Since I had seen her last year, my 5-year-old patient Tiana had gained so much weight that I almost didn't recognize her. I knew that when I looked at her growth curve it would now include a steep upslope. The change had not caught her mother, Maria, by surprise. Tiana's weight was the first topic of her answer to my usual, “How are things goin'?”
Over the years we had had many discussions about how she might remedy the girls' sleep problems. Now we had a new issue to discuss: impending obesity.
My simplistic understanding of obesity has always been that if someone takes in more packets of energy than are burned, those packets will accumulate in the body as fat.
One must also account for genetic variation because it is clear that some of us are better at storing fat than others are.
Likewise, two automobiles of the same size may have dramatically different fuel efficiency ratings just because that's the way they were designed and built.
It seems, to those of who were blessed with lean parents, to be such a blatantly simple concept that we are easily frustrated by other families who “just don't get it.”
Which side of my simplistic equation had changed for Tiana?
Suspecting that it was an intake problem, I began to quiz Maria about the family's diet. It continues to be predominantly vegetables and grains, no soda, rare desserts. She admitted that there has been a slight increase in chips and snack food since she and her husband had taken over a mom-and-pop convenience store. But, the amounts didn't sound excessive.
I then began to explore the energy utilization side of the balance sheet.
“How much TV are the girls watching?” Here the answer was significantly different from the year before. The television was now on all the time.
“Why?” It turns out that since taking over the new business, Maria had been so busy keeping the books that she admitted using television as a babysitter. In the past, she would often take them outside and spend a good part of the day playing. But now the girls are full-time couch potatoes.
I told Maria what she had suspected herself: that the inactivity was the major contributor to Tiana's weight gain.
Digging deeper, I asked if there was a way that she could do the bookkeeping in the evening after the girls were asleep. The problem with that solution is that the younger child still sleeps poorly and Maria feels she must lie down with her whenever she wakes. She feels that she can't let her cry because it will interrupt her already sleep-deprived and overworked husband. With evenings consumed by sleep refusal, Maria must steal daytime from the girls to do the books. So we were back to talking about sleep, the same issue that Maria and I had batted around for the last 4 years.
Although growth curves as dramatic as Tiana's are unusual, when they do occur they reopen my eyes to the complexity of the obesity problem.
Sometimes the steep rise in body mass index is the result of a cookie-baking grandmother assuming the full-time day-care responsibilities. In other cases, opportunities for activity are lost and dietary supervision gets lost in the family shuffle.
In any case, obesity is one of those rare situations where my simplistic survival tool fails me.