Children’s weight woes might start in the womb

Brittany Johnson's appointment calendar is cluttered with doctors. There's her diabetes doctor; her primary care physician; her sleep apnea expert; her podiatrist; her ear, nose and throat specialist; her psychiatrist and her bariatric surgeon. Brittany is 16. All of her medical problems can be traced to one source: She weighs more than 300 pounds.

The Charlotte teen is among the rising ranks of obese children who are developing diseases once associated with aging adults: diabetes, hypertension, heart disease, fatty liver disease, osteoporosis, depression. The crisis is so severe that experts say this generation may be the first in 200 years to have a shorter life expectancy than its parents.

New research shows that the path toward obesity actually might start in the womb. Mounting evidence suggests that what a mother eats, what toxins she's exposed to and how active she is during pregnancy have profound effects on her offspring's weight and wellness later in life.

"People don't realize how early this starts," said Dr. Sarah Armstrong, a pediatrician and the director of Duke Children's Healthy Lifestyle Program, a clinical treatment program for obese kids.

As researchers begin unlocking keys to childhood obesity, some doctors are embracing radical treatments to help young patients.

Brittany is pinning her hopes on weight-loss surgery once reserved for adults. Next month, she will undergo gastric banding, a procedure in which a surgeon will wrap an adjustable silicone ring around the upper part of her stomach, restricting how much food she is able to eat.

The procedure has not been approved for children under 18. But at least three insurance companies, including Brittany's, are funding a clinical trial, approved by the U.S. Food and Drug Administration, as a way to try to stem the costs of treating obesity, estimated at $147 billion a year. Nationwide, more than 12 million children are obese, including 13.4 percent of 14-to-17-year-olds in North Carolina.

Brittany's surgery will take place at Presbyterian Hospital in Charlotte. Duke Hospital in Durham is also exploring the possibility of weight-loss surgery for teens.

"The hope is that weight-loss surgery will reduce the risk of early mortality from obesity-related diseases," said Dr. Caren Mangarelli, a pediatrician at Duke who is drafting protocols for the new procedure.

Brittany's mother, Nancy Johnson, who is also overweight, can't help but wonder whether her sedentary lifestyle, taste for rich, fatty foods and love of eating out contributed to her daughter's condition.

"When I look at Brittany, I see an issue I have that I didn't address and have pushed on my child," said Johnson, who is in her mid-40s. "There are some habits that were developed, and kids learn from the environment they're in."

Eating for two indeed

Ask any obesity expert when the trajectory for excessive weight gain begins, and he or she will answer with one word: conception.

Although the science is just emerging, new research in North Carolina and around the world suggests that the conditions children experience in the womb may predispose them to a lifetime of obesity.

A 2007 Harvard study found that the more weight a mother put on during pregnancy, the more likely her child was to be overweight at age 3, even if the baby's weight was normal at birth. And it might not be a woman's genetic predisposition to obesity that explains this. Another study by State University of New York researchers found that the children of women who gave birth after undergoing weight-loss surgery were 52 percent less likely to be obese than siblings born before the mother had trimmed down.

Scientists theorize that what a mother eats sends signals to her fetus that influence appetite and metabolism for the rest of the child's life. In other words, if a pregnant woman's diet is rich in fat, salt and sugar, it may predispose her child to gain weight. The process begins even before a woman knows she is pregnant.

"In utero programming is the hottest area of biology in this century," said Dr. David Collier, a pediatrician who directs the Pediatric Healthy Weight Research and Treatment Center at East Carolina University in Greenville. "If the mother is obese, it preprograms that offspring to be prone to obesity, prone to insulin resistance, prone to diabetes, prone to hypertension."

One of the most important studies in this field was conducted by Duke epigeneticist Randy Jirtle and his postdoctoral student Robert Waterland in 2003.

Working with a strain of fat yellow mice, they found that mothers on a healthy diet that included folic acid, vitamin B12, choline and other food supplements gave birth to pups that were lean and brown. While the pups still carried the same fat genes, the scientists found that changes in the expectant mothers' diet could affect the way those genes were expressed, much like instructing a computer software program to turn on or off certain preferences.

Environmental factors also might predispose a fetus to obesity.

The National Institutes of Environmental Health Sciences in Research Triangle Park is awarding grants for research on whether exposure to certain chemicals and pesticides also causes obesity. Scientists think estrogen-like compounds in some hand lotions or shampoos used by pregnant women may disrupt a developing baby's endocrine system, which helps control metabolism. Results aren't expected for several years.

Scientists caution that a fatty prenatal environment doesn't necessarily doom an offspring to a lifetime of obesity. The postnatal environment is important, too. But research suggests that a trajectory launched at conception may be all that much harder to alter later.

"These marks aren't permanent; you can alter them later in adulthood," said Jirtle, who heads Duke's epigenetic lab. "But I don't think it's as easy as what you can do very early on. ... What you're talking about later in life is trying to reverse something. That's more difficult."

An obese mom's guilt

Jennifer Joyner of Fayetteville is now doing the hard work of trying to change her children's trajectory.

She weighed 320 pounds in 2005 when she got pregnant with her second child, Eli. In her first trimester, Joyner developed gestational diabetes, or high blood sugar levels, and needed three shots of insulin a day.

Born three months prematurely, Eli weighed 12 pounds - more than most full-term babies. Doctors rushed him to intensive care, not only to monitor his insulin levels, but also because he was found to have a hole in his heart. It has since closed.

"After he was born, I said, 'No more babies for me,'" said Joyner, 38, a part-time television news assignment editor. "I felt so guilty for doing this to my child. I felt terrible."

Eli, 5, and sister Emma, 6, are doing well now. Joyner attributes that to her weight-loss surgery in 2008, which helped her shed 156 pounds and led her to adopt healthy eating habits for the entire family. Joyner carefully monitors what her children eat and allows them dessert once a week, after dinner on Saturday. So far, both youngsters weigh in at the 75th percentile, meaning they are at healthy weights for their ages.

Joyner, who has written a book about her experience titled "Designated Fat Girl" (Globe Pequot Press, 2010), has advice for obese women wanting to get pregnant: Think carefully.

"You really need to educate yourself and be truthful with what it may mean for you, for the baby and for the rest of your life," Joyner said. "If you can avoid that happening to your child, then you need to do that."

Getting families aboard

For Brittany Johnson, the 16-year-old from Charlotte, weight-loss surgery is the last best hope.

"It's an opportunity to start over," she said.

Born 8 pounds, 11 ounces, she started putting on excess pounds when she was 6 years old. By age 11, she was pre-diabetic, meaning her blood glucose levels were higher than they should have been. By 13, she was diabetic. High cholesterol and high blood pressure followed. She also suffers from Polycystic Ovarian Syndrome, a hormonal condition that causes irregular menstrual periods.

Brittany has tried all forms of dieting. Her most successful effort was at Shining Stars, a weight-loss camp for kids in Wilson. During three weeks in the summer of 2009, Brittany lost 14 pounds and felt so good she didn't need her daily insulin injections.

Much as her mother wanted to send her back to camp last summer, the cost - $3,250 for three weeks - was too much. Meanwhile, the weight she lost came right back on and then some.

"What we need is a longer-term fix for kids with similar issues," Nancy Johnson said.

Brittany and her mother have begun a six-month medical management program through Southeast Bariatrics, the Charlotte group that has launched the gastric-banding clinical trial for 14- to 17-year-olds. The program aims to teach patients and their families about nutrition, exercise and behavior modification to help prevent a return to bad habits after surgery.

Dr. David Voellinger, Brittany's bariatric surgeon and the director of bariatrics at Presbyterian Hospital in Charlotte, said gastric banding has two advantages for teen patients: It's reversible, and it reduces the risk that nutrients won't be properly absorbed, an occasional consequence of gastric bypass, in which a portion of the upper intestine is rerouted.

But the key in treating obese adolescents is to get parental support, Voellinger said.

"You've got to have family involvement," he said. "It's Mom that buys the groceries, so it makes sense to educate the entire family."

The gastric banding will allow Brittany to lose up to 60 percent of her excess weight, though precisely how much she'll lose will depend on how willing she is to exercise and change her eating habits. She's already eating a low-carbohydrate, high-protein diet, though she eats out with her mother at least four times a week.

More important, the surgery will give Brittany a nearly 75 percent chance of improving, if not resolving, her diabetes. That alone fills her with joy.

Recently, Brittany created a blog in which both she and her mother, who plans to diet, will record their weight-loss stories. Brittany has been teased mercilessly at school - so much so that she won't divulge exactly what she weighs. She can't wait for the surgery itself to "jump start" her life.

"I know it won't be everything," she said. "It won't help me magically lose the weight overnight. It will be a long-term process. But it will give me the structure I need to get back in control of my life."

Coming tomorrow: Duke doctor defies conventional wisdom

.(JavaScript must be enabled to view this email address) or 919-829-4891