Obesity weighs hard on urban kids

The 4-year-old who sat in the office of pediatrician Arnulfo Delgado, MD, was clearly too heavy. But his parents weren't concerned.

Like many who show up at Dr. Delgado's San Rafael Medical Center in Chicago's mostly Latino Little Village neighborhood, these parents felt their child's heft was nothing more than a case of healthy baby fat. Dr. Delgado had to perform a cholesterol test to convince them otherwise.

"More than 50% of the kids in my practice are obese, and the parents don't perceive it as a problem," said Dr. Delgado.

Dr. Delgado is one of many physicians working in America's inner cities who are observing a pediatric obesity and overweight rate far above the national average of 26% for children 2 to 12 years old, according to data from the National Health and Examination Survey.

"It's a bigger problem than heroin, cocaine, alcohol and HIV put together," said Zach Rosen, MD, medical director of the Montefiore Family Health Center in the Bronx.

Those interested in reducing health disparities are taking note, too.

In April, the Sinai Health System Urban Health Institute in Chicago hosted a day-long Summit on Childhood Obesity, bringing together neighborhood activists, educators, dieticians, public health officials and physicians, such as Dr. Delgado, to develop possible communitywide solutions.

"Awareness isn't working. Everybody knows it's a good idea to be active and that junk food isn't healthy," said Katherine Kaufer Christoffel, MD, MPH, medical director of the Consortium to Lower Obesity in Chicago Children. "We need new approaches because this is a very complicated problem that's going to require numerous interventions in every sector of society in a sustained way."

Health disparity: a striking example

The symposium was in response to a January report issued by the institute that found a rate of pediatric overweight and obesity higher than 50% in several of Chicago's predominantly Latino or African-American neighborhoods. In one case, the incidence rate hit 68%.

Numerous other studies have also suggested that urban minority children have significantly higher rates of obesity and overweight. Still, there is considerable debate about what needs to be done to address the problem. Obesity interventions have very limited effectiveness even in the most ideal environments. In these areas, the barriers are even greater because of cultural norms as well as access and infrastructure issues.

"Every kid is heavier than the next," said Karen Sawitz, MD, pediatrician at the Union Community Health Center in the Bronx. "I just wish there was something we could really do."

Many physicians report that the belief is common among urban minority patients that excess weight is the sign of a healthy child. The Urban Institute study found that up to 90% of the caretakers felt that the child was normal weight or underweight.

"If a kid is normal weight or above, the parents will say, 'He doesn't eat anything. He's too skinny,' " said Dr. Sawitz. "I don't think they see forward into adulthood and see any connection between a fat child growing into a fat adult."

Convincing parents that there is a problem is one thing. Making changes is an even greater challenge, and there are many factors that work in favor of inactivity.

"[Safety] may impact whether or not a parent is going to allow their child to play outside and run around very much or keep them inside," said Benjamin Danielson, MD, medical director and pediatrician at Odessa Brown Children's Clinic in Seattle.

Tightening school budgets may mean that physical education is no longer offered.

Inner-city areas also have higher rates of pediatric asthma which, with obesity, contribute to the cycle of sedentary behavior. Asthma can make a child less likely to be active, and obesity can make it difficult for even non-asthmatics to breathe and can make asthma worse.

"Kids self-limit their exercise because of shortness of breath, and they end up taking in more calories and not exercising it off," said Dr. Danielson. "And our most severe asthmatics are obese."

Meanwhile, on the food side of the equation, physicians complain that many common healthy eating plans may recommend foods that some cultures find unappetizing.

Healthy food choices may also not be that accessible either because they are not available locally or because parents may not have the money to buy them or the time to prepare them. Food insecurity is also believed to play a role.

"If you go to any low-income neighborhood, you generally see fast-food restaurant after fast-food restaurant and very few big grocery stores," said Christine Wood, MD, a pediatrician and a member of the Coalition on Children and Weight in San Diego.

These unique characteristics of urban living are leading many doctors to focus their attention past the individual child to the family and beyond. Most experts agree there is no single change that will turn back these numbers.

"We need to change not just the child or the family." said Esperanza Garcia-Alvarez, MD, a pediatric gastroenterologist with Sinai who also spoke at the symposium. "It will take a community to fix this."

Experts also warn that if these numbers are not improved, there could be broader, more dire implications.

"We're going to see a physical immobilization of generations of minorities who are already facing enough challenges when it comes to trying to be successful in this society, and that is really tying another hand behind their backs," said Dr. Danielson.