CASE STUDY 1

Patient T is a newborn boy. At birth he is 20 inches in length and weighs 10 pounds 4 ounces. Everyone who meets Patient T comments on how beautiful he is and how healthy, big, and strong he looks. His mother revels in the comments and expresses pride in her new baby boy.

During Patient T's early childhood, he maintains a weight in the 95th percentile and a height in the 75th percentile on the growth charts. He is a playful, active child with a love for a variety of foods, including apples, pears, bananas, ham sandwiches, potato chips, and pizza. Although the patient's weight is in the 95th percentile, his pediatrician feels he is developing well and does not want to raise any red flags at this point. He does caution Patient T's mother to be attentive to his caloric intake and to ensure that he remains active. The patient's mother is taken aback and a bit offended at the insinuation that her son is "chubby."

Patient T continues to grow and experience a normal childhood, but he is considered a hefty boy when he enters kindergarten. He is quiet and shy at school and soon finds it difficult to make friends. As he continues through elementary school, he becomes the object of taunting from his classmates due to his physical appearance and submissive nature. His grades begin to decline, and he begins to spend more time watching television and playing video games. Snacking on potato chips and soda becomes a source of comfort for Patient T; soon he is consuming eight cans of soda every day. The patient's parents have become concerned but are reassured by family members who attribute the weight gain to a phase or a growth spurt. They are sure that Patient T will grow up big and strong like his father, who is 6 feet tall and 350 pounds.

As a result of Patient T's decreased activity level, his weight continues to increase. By 12 years of age, he is even more withdrawn from social activities and mainly retreats to his virtual world of video games.

In high school, Patient T starts playing football as a defensive lineman. His performances are worthy of college scouts, and there is talk of scholarships. His parents are thrilled that he is finally fitting in and finding acceptance. As a result, Patient T's grades improve and he enjoys an active social life. During his senior year, Patient T is offered a scholarship to play football at a Division I college. When he leaves for college, he is 6 feet 5 inches tall and weighs 315 pounds.

In his second year of college, Patient T hyperextends his knee and tears his meniscus during the homecoming game. The resulting damage ends his football career. He remains focused on his studies, but alcohol and parties become an alternative to the hours previously spent conditioning in the weight room. Beer, buffalo chicken wings, nachos, and pizza become staples in his diet.

At his college graduation, Patient T weighs 400 pounds. He is hired by a large manufacturing firm as an accountant. He is 24 years of age and is looking toward his future.

One year later, Patient T meets some friends after work to play a game of basketball. His knee is still weak, and his weight, still nearly 400 pounds, slows him significantly. However, Patient T remembers the years he spent as a withdrawn child and does not want to revert back to being lonely and unsocial; he is going to play the best he can.

An hour into the game, Patient T feels a strange sensation in his jaw and a sharp pain down his left arm. He is sweating profusely and becomes dizzy. He describes the sensation as an elephant sitting on his chest. His friends call emergency medical services, and Patient T is taken to the hospital. His electrocardiogram (EKG) reveals ST segment elevation, indicative of a myocardial infarction. He is admitted to the hospital and undergoes cardiac catheterization and angioplasty. Further testing reveals type 2 diabetes, hyperlipidemia, hypertension, and mild kidney disease.

Despite the seriousness of his condition, Patient T takes the news in stride. He reasons that because he is still young, only 25 years of age, he has plenty of time to make the needed changes. Over the next five years, Patient T does not monitor his blood glucose levels or diet and exercises as time allows. He is started on insulin after six years, although he is resistant to this change. He often misses doses, particularly when he is out with his friends. He has also tried to better monitor his diet, but finds this difficult at restaurants and social events.

After missing two appointments, Patient T returns to his physician's office in order to renew his prescriptions. At this visit, Patient T's A1C is 10.5%, his weight has increased 6 pounds, and his cholesterol is at its highest level ever. Most seriously, however, is the discovery of the early stages of renal failure. Patient T takes the news to heart and makes changes to improve his renal status, but these changes only last a few weeks before he falls back into his old patterns. Weakened by blockages and years of hyperlipidemia, Patient T suffers a mild myocardial infarction the week before his 34th birthday. He is rushed to the hospital for a cardiac catheterization and another angioplasty. Although he recovers from the infarction, the damage to his kidneys is great. With his blood urea nitrogen (BUN) test and creatinine levels dangerously high, Patient T is started on hemodialysis three days a week.

The next five years are spent on this dialysis schedule. Patient T is unable to maintain his job as an accountant and applies for and receives Medicare and Medicaid services. During this time, the patient develops a vascular wound on his left lower extremity that requires a home health nurse to visit twice daily for dressing changes. To complicate matters more, Patient T has begun to show signs of diabetic retinopathy. The patient passes away at 42 years of age as a result of massive myocardial infarction. At the time of his passing, he is blind, on dialysis, and has a chronic open wound. His premature death is a consequence of years of obesity and obesity-related complications that started in the patient's childhood.

CASE STUDY 2

Patient E is 15 years of age, 5 feet 10 inches tall, and weighs 370 pounds. He has been overweight his entire life; at 8 years of age he was 4 feet 7 inches tall and weighed 210 pounds. He is currently being home schooled for several reasons, including severe arthritis of the bilateral knees, obstructive sleep apnea leading to severe fatigue, type 2 diabetes requiring four injections of insulin per day, and a history of being bullied. When asked about his quality of life, Patient E states he feels like an old man due to his many health issues and feels like he is existing in the world rather than living in it.

The patient's monthly medical bills average $856 for medications, continuous positive airway pressure (CPAP) machine rental, and physician co-payments. His internal medicine physician introduces the possibility of gastric bypass surgery and explores Patient E's thoughts and feelings regarding the procedure. The patient and his parents agree to talk with a surgeon and explore the possibility further. The thought of regaining a productive life, preventing any further chronic illnesses, and possibly reducing or eliminating some of the diseases that have plagued his young life is intriguing. After a psychiatric evaluation and thorough medical evaluation, Patient E is cleared for gastric bypass surgery. He is scheduled for the procedure at a center with a multidisciplinary team experienced in treating obese adolescents.

Immediately following surgery, Patient E has had a reduction in his insulin requirements and a decrease in his appetite. At his one-month post-surgical evaluation, his weight has decreased 25 pounds and he has discontinued his insulin. He continues to need his CPAP machine at night for his obstructive sleep apnea but feels optimistic about his future for the first time. At his six-month follow-up, Patient E has lost 65 pounds and no longer requires antiglycemic agents of any kind. His knee pain is resolving as his weight decreases, and he reports going to a movie with his cousin for the first time in his adolescence.

After one year, Patient E weighs 260 pounds and no longer utilizes his CPAP machine. His A1C is 6.2% without medications. He is able to exercise without pain or shortness of breath, and he is contemplating attending his local high school the next year. The patient's medical bills are now approximately $150 per month. He has met a girl through his cousin and is actively dating. He is happy and states he is now living in the world instead of watching it go by. For Patient E, gastric bypass appears to have been successful, although he will continue to be monitored for long-term effects and complications.

CASE STUDY 3

Patient M is born in Tucson, Arizona, the daughter of second-generation immigrants from Mexico. Her mother did not receive any prenatal care, although she was overweight prior to conception and has a strong family history of diabetes, hypertension, and heart disease. When born, Patient M weighs 10 pounds 6 ounces and is 20 inches in length. Everyone in the family and community admires the infant and comments on how beautiful and healthy she is. Her precious, cherub-like features, specifically her round cheeks, are declared "perfect" and "the picture of health."

Patient M has many risk factors for obesity, even in her infancy. There is a greater rate of childhood overweight and obesity in Hispanic families, and obese parents impose a great risk that their children will be overweight. Because Patient M had a greater than average weight at birth, it is possible that her mother had gestational diabetes. A prenatal exposure to a sugar-rich environment caused by maternal diabetes can predispose a child to overweight/obesity. Although Patient M was a larger than average infant, the Hispanic view of overweight is generally one of health and strength and is not associated with that of disease or illness.

During Patient M's early childhood, her weight is maintained in the 95th percentile and her height is in the 70th percentile on the growth charts. She is playful and rambunctious, often playing with her two older brothers outside all day. As a child, the patient's favorite foods are rice and beans and fresh fruits. As is common in their Hispanic community, Patient M admires and looks up to her brothers and wants to mimic them. As a result, she develops a taste for American foods, including potato chips, nachos, soda, and pizza.

For children, the diagnosis of overweight or obesity is determined with the use of growth charts that give percentages of height, weight, and/or BMI. The CDC's BMI growth charts can be utilized clinically beginning at 2 years of age. Obesity in any individual is the end result of an imbalance between food taken in and energy expended, but the underlying causes are greater in complexity. Children observe the behaviors and preferences of others around them influencing the future of food selection, especially when the role model is perceived as being powerful.

Although her weight is in the 95th percentile, Patient M's pediatrician is not alarmed because of the amount of outside playtime she receives. When the pediatrician stresses the importance of monitoring the child's weight and physical activity, Patient M's mother thinks it is absurd for an American physician to understand the genetics of a Hispanic person and what is healthy for her daughter.

Patient M continues to grow and experience a normal childhood but is considered overweight when she enters kindergarten. There are a few of the other boys and girls in the classroom who are overweight, which reassures her mother that she is fine and there is nothing to worry about. Patient M is a confident girl, ready to play tough with the boys and join the other girls in playing house. She especially likes to be the cook in the pretend kitchen making all of her favorite foods. At recess, everyone wants Patient M to "make" them a snack.

Before Patient M starts the fifth grade, her father is transferred and the family moves to Miami, Florida. The first few weeks are difficult. She misses her extended family, and life in a big city is different. On the first day of school, Patient M is apprehensive for the first time in her life. When she arrives she notices many of the girls are very thin.

As the school year progresses, Patient M begins to feel self-conscious about her weight for the first time. Eventually, she is able to start making friends and is invited to a beach party. Although Patient M expresses fear of going to a party in a bathing suit, her mother encourages her to embrace her curves.

At the party, some of the boys are joking and teasing the girls, comparing them to different animals. When they compare Patient M to a manatee, she is devastated. Although she holds her head up high and stands up for herself, she is deeply hurt.

Obese children and adolescents become targets of early and systemic social discrimination. The psychologic stress of social stigmatization can cause low self-esteem, which in turn can alter academic and social functioning and potentially persist into adulthood.

The next three years are a series of learning experiences for Patient M. Although she has made some good, close friends, the sting of the teasing still penetrates her memory. When the time comes for the end-of-eighth-grade semi-formal dance, all of her friends have dates and Patient M feels left out. Her father reassures her and tells her that the boys just do not realize how special she is yet. Still, Patient M feels less attractive than other girls. One day, her mother sees her examining and critiquing her body in the mirror. When questioned, Patient M says she is fat and starts crying. Devastated, Patient M's mother realizes that her confident daughter is fading away and a change is necessary.

After speaking to a dietitian, Patient M's mother starts to supplement their regular diet with fresh vegetables and to provide fresh fruits for dessert and snacking. She encourages Patient M to find an activity to occupy some of her free time during the summer vacation. Her brothers go to karate class on Tuesdays and Thursdays, and Patient M's father encourages her to join them and start taking karate lessons. She finds she enjoys the precision and strength of karate immensely. Her self-esteem and confidence start to return, and she is laughing and joking more.

Obesity in any individual is the end result of an imbalance between food taken in and energy expended, but the underlying causes are greater in complexity. Diets are more likely to succeed if individualized according to eating patterns, cultural concerns, degree of motivation, intellect, amount of family support, and financial considerations.

At the end of the summer, Patient M finds that her school uniforms are too big. Her parents are glad to see how much happier and healthier she seems. Although some of the dietary changes have affected the whole family, Patient M's father has found it difficult to give up some of his favorite comfort foods. Seeing the difference in his daughter, he makes a commitment to try to change his diet and become more active. It is a joyful time for Patient M and her family.

Two months later, Patient M's father falls unconscious and is taken to the emergency department. After undergoing several tests, including a computed tomography scan, he is diagnosed with a cerebral vascular accident. The physician tells the family that Patient M's father has a high blood glucose level and that the stroke may have been caused by long-term uncontrolled type 2 diabetes. When Patient M first visits her father in the hospital, she barely recognizes him. He has a ventilator tube, intravenous lines, and a heart monitor. As a result of the stroke, her father is paralyzed on his right side and is unable to speak. Although he regains consciousness, the paralysis will most likely be permanent and he will be unable to work. Eventually, her father is discharged to a rehabilitation center for therapy.

Needing an income to pay for growing medical expenses, Patient M's mother obtains a job as a legal secretary. With both of her brothers in college and her mother working full-time and caring for her father, Patient M spends an increasing amount of time alone. Most meals come from one of the many fast-food establishments near their home. With the financial difficulties, she also has to stop karate lessons. Patient M feels alone and abandoned; the only place she finds solace is in food. By the end of the school year, Patient M weighs 230 pounds and is 5 feet 3 inches tall. Her grades start to decline, and she finds herself spending more time watching television or on the Internet.

The summer prior to her senior year of high school, Patient M and her friends take a trip to the Florida Keys to camp and snorkel for one week. Although she is hesitant, her mother encourages her to go for a change in scenery and relaxation. Although her friends have always been accepting of her and look past her obesity issues, Patient M is depressed at the image of herself in a bathing suit.

On the last day of the trip, Patient M wakes feeling tired and nauseous. She decides to stay at the camp and sleep while her friends go snorkeling one last time. Over the next two hours, the patient feels simultaneously anxious and fatigued while also experiencing an overwhelming sense of dread. When her friends return to camp and find her looking pale and shaky, they pack and return home in hopes she would start feeling better. When they arrive, Patient M's mother takes her directly to a local emergent center for evaluation. The results of the laboratory test completed at the center are:

Patient M is hospitalized until her condition stabilizes. She is diagnosed with type 2 diabetes and is started on simvastatin and metformin. The physician also prescribes diet, exercise, and other lifestyle changes. This diagnosis compounds the patient's depression regarding the future. She can only think of her father, now a resident of a long-term care facility.

After she is diagnosed, Patient M attends education classes and meets with a dietitian to help her understand her disease and the changes she will need to make to control her diabetes and obesity. She has made her mind up to take whatever steps necessary to avoid the path her father has taken. Patient M becomes inspired by her new knowledge and by a television show focusing on adolescents working to control their weight. Starting back at karate class is frightening, but she perseveres and eventually is hired to work with young children just starting in the classes.

Within three months, Patient M's weight is down 15 pounds and her A1C has decreased to 7.5%. She continues to take metformin for her diabetes and simvastatin for hyperlipidemia management. Her goal is to be medication-free by 20 years of age. She exercises daily and has adopted a meal plan she is able to live with. Her long-term outlook is promising because of the decisions she has made and her determination not to face the same future as her father. She is being proactive, which over time should prevent many of the complications of childhood obesity.