out there in society? That’s where we push kids early to do sports that helps them to be active. Then not necessarily shocks off kids at an early age if they don’t have the right skills. Then it causes a lot of parents to sit around and watch their kids rather than being active themselves.
Dr. Mike: Right. Yup, that is true. I think that many times when we talk to families about being active and exercise, they think of organized sports as the only option. We are always trying to counsel our families that exercise doesn’t mean you have to go and run a marathon or join a sports team. It can be helping with yard work. It can be taking the dog for a walk. It can be trying to walk to school when you can. It can be trying to walk more during your day, taking stairs instead of elevators, simple things like that.
I do think that our culture does get us caught up in organized sports. Kids are competing at such an intense level now. They’re almost being trained like Olympic athletes in some circles. I think that does stigmatize exercise and activity a little bit and make it seem unreachable for those kids who are not naturally very athletic or might not be as interested in sports.
I do think it’s important that we have a broad view of activity. We try to call it activity instead of exercise. I just say move or play. For kids of a certain age, it’s just playing. That’s all they need to do. You’re right. We do need to be careful about what we exercise and activity. If there are kids interested in sports, that’s great. They should go for it but there’s a lot of other ways to get there too.
Dr. Lisa: Are there any interesting things coming up in the science of pediatric endocrinology obesity, being overweight?
Dr. Mike: There are definitely are some important advances coming our way. I think the biggest question that is still being studies is how does extra weight at a young age affect health in the future? I think we all take it as obvious that too much extra weight in an early age is going to adversely affect health in adulthood. That seems to largely be true. Exactly how that happens and what kinds of risks are most important to prioritize, that’s something that’s still being studied.
One example would be type two diabetes. There is no formal definition of pre-diabetes in children and teenagers. That’s something actively being studied and being looked at. We use a definition from adults that probably works but children have a special situation with their biology and their growth and puberty puts them in a little bit of a different category that we need to look at careful.
I’m always careful when making that diagnosis of pre-diabetes. There was just a huge study that came out part of the today’s study recently published in the New England Journal of Medicine looking at the progression of type two diabetes in young people. There were some discouraging results showing that young children and teenagers with diabetes tend to have a more severe form of type two diabetes than in adulthood.
The medicines used in adults with a relatively good effect aren’t quite as effective or long-lasting in younger children. These kinds of issues are ones we’ll continue to keep watching as we move forward.
Dr. Lisa: Has it made any difference at all that we’ve taken sugary drinks, sugary snacks out of many of the schools and the vending machines and the hot lunches? Has there been any impact on the child’s ability to study and focus?
Dr. Mike: I think that school is a tremendously important part of this puzzle. It’s a major emphasis of our program at Let’s Go! Yes, I think that not only are you removing calories from children’s environments, extra calories that are usually not necessary but there probably is a beneficial effect on helping kids focus as well. We work with some physicians in the community who work with children who have ADHD. Some of these children definitely need medicine; others may not. Some practitioners are using a more nutritionally based approach to ADHD and having some good results with that.
Dr. Lisa: How can our listeners find out more about the Let’s Go! program?
Dr. Mike: They can visit our website and I would encourage them to do so. It’s letsgo.org. They’ll see information there on the 5210 Program. There are very hand and user-friendly handouts and recipe books for families interested in getting new ideas about healthy snacks and healthy living. That’s a great place to get started. We would love for people to visit our website. We’re very reachable if you need to reach me or Dr. Rogers. Our contact information is on the website. We’re happy to take a call from anyone who’s interested in learning more.
Dr. Lisa: We’ve been speaking with Dr. Michael Dedekian about childhood obesity and some of the issues surrounding it. We’ve been really privileged to spend this time with you. Thank you for coming in and working on this important topic.
Dr. Mike: Thanks for having me. It was a pleasure to be here.