She’s 12, wears her long hair in neat cornrows, and already has some serious risk factors for cardiovascular disease—high blood pressure, high cholesterol, and too many extra pounds from a sedentary lifestyle and high-fat diet. “There aren’t any kids in my neighborhood, so I’ve just been watching a lot of TV and eating stuff that’s really bad for me,” says Angela, the Miami-Dade County sixth grader who is participating in a research program at the Miller School of Medicine’s Department of Pediatrics. She is learning how to exercise more and eat better. About one-third of the nation’s children and adolescents are overweight or obese, and for some minority groups the rate is much higher. Since obesity is considered the second leading cause of preventable disease and death in this country—second only to tobacco use—hundreds of thousands of children are facing an uncertain future. “We have a whole generation of kids who for the first time may not live as long as their parents,” says Steven Lipshultz, M.D., chair of pediatrics and associate executive dean for child health, who has assembled a diverse team of clinicians and researchers to try to change that. The team literally is writing the book on assessing and preventing cardiovascular risks in children, having been asked by the American Academy of Pediatrics (AAP) to contribute chapters on preventive cardiology, high blood pressure, and heart failure to the AAP textbook on pediatric primary care.

“This is the very first AAP textbook on pediatric primary care, and they asked us because we’re recognized as being really unique in the country,” Lipshultz says. “There are very few places that are trying to document not only how significant cardiovascular risk is at a young age, but to come up with interventions that make a difference.”

UM has one of the largest cardiac rehabilitation programs for children and a team of people who specialize in cardiology, nutrition, psychology, gastroenterology, epidemiology, exercise physiology, and endocrinology—all working together as a group. “It’s a multifactorial set of issues that require a multidisciplinary approach,” Lipshultz notes.

In addition to its work on weight and obesity, the team also is working on prevention of other cardiac risk factors, including exposure to secondhand smoke.

“Certainly the risks are higher than they used to be,” says David A. Ludwig, Ph.D., professor of pediatrics and epidemiology and public health, whom Lipshultz calls “among the best in the country at assessing childhood risk and prevention.”

Although experts speculate that the long-term effects of obesity and other cardiovascular risk factors in children will have dire consequences later in life, Ludwig feels ongoing research is essential. “At present, definitive longitudinal data supporting such speculations is limited.”

Ludwig, who serves as biostatistician and designer of studies to assess risk, came to the University in March from the Medical College of Georgia, where he was co-director of the Georgia Prevention Institute.

“There are an incredible number of issues here. Kids are not getting as much exercise,” he says. “They’re not involved as much in free play as was the case 20 or 30 years ago due to the way neighborhoods are structured now. They’re more likely going to an organized sport like soccer, and if they’re not, they’re in front of the TV.

“One of the biggest culprits is the availability of cheap fast food. We actually have a surplus of food in this country, and when it comes in the form of fast food, it’s very inexpensive and high in calories and fat.”

Preventing obesity during childhood is critical, because habits formed early often last a lifetime. Research has shown that overweight adolescents have up to an 80 percent chance of becoming overweight or obese adults, and earlier onset of obesity leads to the earlier onset of related illnesses, such as type 2 diabetes, heart disease, stroke, and certain types of cancer.

About 18 percent of children in this country are obese, up from 5 percent in 1974, according to a study published over the summer [June 27] in JAMA, the Journal of the American Medical Association. An estimated 60 percent of obese children between the ages of 5 and 10 have at least one risk factor for heart disease, the leading killer in the United States, and 20 percent have two or more risk factors, the JAMA report said.

A number of previous studies at UM and elsewhere have shown that African-American and Latino children living in low-income communities are at greatest risk for obesity and related health problems. The American Heart Association has issued a scientific statement saying overweight children and adolescents represent one of the most important current public health issues because of the related medical complications.

In June a committee of health professionals issued recommendations saying doctors should assess children’s weight and height annually and attempt to treat overweight kids based on their age, body mass index (BMI), and any related medical conditions. BMI is a number calculated from a person’s weight and height and, in general, reflects how much body fat the child has. The AAP, which participated in the committee’s work, said while there is a lack of research on the long-term impact of treating overweight children, doctors should still make it a priority.

“The enormity of the epidemic necessitates this call to action for pediatricians using the best information available,” the AAP said.

Childhood onset of metabolic syndrome, which is diagnosed by testing fasting insulin and glucose, systolic and diastolic blood pressure, and cholesterol and triglyceride levels, significantly increases the risk for type 2 diabetes and cardiovascular disease.

Sarah Messiah, Ph.D., M.P.H., a research assistant professor in pediatrics and an epidemiologist, was involved in a study that assessed the prevalence of the metabolic syndrome in a clinical sample of 225 children ages 3 to 18. Reflective of South Florida, the children were largely from minority backgrounds: 66 percent Hispanic, 24 percent Afro-Caribbean/black, 5 percent white, and 5 percent multiracial.

“We found metabolic syndrome in 20 percent of this clinic sample,” Messiah says. “The youngest child was only 7 years old. Those kids who were morbidly obese were four times as likely to have the syndrome compared to kids of normal weight.”

And the risks for disease are showing up in younger and younger children.

Messiah and colleagues in another study looked at 302 children ages 2 to 5 from eight preschools in Miami-Dade County. Overall, 30 percent of the children had a BMI greater than the 85th percentile, which is about 4 percent higher than the rest of the country. Within some groups of Hispanic children, 39 percent exceeded the 85th percentile.

During the research, parents were involved to some degree, she says. “We’d do a cooking night and they would bring recipes from their ethnic background. The goal was to keep the ethnicity intact, but make it healthier or as healthy as possible,” Messiah says.

“Cultural sensitivity is critical to trying to be able to manage this and educate people at the earliest stages,” Lipshultz adds.

Alan Delamater, Ph.D., director of clinical psychology and professor of pediatrics, is working with overweight third and fourth graders at two Miami-Dade schools and their parents on a one-year demonstration program. “The work is focused on metabolic syndrome, which really is a risk for both type 2 diabetes and cardiovascular disease,” he says. “We’re using the schools as a site because people are more likely to take part. You can’t expect the working-class families we’re working with to travel across town to a medical center.”

The study groups are divided into two comparison groups of 16 or 17 children and their parents. “The more intensive group gets multifamily group meetings at the school and several individual meetings at the family home,” Delamater says.

In a small pilot project with five families, he found them to be cooperative and accepting of ideas to improve their children’s health. “The parents and kids both did better, and they’re very responsive and open to having team members come into the house, sit at their kitchen table, look in their refrigerator, and talk about what they’re feeding their kids,” he says.

Delamater is collaborating with Sheah Rarback, M.S., R.D., a registered dietitian and director of nutrition at the Mailman Center for Child Development in the Department of Pediatrics. “With any program, the involvement of the family is really critical,” Rarback says.

Rarback, who sees overweight children in her daily practice, explains that just telling children about the serious diseases they may face in the future if they don’t adopt a healthier lifestyle does not bring about the needed change.

“Fear doesn’t work very well. It doesn’t even work with adults. If I have a 26-year-old in my office and say, ‘If you don’t lose weight, you’re going to be diabetic by the time you’re 40’, it doesn’t work,” she says. “When do they change? When they have the heart attack, not ten years before they have the heart attack.”

Delamater and Rarback also have another project with the school system involving 5- and 6-year-olds—not just overweight kids, but all kids. The purpose of this project is to test the feasibility and efficacy of a school-based, multicomponent intervention to prevent metabolic syndrome.

“Part of the program will utilize SPARK (Sports, Play and Active Recreation for Kids), based in San Diego. They have a whole lot of gadgets and toys, jump ropes and things, that can help the teacher get the kids up and moving during the school day, and that is fun for them,” Delamater says.

The increase in the youngsters’ physical activity is coupled with creating a social environment within the schools that emphasizes and values healthy lifestyles. Other components are based on a tool developed by the Centers for Disease Control and Prevention called the School Health Index, which schools can use to improve physical activity and encourage healthy eating, as well as prevent tobacco use, accidental injuries and violence, and control asthma in students who have the disease. The CDC makes copies of the program available to schools for free.

“Our approach is to work with the principal, the administration, the staff, the food-service people,” Delamater explains. “We have a planning grant, and we’re going to develop the program in one school and have a comparison school, working with 60 kids in each school.”

South Florida’s richly diverse population also has given researchers the chance to break new ground studying a Haitian population largely ignored in the past. Nancy Stein, Ph.D, M.P.H., an epidemiologist and research assistant professor in pediatrics, is finding they have their own unique set of health issues.

“They may not have anything in common [with other black groups] other than the color of their skin,” says Stein, who, along with UM colleagues, has done the first studies on the Haitian population and is applying for grants to do more.

Stein says a first step in research is often to do a medical chart review and collect information that may generate hypotheses for future funded research. She says that Lipshultz and Tracie Miller, M.D., director of the Division of Pediatric Clinical Research in the Department of Pediatrics, both encouraged her to pursue the research.

“We know that overweight and obesity is everywhere but much higher in the minority populations. I thought Haitian kids were going to be different because they all looked thin to me,” Stein says. “But I was shocked, really surprised, that once they come here they gain weight very quickly, about 4 percent per year, and in no time it’s the same as if they had lived here forever.

“The bottom line is they gain weight, and that puts them at risk for cardiovascular disease and other diseases. It shows that the time to intervene is when they come here. And that’s what we’re going to do next.”

Stein and colleagues are working with UM’s Center for Haitian Studies to set up a pilot program to try to prevent young Haitian newcomers from joining their American counterparts in becoming overweight. Stein says Haitian families have a complex set of issues that may make it difficult to live a healthy lifestyle.

“These are not the parents who are staying home and making sure their kids eat well after school. They’re holding two and three jobs; they’ve got double minority status; they speak Creole but many don’t read Creole, so it’s not a matter of handing them a pamphlet to study.”

Stein found that Haitian adults who immigrate to the United States weigh 10 to 15 percent less than average Americans and may close the gap over about ten years time. “But for kids, that time element isn’t there. They get immersed in the whole culture very rapidly.”

Miller, a pediatric gastroenterologist and professor of pediatrics, says once research shows results in bringing kids back from the brink of obesity and all of its inherent risks, the next hurdle is getting insurers to pay for such a program. Her research shows that a 12-week active intervention program, counseling kids on the importance of a healthier diet coupled with a structured fitness program, produces results.

“Our pediatric exercise physiologist, Gabe Somarriba, in the Division of Pediatric Clinical Research, works with the children twice a week for an hour and a half, using aerobic training on a stationary bike, the treadmill, and with weights, and ellipticals, and as they get stronger he gets them to do more,” Miller says.

On a recent morning in the gym at the Batchelor Children’s Research Institute, Somarriba was putting Angela through an individualized workout. He works with children as young as 6. They each get baseline blood work, bone density scans, and other tests that are repeated at three- and six-month intervals to measure progress.

During the last two weeks of the 12-week intensive program, Somarriba begins to teach them how to continue to work out at home and sends them out with some dumbbells and a Thera-Band, a stretchy elastic band they can use for resistive exercises. During the three months the kids are working on their own, he calls them to provide encouragement and to see how they’re doing. After the three months, Miller brings them back in to reassess their progress.

“We’ve gotten some good data to show the kids do really well in the first three months, and most continue to improve at home but not as dramatically.”

Miller wants to expand the program to bring in kids from the community whose parents are willing to pay out of pocket for it. She started talking to HMOs about six years ago to try to get them to buy into the idea of covering such a program, but to no avail.

“I keep hoping that with all the focus now on childhood obesity, they will change their attitude. I’m trying to prove this would save them money in the long run,” she says, “but unless you’ve had a heart attack, they won’t pay for a program such as this that may actually prevent the child from having the heart attack.”

Nancy McVicar is a freelance writer living in South Florida.
She has been writing about health and medicine for 18 years.