What played a role? In some cases, junk food and lack of exercise as the COVID-19 pandemic wears on.

Childhood obesity was already a concern in the United States. In 2018, the Centers for Disease Control (CDC) reported that 19.3% of the 2-19 age group were considered obese. That’s about 14.4 million children and adolescents with excessive weight that could lead to other medical problems like diabetes, heart disease, high blood pressure, and joint pain.

But doctors and dietitians fear obesity has gotten worse due to habits that changed during the COVID-19 lockdown and afterward, continuing today. A study cited by the National Institutes of Health (NIH) even uses the term “covibesity” to describe the phenomenon of rapid weight gain that resulted when people changed their eating and exercise routines during the pandemic.

If the early months of the pandemic set the stage for higher obesity rates, the toll on health is current and ongoing. Consider diabetes, for instance: Cook Children’s has seen 91 new cases of Type 2 diabetes diagnosed already this year.

Escalation in childhood obesity becomes an even more relevant and urgent concern given reports of higher risk of severe COVID-19 symptoms for those with obesity. The CDC points out that excessive weight can cause impaired immune function and decreased lung capacity, which may worsen the illness. The CDC cites one study that linked obesity in pediatric patients to higher rates of hospitalization, admission to intensive care, invasive mechanical ventilation and death from COVID-19. At Cook Children’s Medical Center, this rings true. Many of the patients admitted to the COVID-19 ICU are obese are require life-saving measures.

Alice Phillips, M.D., a pediatrician at Cook Children’s, described the accelerated rise in childhood obesity as an outcome of the dramatic lifestyle changes brought on by the COVID-19 lockdown beginning in 2020. Multiple times a day, Dr. Phillips encounters and counsels patients whose body mass index (BMI) has surged since their last checkup.

When the schools were closed, lots of homebound kids began to snack out of boredom. They watched more TV and did online learning in front of a computer – no walking required. Recess, PE classes and team sports were canceled.

“Parents have been trying to nurture their children during a very difficult time. Food remains a cultural norm of nurture for families, and we are seeing the unexpected consequences,” she said.

Dr. Phillips emphasized it’s appropriate to expect a child to pick up some weight during a growth spurt. Pediatricians track the curve using the BMI calculations, which take a patient’s age, height and gender into consideration. Obesity by definition occurs when BMI reaches the 95^th percentile or higher.

Dr. Phillips and her colleagues at Cook Children’s point out two trends: an increase in patients whose recent weight gain put their BMIs in the 95^th percentile for the first time, and previously obese patients who became even heavier.

“When you see an acute change in the BMI from the 75^th percentile to the 99^th percentile, that’s when it catches your eye and you say, ‘What was different this year that caused that change?’” she said. “All too often during the pandemic the families will say, ‘We haven’t been getting any exercise, and our eating habits are maybe a little worse.’”

She worries about the long-term consequences on their health. When she raises the subject of obesity with her patients, she speaks with sensitivity and tries to help the families feel empowered to set goals they can achieve.

“You have to be very careful that you handle that conversation in an empathetic way,” Dr. Phillips said. “I don’t want how I handle it to be part of the problem for this child.”

Here’s what’s important to know:

• Obesity commonly begins between the ages of 5 and 6, or during adolescence. The causes include overeating, genetic predisposition, stressful life events (such as divorce or a move), depression and low self-esteem.
• Obesity is a chronic disease that adversely affects both physical and mental health. It’s easy to diagnose but hard to treat – potentially setting up a lifetime of complications.
• Studies referenced by the NIH show that a child who is obese between the ages of 10 and 13 has an 80% chance of becoming an adult with obesity.

Susan Hsieh, M.D., a pediatric endocrinologist at Cook Children’s, is seeing more patients diagnosed with obesity-related spinoffs that used to be considered adult diseases: hypertension, high cholesterol and Type 2 diabetes. She also points to the COVID-19 lockdown as a tipping point for kids who gained 30-40 pounds since last year. “The body isn’t designed to take on that much weight in such a short period of time,” Dr. Hsieh said.

She explained that obesity causes insulin resistance, impeding the body’s ability to control the blood sugar. It used to be rare, she said, to see an 8- or 9-year-old diagnosed with Type 2 diabetes. Not anymore.

Data at Cook Children’s show that Type 2 diabetes has been on the rise, with 55 new diagnosed cases in 2018, 107 new cases in 2019, and 126 new cases in 2020. The count so far for 2021 is 91 new cases through early September.

Early onset diabetes, if hyperglycemia is mild, can be treated with oral medications. For those patients who require insulin injections, Dr. Hsieh encourages weight loss as a motivation to wean themselves off the injections. She urges families to address their child’s escalating obesity sooner rather than later.

“In general, it’s easy to gain weight and very hard to lose weight,” Dr. Hsieh said. “The more we educate, the better, because prevention goes a long way.”

The Endocrine Clinic at Cook Children’s offers a program called Risk Evaluation to Achieve Cardiovascular Health (REACH), targeting kids affected by cardiovascular diseases caused by obesity or other factors.

Since the start of the pandemic, registered dietitian Lauren Williams found that her REACH patients and their parents often report more junk food consumption and less physical activity. She counsels them to treat food as a source of nourishment.

Williams’ main message? “We need a healthy relationship with food. We don’t snack throughout the day when we’re not hungry. We move our bodies because our bodies were made to move. Exercise helps our mind; it helps our sleep. Get out and run and play even if it’s just with your siblings in your backyard, having fun.”

Cook Children’s also offers a one-time, free-of-charge class called Healthy Weight Healthy You, which promotes the MyPlate nutrition guide and other tools to eat right. The class is offered in both English and Spanish for children ages 5-18 and their parents. A physician’s referral is needed.

Another resource to fight obesity is the Cook Children’s Outpatient Nutrition Services, available only through referral from physicians in the network. Jean Mankin, a registered dietitian in the outpatient clinic, said the incidence of childhood obesity “exploded” during the COVID-19 pandemic.

“Almost every patient that I’ve seen will admit to boredom eating. And the parents will agree,” Mankin said. “The parents will say ‘I was trying to work… I was there for emergencies but the kids were left to their own devices and they were grazing all day on chips and cookies and crackers.’”

Now she works with families to undo the damage. Bad habits – constant snacking, inactivity -- can be corrected. But it starts with recognizing the problem.

The patients Mankin meets with often arrive with complications tied to the excess weight on their bodies. She lists orthopedic problems, respiratory issues, elevated lipids, elevated liver enzymes and sleep apnea among the ailments.

A one-hour consultation with Mankin encompasses a review of the family’s journal of food intake over several days; guidance on problems she identifies; a packet of information to take home; and lots of encouragement. No one is forced to get on the scale. Mankin says she frames the conversation around the proper nutrition necessary for growth and development -- avoiding the word “obesity” out of sensitivity.

“Some of these little ones and adolescents can easily get their feelings hurt. And when that happens, they shut down. I also encourage parents to be mindful of the language used at home,” she said. “I work really hard to focus on overall health and to keep a positive vibe in my office. Initially, many kids that come to me are somewhat fearful or trepidatious, but most leave with a smile on their face.”

She emphasized that parents must be committed to making changes in the family’s approach to meals and exercise. Improvements don’t usually happen right away. A follow-up visit with the dietitian might be needed after the initial consultation.

If you have a concern about your child’s weight, contact your pediatrician.

The onset of loneliness, anxiety and depression in teens and adolescents during the COVID-19 pandemic has fueled a sharp rise in reports of dangerous eating behaviors.

The National Eating Disorders Association (NEDA) helpline saw a 54% spike in calls for support and resources to treat anorexia nervosa, bulimia, binge eating and other illnesses. Experts blame the surge on factors including stress, isolation and excessive use of social media during the coronavirus lockdown beginning last year.

Health care professionals have long known that eating disorders can be brought on by major life changes. Specialists say that for some young people who already were predisposed, the disruptions from COVID-19 triggered a full-fledged illness or a relapse from their recovery.

“Eating disorders are somewhat of a secret disorder. The more isolated you are at home, the more these types of disorders thrive,” said Joy Crabtree, a licensed psychologist at Cook Children’s. “These disorders often go hand-in-hand with anxiety disorder and depression, and the pandemic has played a role in that.”

At Cook Children’s, we initiated the Joy Campaign – a weekly series of stories addressing mental health issues in children and teens – in response to an alarming rise in suicide attempts in the past year. Eating disorders carry an elevated risk of suicide, particularly in those who suffer from anorexia. One out every of five deaths among anorexics is by suicide, according to the NEDA.

But the hopeful news: Although serious and complex, eating disorders can be treated through a combination of medical, behavioral and psychological tactics. Early diagnosis and intervention lead to better outcomes, Crabtree said.

Keep in mind a few key points:

• Eating disorders cover a spectrum of mental and physical illnesses that in the most severe cases lead to death. Anorexia typically involves severely restricted calorie intake, dramatic weight loss and distorted body image. Binge eating involves rapid and often secretive consumption of large amounts of food. Bulimia causes cycles of binge eating followed by forced vomiting, misuse of laxatives and/or excessive exercise. More information and other types of eating disorders are listed here.
• Eating disorders happen more commonly in girls and women, although boys and men can struggle too. The disorders affect people regardless of age, race or body shape.
• The American Academy of Pediatrics reported the estimate that 0.5% of adolescent females in the United States have anorexia nervosa, and that 1-5% meet criteria for bulimia.

Depression often co-exists with eating disorders. When it comes to adolescents, studies cited by the National Library of Medicine recommend a strategy of aggressively treating the depression and not just the unhealthy eating behaviors alone. Studies also recommend routine monitoring for signs of suicidal ideation, which surface when someone doesn’t want to live anymore.

The reported rise in new or recurrent eating disorders remains a relevant story, even as many of the COVID-19 restrictions have ended, because these illnesses require specialized and sometimes long-term care. As one dietitian put it … eating disorders don’t go away overnight. Treatment options range from outpatient visits to residential care to hospitalization for complications from severe malnutrition (heart disease, organ failure and electrolyte imbalance in the most extreme cases). But access to treatment isn’t always available.

In the past year, inquiries about eating disorders have trended up at Cook Children’s, although the medical center’s behavioral health Intake department doesn’t keep an exact count. Crabtree sees a tie-in to the general anxiety and depression that the COVID-19 pandemic inflicted. She listed contributing factors such as last year’s school closures, cancelation of extracurricular activities and separation from friends.

What else came into play during the pandemic? Lack of routine for sleeping and meals. Poor coping skills. Messages about food hoarding. Fears about weight gain. Pressure to look thin in social media photos and on the Zoom screen.

“Seeing yourself on camera, seeing others on camera, making those comparisons has played a role” in the rise of eating disorders, Crabtree said. “It was kind of a perfect storm, all this focus on food and bodies. It was very overwhelming.”

She urged parents to watch for signs of eating disorders in kids. Red flags include preoccupation with dieting, dramatic weight loss, withdrawal from friends, fatigue, dizziness, fainting, anemia, hair loss and menstrual irregularities. Anyone with concerns should contact their child’s pediatrician or call Cook Children’s to discuss referral options or possible psychological or psychiatric treatment, Crabtree said.

Getting started on treatment

Jean Mankin, a registered dietitian with Cook Children’s Outpatient Nutrition Services, works with primary care physicians to help with food allergies, obesity, picky eating and other issues. When it comes to someone with significant weight loss, Mankin starts by trying to determine whether the patient’s weight fluctuation is intentional.

“If you feel like they’re purposefully withholding food or telling you that they’re binge eating or purging, it’s important to get help,” she said. “A lot of kids are finding themselves having issues they didn’t have prior to the pandemic.”

Mankin emphasized that adolescents need to eat a well-balanced and sufficient diet because all vital organs and bone are rapidly growing and developing at this stage. Anxiety and depression can cause a dramatic decrease in appetite for some, and for others it can lead to stress eating or binging. As long as mental health problems go unresolved, the eating behaviors won’t improve, she said.

At Cook Children’s, patients with suspected eating disorders are referred to local specialists such as Carol Ann Darwin, a registered dietitian in Fort Worth who has met over her career with clients from age 8 to age 70. In April 2020, Darwin started seeing a big increase in anorexia and bulimia mainly among the 13- to 17-year-old set. She called the pandemic a nightmare.

“I went from working three days a week to working six days a week just to get these kiddos in,” Darwin said. Some individuals with eating disorders had to be hospitalized with feeding tubes until spots opened up in residential treatment centers, she said. Dietitians, therapists and treatment centers in North Texas and nationally still have waiting lists up to a month, Darwin reported.

The pandemic caused an onslaught of maladies that Darwin’s youngest clients bring up: isolation, stressful dynamics in a quarantined household, frustration with online school, loss of control. Food became a crutch to comfort and to alleviate loneliness. The challenges that were particular to 2020 compounded the usual causes of eating disorders, such as genetic predisposition and being bullied.

There’s no quick fix; Darwin typically meets with her clients in weekly nutrition consultations for two or three years – although the time frame can be less for those whose underlying depression and anxiety are mild. She said she prefers to use “gentle nudging,” rather than scare tactics, to motivate her clients to start eating appropriately.

“I’ve had several (clients) where I thought, ‘Would this have happened if COVID hadn’t come along?’ Maybe not,” she said.

Disconnection and disappointments

Dawn Dillon, a therapist in Fort Worth who has specialized in eating disorders since 1998, characterized the current demand for mental health services as an explosion. Disordered eating can come from the instinct to take action during times of uncertainty and fear, Dillon said. She drew an analogy to the people who rushed out to buy toilet paper in the early days of the pandemic. The same instinct applies to food and body image.

“We take all these things that are messy, uncertain or scary, and we manifest it through our body,” Dillon said. “Instead of saying ‘I’m scared, I don’t know what to do,’ it gets put onto the body as ‘I’m fat. There’s something to do with that – I can lose weight. I can sculpt. Or I can tone.’”

Eating disorders can originate out of a misplaced attempt to manage distress when someone feels stuck or trapped. Dillon listed a variety of scenarios that particularly applied to life for teens and young adults during the height of the COVID shutdown: Disconnection from social support. Disappointment when prom and graduation got called off. When will colleges and dorms reopen? So many unknowns.

Additionally, refusal to eat can be a way that teens, like toddlers, exert their separate identity. “In a home with no personal space and no autonomy, a lot of times eating disorders will creep up because it’s a way to assert boundaries,” she said.

Once a patient’s medical condition and food intake have stabilized, Dillon said, the mental health piece of treatment becomes vital to get to the root of the anorexia, bulimia or binge eating. Everyone involved in treatment stays vigilant for warning signs of suicide.

No one chooses to develop an eating disorder. Dillon’s current clientele includes first-timers as well as patients with persistent struggles in and out of treatment. Some patients who were handling recovery well prior to COVID-19 had to return for more therapy.

“From the research, we know that life-stage transitions are high-risk times,” she said. “You look at this pandemic, and it was a huge transition that nobody planned for, nobody expected, and nobody knew how to do it. So it makes sense that there would be a rise” in cases.

Dillon acknowledges it can be a terrifying experience for families to go through. Don’t blame yourself or make it a power struggle, she advised. “It’s hard on parents on a fundamental level, but it’s not their fault. The goal is to be aligned with your loved one as the two of you fight against the eating disorder together rather than the two of you fighting with each other.”

School physical season is one of my favorite times of the year for many reasons:

• It’s really fun to see kids grow up and get big over time.
• I love watching my patients’ personalities mature.
• I love that the visits become progressively more about my relationship with the child in addition to my relationship with their parents.
• For the most part everyone is healthy and happy.
• For most children, the promise of a new school year and new beginnings is exciting.

I have a few things on my agenda for each back-to-school checkup.

I want to talk about diet, exercise and sleep. I want to talk about how school went last year and what the plans are for the upcoming year.

But checkups are more than just about what I want. In order for the checkup to be a success, it must meet the goals of the child and parent. Parents are all over the place when it comes to their expectations for physicals.

Here are just a few examples:

1.“Let me get out my list.”

Whether your weapon of choice is a spiral-bound notebook or long thumb-scrolling iPhone lists, you know who you are. And frankly, I love you. Having a guide that directs the visit through any questions and concerns that you have is beyond helpful. It keeps me from having to talk about stuff that’s not important to you and wasting both of our time. So, bring it on, Listers, and I promise not to roll my eyes.

2.“I’m just here to get my form signed.”

No worries. That may be all you need and that’s great. In the meantime I can provide a quick screen for height, weight, body mass index, high blood pressure, heart murmurs, risk for sudden cardiac death, hearing and vision (and much more). I can also screen for drug/alcohol abuse, depression, attention problems and other school issues. “Here’s your form, thanks for coming in.”

But seriously, even in those children who come in with no apparent concerns or complaints, we do pick up health problems that need to be addressed to maximize your child’s ability to function well in school or compete at their best in their chosen activity.

3.“I’m not worried, but __________ wanted me to ask about __________.”

This is a tricky one. I’m totally cool with it, but it can be hard to get at exactly what the concerns is if that person isn’t there to ask questions. My advice … if that person is close enough to be providing this type of advice, they could probably come to the appointment. If the concern is coming from the child’s teacher, a quick note explaining what is going on can be really helpful.

Just don’t leave it up to chance that we can figure out what the problem is, especially if you don’t quite understand why they are concerned. Get specific information about the concern or have them come along.

I’m sure there are many more ways that parents think about their children’s checkup, but these are some common ones I notice.

No matter what, regular checkups are an important part of helping you maintain your child’s health. Good health increases their ability to be present for and to participate fully at school and extracurricular activities.

Which category do you fall in? Is there a different one you think I should include?

Sports EKGs are free through the month of August at specific locations in Arlington and Fort Worth. Cook Children's offers a $25 Sports EKG (electrocardiogram) screening test at our Cardiology offices in Mansfield, Southlake and Denton. Adding a sports EKG to your child’s physical can help detect most heart conditions that may lead to sudden cardiac arrest. Click to learn more. 

For school physicals, visit your local Cook Children's pediatrician. Click to find one near you. 

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer