The other day in clinic, I saw two siblings for a well-child visit. Both were happy and well-adjusted and bright. The nine-year-old girl, we’ll call her Cristina, was obese. The seven-year-old boy, we’ll call him Luis, was a healthy weight. If Luis had been my only patient for that visit, I would have discussed healthy behaviors with the family to some extent, but his BMI wouldn’t have raised a red flag suggesting that an intensive family discussion about nutrition and physical activity was in order. Cristina’s BMI, an indicator of impending childhood obesity, was the impetus for the in-depth discussion we had that day. And she knew it.
But in serving as the impetus for that discussion, Cristina was doing her younger brother a fantastic favor. We had objective evidence that Cristina needed a better balance in her energy intake and her energy expenditure. But as I talked with the family, I learned that although Luis was more active than his sister, he too needed to make healthier nutrition and physical activity choices. Moreover, both children could benefit from a home environment that encouraged healthy options rather than making them difficult.
The BMI conundrum and risk beyond obesity
I also wanted to alert the children’s parents to the fact that while we know that being obese makes health risks more likely, we also know that there are individuals with healthy BMIs who have high body fat percentages and are at increased risk of type 2 diabetes and heart disease, a condition often referred to as normal weight obesity. The point was this: Within the context of whole-family health, Cristina was not a problem child nor Luis risk free. I wanted the family to understand the importance of addressing both children’s very real health needs before they experienced the consequences of poor eating and sedentary behavior. And I wanted them to understand that, for children and adults alike, health isn’t a simple matter of being obese or not.
Even among medical professionals, understanding the implications of BMI isn’t cut and dried. For instance, we know that some ethnic groups, like South Asians are at higher risk for chronic disease at relatively lower BMIs because they tend to deposit body fat around their organs (which can affect normal organ function) rather than subcutaneously. This reduces the threshold at which they should become concerned that their weight might be unhealthy. Conversely, we know that there are some obese individuals that have fantastic chronic disease profiles despite their weight, the so-called healthy obese. That is not to say they have the same quality of life as their healthier weight counterparts, and certainly children are a special case because achieving a healthy weight in childhood can help stave off disease that may develop later in life. Still, Cristina was not doomed by her BMI and Luis couldn’t walk away scot free.
For children and adults alike, health isn’t a simple matter of being obese or not.
A healthier family: What a little girl understands
And so, I wanted to share with my young female patient that although her BMI may have been the reason for the in-depth discussions we were having that day, she was going to help Luis and the rest of her family become healthier. We discussed that rather than singling out an individual, family-wide changes result in a more supportive and sustainable healthy home environment. That meant the television would be out of her room and her brother’s room. The whole family would begin drinking more lowfat milk and water and cut out the soda and excessive juice drinking. It meant more fruits and vegetables for snacks and evening walks when the family could spend time together and be active.
I knew it would be hard for Christina to take one for the team. After all, it was her, not her brother, whose BMI was unhealthy. She had more obvious changes to make, and would inevitably be followed more closely. Life isn’t always fair that way. So it was important to me to make sure that, before the family walked out the door, they knew how important it was that Cristina had set those healthy changes in motion. The entire family was going to be spared potentially negative health consequences by changing their lifestyle. For that, Luis owed his sister big time. So, before the family left, I let Christina in on one of life’s most important secrets: When it comes to little brothers, debt can be very valuable. I suggested she hold on to Luis’s IOU for future use.