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Prakash Chandran (Host): Childhood obesity is a growing epidemic in the United States. It affects more than 18% of children making it the most common chronic disease of childhood. This number has more than tripled since 1980. How did this happen and how can we prevent the next generation from inheriting this nationwide health epidemic? Here with us to discuss is Dr. David Milligan. He's a pediatrician at Carle BroMenn Outpatient Center.

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This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world-class accessible care. This is Expert insights. Here's your host, Dr David Hill.

Host: This is Expert Insights with the Carle Foundation Hospital. My name is Prakash Chandran. So Dr. Milligan, I really appreciate your time today. Thank you so much for joining us. There's a lot to talk about here. But at a high level, in your opinion, what do you think is the largest contributor to childhood obesity?

Dr. David Milligan: I don't think there's just one. I think there's many. What we do know is that obesity in children and adolescents affects 14.4 million people in the United States. And this is due to a multifactorial situation. It's socio-ecological, it's environmental, genetic, many things that play into it. And so, we actually saw that during the pandemic, as you said, obesity increased quite a bit. Part of this is access to good foods. Some families in poor socioeconomic status really don't have access to good, healthy foods. They're more expensive. Psychiatric illness definitely increased during the pandemic, and I think there's many reasons for that. People are living at home, they're not socializing, and that led to an increase in obesity. Lack of exercising during the pandemic, when things closed down, there's no gyms to go to. People are locked inside their homes and not exercising. All these things contributed to increasing numbers of obesity.

I think the AAP with their latest guidelines released three months ago are tackling this. And when they release guidelines, this is not something they do very often, when they release guidelines, it is a statement saying, "We're taking this seriously and we want to make pediatricians aware of how to tackle this properly." And so, what I will say is that their approach definitely identifies that there is an issue, there's a concern with growing numbers and it takes a more aggressive approach with how to treat this.

Host: As I hear you talk about this, I think that everyone generally knows what obesity is. However, a parent might be listening to this and be like, "Well, that's not my child." So, can you talk a little bit about how obesity is defined?

Dr. David Milligan: Sure. So, it's different in pediatrics than adults. With adults, we look at numbers of your body mass index. And body mass index basically compares height and weight together. If you think about it, if someone is taller, they should weigh more, vice versa. So, it's a comparison of height and weight. Over the age of 18, we just have strict numbers for your BMI. If you're more than 25 for your BMI, you're overweight. And at a certain point, you're obese and then go from there.

With kids, it is different. So, we use percentiles which basically it's gender and age specific. We look at percentiles to compare your child to other children of their same age and gender. And we also do this for height and for weight. But essentially if your child is over the 95th percentile for their age and gender for their body mass index, that classifies as obesity.

Host: Yeah, makes sense. One of the things that you spoke about was good foods and sometimes good foods might be more expensive. When you say good foods, what do you mean by that? And also, conversely, what is considered a bad food?

Dr. David Milligan: Well, basically there's some recommendations that we have for daily nutrition, and one of the things is we want children to have five servings of fruits and vegetables every day. And produce is not cheap. And personally, during the grocery shopping in my household, I'll tell you that produce did not decrease in price during the pandemic. It's very expensive now. And so, getting those servings and fruits and vegetables is hard to do. Bad foods for you are foods that really don't offer nutritional value as far as healthy fats, proteins and are high in calories. Refined foods are probably not the best choices for your child. But healthier foods that are whole grain, that's produce and then so forth are typically more expensive foods. And there are families that unfortunately have to make the choice between do we get more food that'll last longer with what we can afford, or should we get healthier food that might not go as far and use that money that way? It's a tough decision to make.

Host: That is a really tough decision. And you are right, it almost feels like prices went up since the pandemic, making it a little bit harder to eat in a healthy fashion. I am curious, for the families that do have to make that decision around eating healthy food versus eating more food, do you have any recommendations around things that they can do, like supplements or other things to get that good nutrition into their child?

Dr. David Milligan: Well, that's a tough question, but how we start with is having kids see a nutritionist, okay? And having parents and their kids both visit a nutritionist, because they can start with a thorough history of what the family's eating. And once they can assess what they're eating and assess their income, their resources to provide food for the family, they can look at options that might be better choices than what they're doing with their resources. And so really, it's a patient by patient and the person by person assessment. But typically in my office, if I see that there is some hardships over food nutrition, first thing I'll do is refer to a pediatric nutritionist and have them do a thorough assessment and go from there.

There's also online resources that are put out by the government and various organizations that you can go on there and you can make your own plate, and it tells you what foods are good options, what food are bad options. And that's a resource also that anyone with a smartphone or internet capability can access and see if the foods they're choosing and they're buying are good options or bad options. And they'd be finding better options for what can they afford.

Host: Yeah. And another problem that I have as a parent is just how picky my children are, right? And just to basically make things easier on myself, I'll just be like, "All right, have that chocolate bar instead of the eggs in the vegetables that I want to give you this morning for breakfast." I just did that this morning. In fact, that is probably something that you see often. Do you have any tips around how parents might deal with that, you know, the kids just being picky eaters and trying to get the right nutrition in them?

Dr. David Milligan: That's a good question. So, first of all, I'll say that I have two kids of my own. They're 10 and eight years old. And whenever I look at a concern from families, I have two ways to think about this. One is my pediatrician hat, what I learned in medical school and residency. And the other one is just being a parent. And I will say that I'm not perfect in my household. My kids eat ice cream and sweet and things like that. We definitely eat a healthy diet, but we splurge here and there as well. And it's tough because a lot of kids are picky and that's really a common thing we see in households, that at least one kid, if not multiple, are somewhat picky eaters.

What I hear a lot in the office is "My kiddo doesn't like vegetables, doesn't like meat," it's a common thing actually for a toddler that they just don't really care for meats. There's no approach to really fix this necessarily. I think what it comes down to is, one, modeling good food choices, right? So, I think what parents eat will definitely influence what the child eats, and so really having that good influence there.

Number two is really only offering certain things for a meal. So, what we find sometimes is that if there's food substitution, For example, you give your kiddo chicken and broccoli to eat and they refuse to eat it. So then, you say, "All right, here's the chicken nuggets." So once you substitute that food, kids are smart and they figure that behavior out. Next time, they're like, "Oh, you know what, if I just don't eat this food, I'm getting the good stuff." So really trying to stay strong and only offering certain things at a time and not having that substitution in there is really important. And then, the last thing is just everything in moderation, right? So, I think it's okay for a child, they're children, they need to have some of the good things in life and enjoy ice cream and certain treats and things like that, that's okay, but in moderation is important.

Host: Now, I think the moderation piece is very important because I think some parents might be like, "Look, my child's a little overweight. Who cares? You know, they're a kid. They're going to grow out of it." Can you talk a little bit about the dangers of letting things get out of control?

Dr. David Milligan: Absolutely. So, the mindset used to be and has been that kids will grow out of the weight, and that is sometimes true. I certainly assume a number of kids who enter adolescence, they shoot up for their height and things kind of even out. But we are learning that that's not always the case and oftentimes really isn't the case, that it doesn't improve with age. And I've seen many cases that actually gets worse over time. The concern is that we are seeing kids, and when I say kids, I'm really meaning like teenagers, adolescents who are suffering from what used to be adult illnesses. We are seeing adolescents with type 2 diabetes with high blood pressure we call hypertension, high cholesterol. They're having these issues and the concern is that these are chronic illnesses that long-term can lead to serious health consequences. And among those include heart attack, stroke, kidney disease, other things as well. And so if you think about it, if you're diagnosed with one of those things when you're 40 or 50, the long-term effects will hit you eventually. But at an older age, the concern is that if we see someone when they're 13, 14 years old with this, they might have these effects when they're in their late 20s, 30s. And the concern for that really grows. We're trying to prevent that from happening for these kiddos.

Host: Yeah. I don't think parents realize the lasting effects that some of the decisions that kids are making today in terms of what they're putting in their bodies can have for the long term. So, I think another piece of it is, I think, as you mentioned, setting a good example in terms of how you model the right diet and what you're putting in your body. And then secondly, also just talking to them about the importance of good food because your kids are really intelligent, they get it right, and so maybe having that conversation with them might be a good idea. Would you agree with that?

Dr. David Milligan: Absolutely. And I think modeling is really an important thing. What worries me is that if a child is singled out in the family and we focus on this one child having a weight concern and really focus more on changing that child's nutrition, there can be different consequences of that and negative consequences, and can that turn into an eating disorder where the child is fixated on what they're eating and then health in general? Whereas if you have an approach where it's really the family, the whole family's eating a certain way and having exercise a certain way and so forth, it would just becomes more of a lifestyle mindset, that this is the way it is versus I have a problem that I need to fix it.

Host: I'm so glad that you added that clarification because that is equally as important. Kids are super malleable and just making sure that collectively as a family unit, this is the way that we operate. That's probably the best thing and the best approach.

Dr. David Milligan: Yeah. The approach is really we do this because it's healthy, not because I have a problem. That's where I think kids can give them the territory of bad lasting affection psychiatrically and also other things as well.

Host: Yeah. So just before we close, Dr. Milligan, you know, you probably worked with lots of parents, lots of kids around the obesity topic. If there's one thing you know to be true that you really just want our audience to know, what might that be?

Dr. David Milligan: What I want to say with that is be open to a discussion with your doctor about it. And I think that that can start one of two ways. I've had families come into my office who initiate the conversation and they say we are concerned about health in general. We're concerned about the weight being high, can we discuss numbers and different options that we have? And that's great. As a doctor, that is wonderful because I think that shows initiative and the outcome often is better in that situation.

But a lot of times and more often, I would say, is that the doctor initiates that discussion. Maybe someone's here for a routine physical exam or going over numbers, we notice that the BMI is elevated and that discussion really comes from us more than the parents. And what I would say is be open to that conversation. If you have a doctor who is addressing this and discussing it with you, you have a good doctor. Obesity is a chronic condition, and much like if your child had asthma or diabetes, you wouldn't want your doctor ignoring that. Don't expect your doctor to ignore this either. A conversation is a good thing. And so, just join in that conversation and be open to it. It's a touchy subject, you know, it really is. And I think there's a right way and a wrong way to have that discussion, open that door with families. But again, be open to that discussion taking place.

Host: Dr. Milligan, I think that is great advice and the perfect place to end. Thank you so much for your time.

Dr. David Milligan: Thank you. Appreciate it.

Host: That was Dr. David Milligan, pediatrician at Carle BroMenn outpatient Center. For more information about connecting with one of our providers, you can visit carle.org and that is C-A-R-L-E.org. For listing of Carle providers and to view Carle-sponsored educational activities, you can head on over to our website at carleconnect.com.

And that wraps this episode of Expert Insights with the Carle Foundation Hospital. My name's Prakash Chandran. Thank you so much. Stay well.