Guide to Weight Loss for Kids (Long)

This is about *how* to treat your kids, not *why*.  If you haven't already read my other posts, you'll get more out of this Guide if you first understand why you should become a DIY expert on obesity and look for an A+ doctor.  

You can download your own copy of this guide here.

Here's what I wish I'd know a few years ago when I realized that my middle child, just 10 years old then, had gained 40 lbs in 18 months.

That is 4x normal.

 Her dad and I noticed her gaining weight and were doing what we thought were the right things. She was exercising a lot. She was on a carb-restricted diet and we cooked almost all her food. We were acting as good role models, and talked about moderation and “listening to your body”.

Her body didn’t care. Lab results 8 months later showed she’d gone from normal to almost diabetic. She'd gained an additional 10 lbs.

I had to become an obesity expert to find the right treatment for my child. This Guide is what I've learned so far, and I'll update it as I learn more.

Table of Contents

·       Assess & Record

·       Urgent vs. Wait-and-See

·       Finding Professional Help Quickly

·       Getting Labs

·        Medications that Help

·       What to Eat

·       Medications That Cause Weight Gain

·       Setting Up Ongoing Support

1: ASSESS & RECORD

An unexplained weight gain is the earliest sign of insulin resistance. Insulin resistance is the precursor to diabetes and what is the underlying hormonal problem causing diabetes and obesity.

If you have concerns about your kid's weight, record weight, height, waist and hip circumference every 4-6 months.

 

CALCULATOR

I verified that my child was obese, and the severity of the problem, by plugging in height and weight into this calculator from the US Center for Disease Control. If you live outside the US and Canada and don’t think the calculator is correct, try these charts from the World Health Organization. 

OK, does the calculator say your child is obese?

Or, is your child overweight, but used to be in the normal bracket, and you’ve seen an unusual rate of gain?

If so, call your pediatrician to get a clear history of your child’s BMI over time.

Going forward, I recommend taking these measurements on all of your kids every 4 months.

·      Weight. Any scale is fine. I ordered one from Amazon; from the brand Yunmai. It’s worked well and connects via Bluetooth to many iPhone apps like Apple Health and Fitbit, as well as the Yunmai app.

·      Height. Easiest to mark it on a wall or door.

·      Waist circumference

·      Hip circumference

At this year’s meeting of the Obesity Medicine Association, many speakers showed how waist circumference, as well as waist to hip ratio, can predict metabolic health or sickness. This is likely because it’s a proxy for visceral fat, which is metabolically harmful fat that surrounds organs in the mid-section.

About BMI:
Some experts in the field of obesity criticize the tyranny of the BMI scale.
As a parent, just use common sense and know that if your kid is unusually muscular, you might get a high BMI number.
Obesity isn’t about weight or height, hence the BMI criticism. It is about fat dysregulation, an abnormal accumulation of adipose tissue. But it’s easy to be accurate when measuring weight and height, and comparing them is a good proxy for a more difficult body fat measurement.
If your child doesn’t have much adipose tissue, and is muscular, you can ignore the high  BMI number.  And the entire Treat Kids website.

2.    URGENT VS. WAIT-AND-SEE

My child was always “chubby” and then gained 40lbs in 18 months. The weight gain continued despite our intense focus on a low carb diet and a lot of exercise. And no, the gain wasn’t caused by puberty.

A great, well meaning, family medicine doctor said to me, “My daughter was fat and she grew out of it. Just wait it out.”

When I confided in friends, they tried to make me feel better.  “She’s adorable. It’s just baby fat.”

Nobody except you is going to make your child’s weight gain an urgent issue. It would be rude.

When I attended my first Obesity Medicine Conference, the message was completely the opposite. We should be vigilant about unexplained weight gain, even unexplained weight gain of 5-10lbs.

This unexplained weight gain can be an early sign of metabolic disease.  It may mean that the cells in the body have become less sensitive to insulin, and there may already be damage to the cells in the pancreas that make insulin. They’re called beta cells and typically labeled as “β cells.”

For my kid, the impact of unexplained weight gain was medically serious. Her A1C rose from 5.6 to 6.2 in 9 months, while eating as few carbohydrates as we felt possible for an 11 year old. If she hadn't gotten medical help, she’d be diabetic today. (A1C of 6.5 is the threshold for diabetes.)

Her pancreatic cells are probably better able to recover than an adult’s cells, but the point is, once you’ve got that high A1C, even just a bit high, there’s probably already pancreatic beta cell damage.

If your BMI assessment, your child’s medical records, your family history, and your common sense all tell you that your child has obesity, it’s up to you to make it a top priority. Nobody else is going to.

 

 Reasons to treat your kid’s obesity seriously.

 

1.     Diabetes develops faster in kids than adults.

During the 2015 Obesity Medicine Association conference in Washington, DC, I heard Dr. Suzanne Cudas, a pediatric obesity specialist from San Antonio, talk about her practice. Sometimes when she has diagnosed kids with full-blown diabetes, the parents say, “Oh, sure, no problem, grandma has diabetes too.”  She emphasized that this isn’t your grandma’s diabetes.  Diabetes progresses more quickly in kids and kids’ organs will be under the assault of diabetes for a lifetime.

2.     There’s no growing out of obesity.

Overweight and obese kids are 5x more likely to be obese adults.

3.     Permanent damage to the pancreas occurs early.

Unexplained weight gain is an early indicator of insulin resistance. If your child has a sudden weight gain, it could indicate a metabolic problem long before and A1C test shows pre-diabetes.  Catching it early is ideal.  By the time we see prediabetes in our kids, the cells in the body are already insulin resistant and the pancreas is already damaged. There may even be death in the pancreatic β cells that produce insulin.

4.     Conventional recommendations don’t work.

You’ll need to treat the problem as urgent, since few others will.  Much of the advice that you’ll get -especially ‘eat less, move more’ - doesn’t work.  Other things that well-meaning people will recommend:

·      Just eat in moderation.

·      Stop serving fatty foods.

·      Get your child into a sport.

·      Just eat more vegetables.

·      Limit screen time.

·      Avoid video games.

·      Drink more water.

·      More sleep.

·      Parents need to model better eating and exercising.

·      Don’t buy junk.

·      Cook from scratch.

Some of these are good suggestions, but they don't reverse obesity; it takes much more intervention.

FINDING PROFESSIONAL HELP QUICKLY                

What’s the biggest difference between an obesity clinic with a formalized weight-loss program and the typical pediatrician or family doctor?

The clinic treats obesity with medication.

The second common difference is that they don’t blame the patient for their disease.

There’s no reason you can’t ask your current doctor for the same medications, but remember she or he wasn’t taught to prescribe medications for insulin resistance in medical school and may feel uncomfortable doing so.

‘Eat less, move more’ isn't effective, so if you go to a doctor and that's all they offer, feel free to tell them that hasn't worked.

Don’t forget that it always feels like we can diet if we just try harder, but eventually, our bodies will feel like they're starving and adjust hunger and metabolism until we regain the weight.

It is perfectly OK for a clinician to recommend you eat different foods or avoid foods. Most of the obesity specialists I spoke with at the conference treat with medication and recommend your family eat food lower in carbohydrates.

However, if you’re seeing somebody that insists on calorie counting, even after you object to it, you should probably look for help elsewhere.

Calories aren't created equal. 200 calories of cheese may be a snack that keeps your child fueled until dinner. A 200-calorie granola bar may trigger your kid’s body to store fat and make a kid hungry for dinner 45 minutes later. If calories aren't equal, why count them?

When we restrict calories, our calorie burn rate slows. We get cold. We’re tired. This makes calorie counting even less meaningful. You would need to count not just the calories, but the metabolic rate as well, something medical studies find challenging even in hospital settings.

And last, only in retrospect did I realize that if I’d known what to ask my pediatrician or other doctors, I might have found my child effective treatment much earlier.

Below are places to look for help and then detailed lists of labs and medications to discuss.

OPTION 1: PEDIATRICIAN, NURSE PRACTITIONER, OR FAMILY DOCTOR

You can get tests done most quickly by starting with your current provider.

It’s perfectly acceptable and usually reimbursed, for you to make an appointment for treatment of obesity.

Doctors’ schedules are tight. If you’re in for a well-child visit, be prepared to return for a visit solely about your child’s weight issue.

When you do, explain you’d like to partner with the doctor and are highly motivated to help your child. Do make follow up appointments and go into the office instead of calling or sending email.  You’ll get better care. Doctors aren’t reimbursed for time unless you come into the office, and the time gives your child a way to form a real relationship with the provider.

OPTION 2: OBESITY SPECIALIST

I highly recommend a specialist if you can find one. Search here on the Obesity Medicine Association web site. Since there aren't many that are board certified, leave the boxes unchecked. Then you'll get a list of all the doctors and nurse practitioners that have joined the Obesity Medicine Association.

OPTION 3: WEIGHT LOSS CLINICS

A search for local weight loss clinics may help you find treatment; some are smaller and privately run, others are at major hospitals. You just need to make sure that you get real care and can voice concerns by asking the questions below.

RELATED: ASK AROUND

I found my own child's doctor by talking to friends. 

Ask around or ask for referrals on the private Treat Kids Facebook group.

 

QUESTIONS AND WARNINGS

First, two warnings.

Do not be intimidated or impressed by name brand doctors.  The care we got from the obesity clinic at big children’s hospital near us was terrible. They used nutrition information circa 1981 and their medical director focuses on curing obesity with mindful eating. (How does this help the newborn that exhibits obesity almost immediately?)

One of the most caring obesity specialists I know is a lone nurse practitioner who works out of her own office in a cozy building. She’s the one practicing state-of-the-art obesity medicine.

My other cautionary warning:  don’t let a white lab coat make you feel you aren’t the #1 expert on your child. I had a dietician in a white coat ask me whether my daughter was an “emotional eater” in 5 different ways, 5 different times. When I was questioned over and over, it made me doubt my answers, but just for a second. It’s fine to be open and dig deep when answering questions, but that’s it. Stick to what you know about your child because you really do know the most. 

Here are two key questions to ask a doctor as you get started:

1.      When appropriate, do you prescribe medications, like metformin, to kids to treat weight gain, prediabetes, and diabetes?  Or do you typically refer out? If you refer, to whom do you refer?

Here you’re probing to see if this can really be your primary contact for obesity treatment. If the doctor will be referring on to an obesity clinic or endocrinologist, you might as well start there. Again, the goal is to save time. You’re the only one who will treat your child’s health problem as urgent.

2.     How do you counsel your patients with obesity?

This question probes for bias. You’ll get some idea of how the clinician talks. This should help you figure out whether they blame the person with the disease or not. Your kid will probably already feel a lot of responsibility for his or her weight gain. Making your kid feel worse won’t help with weight loss.

Other questions to ask:

·      Do you have other patients in this situation? How have you treated them? What have the results been?

·      What sort of lab tests would you recommend for my child?

·      What diet changes do you recommend?

·      How frequently should we check in with you?

·      What haven’t we talked about that we will cover in our next appointment?

GETTING LABS

At your first visit, ask your doctor about getting labs.

Your child may need to fast. Visit the lab in the morning before your child has anything to eat.  Drinking water is fine.

Make sure you get at least an A1C, fasting insulin and fasting glucose.

•       Hemoglobin A1C

•       Fasting glucose

•       Fasting insulin (You’ll need to request this one.  It isn’t standard, but isn’t expensive either.)

Other labs that might be ordered:

•       Oral Glucose Tolerance Test (OGTT), 4 specimen

•       Lipid profile aka cholesterol test

•       Thyroid function

•       Vitamin D

•       AST and ALT (liver tests)

For the OGTT, most doctors and labs have the patient drink a glucose soda that contains 75g or 100g of glucose.  

Our doctor draws the fasting glucose and insulin, and then has my child eat a normal breakfast. From the time the food is gone we start timing and then draw blood 30min, 60min, and 90min after.

Adults at the same clinic also take a 120-minute reading.

It’s worth discussing a real food vs. glucose drink test with your doctor. 

MEDICATIONS THAT HELP

These are prescription medications that have been proven to help with diabetes or pre-diabetes, or weight loss, or both. Your doctor may bring these up or you may need to ask about them. 

•       Metformin

•       Acarbose

•       Topiramate

•       Phentermine

•       Buproprion

•       Glycet

•       Byetta 

•       Naltrexone

•       Orlistat

•       Qysmia

•       Stimulant medications used for ADHD

•       Thyroid hormone

•       Lorcaserin

•       Qysmia (combination of topiramate and phentermine)

If your child is insulin resistant, he’s probably hungry a lot. Using medication to calm the insulin resistance can also calm the hunger, making it easier to eat better.

I hate giving my child medication. But that’s not my reality. Reality is that I can medicate now or wait for full-fledged diabetes and medicate later. 

If preventing obesity and diabetes is considered aggressive treatment, then I want this guide to help you get that aggressive treatment.  I also hope that if enough of us treat our kids, that preventing these diseases will become standard, accepted treatment.

WHAT TO EAT

99% of the doctors of the Obesity Medicine Association, including the endocrinologists, eat low-carb and recommend their patients do the same. (Some call it the Mediterranean diet, but it is still low in carbohydrates, moderate in protein, and high in fat compared to the Standard American Diet.)

One pearl from the Obesity Medicine Conference:  for overweight and obese kids, any carbohydrate restriction is the absolute best thing you can do.  

And we all have access to it without an Rx.

The data from the scientific studies shows that carbohydrate restriction improves health in those with metabolic issues in almost every way, both short term and long term.  And that includes cardiometabolic health, aka heart health.

These studies aren’t new, but our low-fat diet dogma has hidden the truth for decades.

The data from the scientific studies shows that carbohydrate restriction improves health in those with metabolic issues in almost every way, both short term and long term.  And that includes cardiometabolic health, aka heart health.

These studies aren’t new, so I’m not sure why our pediatricians still recommend lots of skim milk and “healthy” grains.

Does low-carb seem impossible?

If you’re struggling to get your kids and teens to eat better, I get it.  I live it every damn day.

Fighting with your kids (or spouse) about going low carb won’t work. There’s sugary junk food everywhere. They can always get it.

Here’s some wisdom from Dr. Rader, an obesity specialist and family medicine doc from Idaho.

Just focus on breakfast.

Get as much protein and fat into breakfast, or the first snack or meal of the day as you can.

Anything you can throw together with eggs, bacon, sausage, green veggies, berries, cheese, full-fat yogurt, cream, nuts, and peanut butter will work.

Here are two delicious, easy muffins you can prep ahead. They’re good for breakfast, but also for after school.  I’ve made them myself and offer some tips.

Beth's Low Carb Blueberry Muffins

Beth is in our Treat Kids private Facebook group and posted this recipe that we all love in our house. (The first time we baked these, my 15 year old and husband loved these so much they each ate 4.)

300g full-fat plain Greek yogurt
350g almond flour (not meal)
5 XL eggs (6 medium)
4T melted butter
1T baking powder
1T vanilla
1c Truvia/Swerve*
2t cinnamon
1/4t salt
1c blueberries

Preheat oven to 350. Mix dry ingredients. Mix wet ingredients, except blueberries. Add wet to dry and mix well. Fold in berries. Cook 25-30 mins. Makes 18 muffins.

Pancake muffins.  Make these in the blender. Some tips:

•       Err on the side of using less sweetener.

•       Add more berries than recommended. 

•       I fill the cups with the batter then sink berries into each muffin individually to make sure each muffin gets lots of berries.

•       When reheating, toast them bottom-up if they get soggy, and then split and toast. Eat plain or top with butter, whipped cream, or sugar-free maple syrup.

Pecan pie muffins These could just as easily be dessert! Tips:

•       Use parchment paper liners and use slightly less sweetener than the recipe calls for.

•       These travel well.

If you want to learn more, here are suggestions.

Books (and some cheats if you don’t have time to read.)

1. The Case Against Sugar by Gary Taubes, an investigative journalist. 

I’m a sugar addict. I’ve always craved something sweet after lunch and dinner. I listened to this audiobook and then heard Taubes speak on January 6th and I stopped. I realized I was an addict, and the sugar haunted me no matter how much I ate. 

So yes, this book is convincing. It will also make you the least fun mom ever.

Here’s a good summary of the book if you don’t want to read the whole thing.

And here’s a video of Taubes speaking about sugar to an audience of teachers. 

Why We Get Fat is another book by Gary Taubes. Read this after The Case Against Sugar. It’s a shorter version of his original work on our faulty nutrition science, Good Calories, Bad Calories. 

2. Fat Chance by Dr. Richard Lustig, a UCSF pediatric endocrinologist. He explains how sugar is making our kids sick. His video on YouTube is called “Sugar: The Bitter Truth” and has more than 6 million views. His research has shown that children with obesity who refrain from sugar for just 10 days show markedly better metabolic function. He is also the first person to explain and confirm that sugar is such a strong, long-acting toxin that we have babies being born insulin resistant. 

3. Always Hungry by Dr. David Ludwig.  Dr. Ludwig is a pediatric endocrinologist out of Boston and this book has a very good eating program targeted at adults but great for kids.

Great web sites.

•       Diet Doctor – This Swedish doctor has gathered the world’s obesity experts to cure his country, and the world, with a low-carb diet. Some parts require a subscription, but there’s a lot of free information. You can also find real podcast interviews with these doctors by typing their names into your podcast app.

•       Low Carb Program and related Low Carb iPhone App. A step-by-step 10week program that just won an award for innovation. Free.

•       Recipe sites

o Ditch the Carbs – Kid lunchbox and snack ideas and photos.

o All Day I Dream About Food – She uses nut flours to create goodies that kids eating low-carb might miss.

MEDICATIONS THAT CAUSE WEIGHT GAIN

The slides below, from the Obesity Medicine Association Pediatric Algorithm, give an overview of medications that can cause weight gain (and a few that lead to weight loss.) 

 

Obesity Algorithm®. ©2016-2017 Obesity Medicine Association.

 

Obesity Algorithm®. ©2016-2017 Obesity Medicine Association.

SETTING UP ONGOING SUPPORT

Frequent doctor visits allow your child to build a relationship with their provider, and takes some of the pressure off you as a parent.  There’s evidence that getting support every other week for the first year of treatment leads to the highest rate of success.

A doctor, nurse, or physician assistant would be ideal, but a great nutritionist or dietician endorsed by your doctor would work in a pinch.

The more comfortable your child becomes with the doctor, the more likely he or she will be to make changes and take the medication as prescribed.

If you’ve chosen to eat low-carb, you and your child will need a lot of support. Low-carb eating is difficult for any person, but especially for a kid.  They have less control over their lives, and they’re bombarded with high sugar, high-carb food during most activities.

Don’t hide setbacks from your doctor. They’re normal. Commiserate and be open. Try to look for things that are going well and talk about ideas for improvement.

Weight loss and weight management can be frustrating, if not infuriating. Sometimes you and your child do all the right things and the scale stays the same or goes up. Other times you are lax and the scale goes down.  Having third party support can put these frustrations in perspective, help you find medical solutions, and help you and your child stay focused on the long term goals.

THANK YOU

I hope this will help your family.

As you embark on protecting your child from this disease, I hope you can keep

We've got to stop pretending that kids can cure themselves by having more willpower or “taking responsibility”. 

Our kids are born with the insulin resistance that leads to obesity. Blaming ourselves and our kids for the problem just prevents us from getting real medical help.

I hope you find a provider to help you who understands the biological basis of obesity and that you and your child aren’t to blame.

Directory of Doctors

Have you found a great doctor, nurse practitioner or dietitian? I’m assembling a worldwide directory of helpful clinicians.  Please email me the clinician's name deb@treatkids.co or post to our private Facebook group or public Facebook page. 

Top Book on Endocrinology by Dr. Robert Lustig

I loved Dr. Robert  Lustig's book "Fat Chance". If you ever want to feel less alone in this whole thing, read it or listen to the audiobook. It's probably at your library.

In the book he talks about infant patients with obesity, something I've claimed I noticed in my own child. When I say my child was born with obesity, that she was very fat despite being breastfed exclusively, people look at me weird and say, "fat babies are the best babies." But this was next level fat. This wasn't squishy and normal, this was different. And it makes you realize, the standard of care doesn't work for our kids with obesity. Who would advise an infant to eat less and move more? 

In his YouTube videos, Dr. Lustig comes across as a gruff, serious, somewhat unpleasant guy but I think he's pissed off because he really cares.  I'm pissed off too Dr. Lustig.  Fist bump. 

Now, in his writing, he shines with kindness and empathy for his patients.  Read his forward to the book:

This book is dedicated to all the obese patients worldwide who suffer daily, and the family members who suffer with them. The children who will not know a normal childhood, who will endure an inhuman existence, and will die a slow and early death. The parents who are engulfed by guilt. The unborn children, who are already imprisoned by changes in their brains and their bodies. But most of all, I dedicate this book to those of you who are or have been my patients; for it is you who taught me the science of your affliction. You also taught me more than medical school ever did or could; and that each life is valuable, precious, and worth saving. You maintained your dignity in the face of the most adverse circumstances imaginable. You shared with me your misery, and your joy in small victories. We cried and we laughed together. I hope I was of some service and comfort.
This book is my way of returning the favor.
Thanks Dr. Lustig.