"To me, the hardest part of our clinical program is seeing a child who's 12 years old who weighs 300 pounds and is 5 foot 2. That child didn't get to be 300 pounds overnight. Why was that child not recognized when they were five, six or seven and starting to pull away from the curve?" That's the lament of Frank Franklin, MD, PhD, medical director of the Children's Center for Weight Management at Children's Hospital and professor of pediatrics and nutrition science at the University of Alabama at Birmingham. The center treats childhood obesity through a multi-disciplinary approach, treating medical problems and psychological issues, revamping diets, devising appropriate exercise programs, offering peer group support programs, even doing bariatric surgery. Childhood obesity demonstrates how the job of pediatricians has changed, says Lillian Israel, MD, senior partner at Shades Crest Pediatrics in Brookwood Medical Plaza. "Twenty-five years ago, we were seeing a lot more worrisome infectious diseases," she says. "With the advent of several vaccines, we're seeing fewer and fewer of those more serious infections. We're much more concerned with lifestyle issues," such as ADD, depression, social problems relating to higher divorce rates — and obesity. "It's a gigantic problem, both literally and figuratively," Israel says. "I didn't used to see fat kids, and now I see some that are morbidly obese. It's really scary." General pediatricians are the front line in the fight against obesity, but it's often an uphill battle. "The American Academy of Pediatrics wants to get obesity prevention down into early childhood, because we think that's where the issues are," says Carden Johnston, MD, FAAP, FRCP, immediate past president of the American Academy of Pediatrics and emeritus professor of pediatrics at UAB. "An obese preschool child is apt to become an obese adolescent, and once they become an obese adolescent, there's a 60 to 70 percent chance of them becoming an obese adult, with [complications such as] diabetes, high blood pressure and early death." Both Franklin and Johnston say it's very important for pediatricians to track the body mass index, or BMI, of their patients and compare. "You can get the index out so you can be sure they're not [gaining weight] any quicker than they should," Johnston says. "If the BMI is going up, then we can start intervention before the child starts getting obese." There are many reasons why pediatricians find it hard to do this. They're pressed for time in the office. They're afraid parents won't take the bad news well or won't want to do anything about it. They feel they don't have the skills to effectively counsel patients and their families about weight loss. They don't have the resources in terms of nutrition backup. And they know that obesity prevention efforts typically aren't covered by insurance. The AAP is trying to work on some of these stumbling blocks, Johnston says, including working with insurance companies to convince them to pay for visits to primary care physicians to treat obesity. "Insurance companies will not pay for the counseling and intensive care that is required to prevent obesity and diminish it in early childhood," he says. "They'll pay for the complications, but not for the prevention." Franklin notes that it's important to look at the family as a whole. "If you have an overweight parent and you have a large child, that child is not going to outgrow that body fat," he says. "When you plot the child's BMI and recognize they're already large or getting larger, and you see a large parent, you have to start working with that family." They should be counseled on tactics such as increasing intake of fruits and vegetables, portion size, turning off the TV and computer and video games, increasing activity levels, and limiting high-calorie foods such as soft drinks, fries, sweets and chips. Of course, that's not always easy. Israel recently saw a 9-year-old patient who weighed more than 130 pounds — twice the weight he should be for his age. The father, who brought him in, was overweight but trying to work on it, she says. The mother, on the other hand, was also overweight, "and was busy buying him as much junk food as he could consume. I asked this kid how many soft drinks he consumed in a day, and he said five or six. I asked, 'How do you do that when you're in school all day?' and his daddy said, 'He starts when he gets home and just opens one after another after another.' And my reaction was, and nobody's stopping him?" It's time to think about referring a patient to a specialist, Franklin says, when the child is not losing weight; has co-morbidity issues such as diabetes, hypertension or sleep apnea; or when family members are sabotaging weight loss efforts — for instance, when a parent insists on eating chips and Oreos, ordering pizzas, or insults or threatens the child instead of being supportive. "The pediatrician can recognize the problem early and work with the families," Franklin says. "For the families that don't seem to be doing well, they can refer the child to us [at the Children's Center for Weight Management]. The earlier we see the child, the more effective we're going to be."