WORKING TOWARD HEALTHIER TOMORROWS
Pediatrician Ulfat Shaikh has launched the Healthy Eating– Active Living Telehealth Program to help adolescents fight obesity and adopt healthy lifestyles. Here, Shaikh completes a medical exam of Sacramento patient Joshua Martinez.
The top three causes of death in the United States – heart disease, cancer and stroke – are all illnesses that research shows could be prevented by changes in diet and exercise. Increasingly, health experts believe that the key to preventing lifestyle diseases in adults is to focus on childhood health.
That's no easy task when so much about modern life encourages poor eating habits and discourages physical activity, says pediatric endocrinologist Dennis Styne, who leads UC Davis' Childhood Obesity Clinic.
"I thought you couldn't stop a toddler from being active. I was wrong," says Styne who has seen lifestyle factors affecting children younger than 5 years old. "We're now diagnosing children with conditions and diseases we used to see only in adults."
Styne is among those UC Davis researchers bringing the best of basic and clinical science to the prevention of lifestyle diseases. From the most effective ways to get kids moving and eating right to understanding what secondhand tobacco smoke does to developing brains and lungs, their findings promise to improve the current health of children and the future health of the population.
Treating an epidemic
When 16-year-old Maricela Gonzalez was diagnosed with high cholesterol, her primary-care physician in Brawley, in Imperial County, turned to UC Davis experts in pediatric obesity nearly 600 miles away.
Maricela was enrolled in the one-year Healthy Eating-Active Living Telehealth program (HEALTH) that augments her primary care with an initial assessment, access to a nutritionist, clinical psychologist and social worker, and every-othermonth visits with UC Davis physicians via telemedicine.
"We integrate our care with that of the medical home of the child," says pediatrician Ulfat Shaikh, who created the HEALTH program.
Participants visit their home clinics monthly, alternating between visits with their primary physician and ones that include videoconferencing calls with Shaikh and her multidisciplinary team of clinicians.
"Our goal for this service is to help children become more healthful while also enhancing the capacity of clinics in rural and remote areas to care for children and adolescents with obesity and its many associated medical conditions," Shaikh says.
"Primary-care providers who have referred patients have told us that sitting in on part of our consultations helps them in turn provide similar behavioral counseling and treatment to their other patients."
The program has already been a huge success for Maricela. Five months after Maricela started the HEALTH program, her cholesterol is back to normal levels and her entire family is eating better and getting more exercise.
"With the information they have given us, I can take better care of my children and of myself, too," says Gloria Gonzalez, Maricela's mother, who works at a gas station and primarily speaks Spanish.
Though she herself has diabetes and high blood pressure, Gonzalez says the HEALTH program connected her and her children to a dietitian for the first time. Now, they eat more salads and drink less sugary soda. They walk more often and enjoy biking – thanks to new bicycles Gonzalez bought at the suggestion of HEALTH staff.
"Both my children are losing weight, and they have more interest in nutrition and exercise," Gonzalez says. Maricela's brother, 12-year-old Tino, who was overweight, was also enrolled in the program.
Gonzalez says meeting with Shaikh via teleconferencing equipment the first time was a bit strange for the family. They soon got used it, however, and are now very comfortable with both telemedicine and Shaikh.
"She explains things very well to the children, and we all have a lot of confidence in her," Gonzalez says of Shaikh.
The HEALTH program is based on research Shaikh has been conducting since 2005 on the effectiveness of telemedicine consultations on pediatric obesity. Shaikh and her colleagues published a paper in 2008 that showed that 81 percent tomorrows of kids in the study improved their diet and 69 percent increased their activity levels. The UC Davis Clinical and Translational Science Center supports her research.
"Some people are skeptical about using long-distance communication to provide care, especially for diseases that have a strong behavioral component," Shaikh says. "We have shown that through telemedicine you can establish a personal connection with a family, and that's reassuring.
"The fact that Maricela's mother and brother are so involved in the HEALTH program has helped her stay motivated and stick to her lifestyle goals. We have also been able to discuss Maricela's treatment with her primary-care doctor in Brawley during her telemedicine visits, and this has helped everyone involved in Maricela's care communicate much better," Shaikh says
Engaging the community
Treating individual children is only one way UC Davis researchers are working to prevent childhood obesity and the onset of lifestyle diseases later in life. Styne, for example, is working to empower entire communities – those most at risk – to create environments that encourage healthy eating and physical activity.
Styne, who holds the Rumsey Chair for Pediatric Endocrinology at UC Davis, created the Fit Kid, Fit Teen program. The communitybased program uses behavior mod-ification strategies to teach kids and their families about nutrition, exercise and habits that can better manage weight.
With support from the California Endowment, pediatric endocrinologist Dennis Styne introduced the Fit Kid, Fit Teen obesity management program to Native Americans on the Round Valley Indian Reservation where childhood obesity disproportionately affects the population.
With support from the California Endowment, he introduced Fit Kid, Fit Teen to Native Americans living on the Round Valley Indian Reservation because Native Americans are disproportionately affected by childhood obesity.
Styne says the program has successfully empowered community members to adapt the program to fit their needs.
"They inspired the whole community to start moving in creative and innovative ways," he says.
For example, several educators trained as lifeguards so the school's pool could remain open in the summer. Another worker, whose hobby was racing BMX bikes, taught a bike safety course and started a bike rodeo. Program staff members were also able to convince the local food market to offer more healthful choices.
Styne has also been working to educate the community about type 2 diabetes, a disease that also disproportionately afflicts Native Americans. In April, he served as chair of the first-ever Native American conference on how to prevent and treat type 2 diabetes. The Rosalinde and Arthur Gilbert Foundation and the Yocha De-He Community Fund underwrote the conference.
"These are some of the ways we are working to encourage the community to give their kids the support and tools they need to live healthier lives," Styne says.
Breastfeeding for better health
The likelihood that a child becomes obese – or faces many other chronic illnesses in the future – may depend in part on whether the child is breastfed, says pediatrician Caroline Chantry, a breastfeeding expert.
"For both mom and baby, the lack of breastfeeding is linked to increases in risks for lifestyle diseases," Chantry says.
Mothers who do not breastfeed are at higher risks for breast and ovarian cancers, as well as type 2 diabetes, she says. Breastfeeding also reduces the risks for childhood obesity and diabetes for the child.
Pediatrician Caroline Chantry , right, has shown in multiple research projects the many ways breastfeeding helps to enhance the health of both mother and baby. Here, she evaluates how newborn Emma Jarvis is latching on to her mother Jennifer Jarvis as proud dad, Jeremiah Jarvis, and lactation consultant Karen Dietzen look on.
Despite the health benefits, breastfeeding is a choice that, all too often, is not adequately supported in this country, Chantry says. As president of the Academy of Breastfeeding Medicine, an international, multidisciplinary organization of physicians, she works to promote breastfeeding and increase the support for breastfeeding mothers at UC Davis, and across the nation and globe.
At UC Davis, Chantry led the establishment of an early follow-up breastfeeding clinic, available to any mother who gives birth at UC Davis Medical Center.
"We know that 80 percent of moms will have difficulty on about day three," Chantry explains. "If they don't get the early support they need, then they are more likely to switch to formula."
Chantry also works to help the health-care system – from hospitals to individual physicians – support breastfeeding. This can be done in a host of ways, including refraining from providing formula samples to new mothers, explaining the health benefits of breastfeeding and helping mothers attempt breastfeeding within one hour of birth.
"There are lots of things we can easily do that have been shown to increase breastfeeding initiation and duration," she says.
Chantry's research has shown the proven benefits of breastfeeding. In 2002, she was part of a team that found that babies who are fully breastfed for six months are less likely to suffer from respiratory illnesses than babies fully breastfed for only four months.
More recently, Chantry began working with researchers in the Department of Nutrition to look at the growing problem of delayed lactogenesis and other factors related to early lactation success.
"Delayed lactogenesis has been linked to maternal obesity and C-sections. It results in fewer breastfed infants and, unfortunately, is becoming very common in our country," Chantry says. "We're currently analyzing data from a large study to look for potentially modifiable factors related to early lactation success."
For children's sake: Don't smoke
Just as a lack of breast milk can jeopardize a child's future health, so can exposure to tobacco smoke, says pediatric lung specialist Jesse Joad. She has spent her career researching the effects of secondhand smoke on children.
"There is a whole lot of evidence that exposure to environmental tobacco smoke, both in utero and after birth, causes health problems," Joad says.
As probably every smoker knows, quitting smoking has been shown to be the number one step people can do to avoid lifestyle illnesses, from cancer to heart disease.
Still, despite risks to their health, many people avoid fighting their addiction.
Joad and her colleagues believe that smokers may be persuaded to quit tobacco use if they see how secondhand smoke harms the health of their children.
"People will often times do things for their children that they won't do for themselves."
Joad's research using animal models has shown that early exposure to secondhand smoke makes the nerves that control coughing more sensitive to other environmental triggers.
"We hope our published findings will convince people that environmental tobacco smoke can change the brains of young children, impacting their future health."
Physicians treating the children of smokers also need to be aware of the health effects in order to better help their young patients.
In another line of research, Joad showed that human infants exposed to even low levels of secondhand smoke and diagnosed with respiratory syncytial virus (RSV) bronchiolitis have higher levels of chemicals known as leukotrienes in their urine. This chemical is associated with constricted airways.
RSV bronchiolitis is a very common infection in infants and can lead to reactive airway disease that lasts for years.
Other research has shown that exposure to secondhand smoke may cause asthma in children and makes asthma worse in children who already have it. Research also shows that children born to mothers who smoke have reduced lung function.
"It's not clear yet whether environmental tobacco smoke causes lifelong asthma."
What is clear is that the more exposure to secondhand smoke, the worse for the child's future lung health.
"Our studies have shown that it takes much less of a particular chemical to close airways if exposure to environmental tobacco smoke occurs both before and after birth," Joad says.
Making modern life more healthy
Despite the contributions being made by UC Davis faculty and other pediatric researchers around the country, Styne says science has yet to find measures proven effective for protecting children from what he calls our modern, toxic environment.
For example, children drink a lot of high-fructose corn syrup that is a metabolic poison. They have lower levels of activity since elevators are easier to find than stairs, and new neighborhoods have no sidewalks where one can safely walk, he says.
"We need continued research, innovative partnerships with community organizations and new approaches to promoting and supporting healthier lifestyles for children if we are going to prevent the preventable diseases that otherwise are going to sicken or even kill them."