By Katie Kerwin McCrimmon

The young sisters come to the doctor’s office proudly carrying pink and purple water bottles clinking with ice and etched with the logo that says “Get Fit.”

The medical assistant checks their height, weight and blood pressure, then walks Gabby, 9, and Laila, 6, into the exam room past a medical tray. There are no vials with shots or medical tools. Instead, the tray is filled with shiny red apples, the first sign that this is a very different kind of doctor’s appointment.

Welcome to cutting-edge care in the escalating war on child obesity.

The girls’ pediatrician, Dr. Kim White, chats with Gabby, Laila and their mother as she examines them. Laila was having some problems with snoring. White asks their mom how a prescription for Flonase is working.

“It’s helping,” Teresa Jammal says.

Laila slides off the exam table, then heads with her sister, mom and grandmother to the second part of this visit: a group appointment in a conference room in this office building at Denver’s Presbyterian St. Luke’s Medical Center.

White sees another family with three children. This time, she speaks English to the kids and transitions seamlessly into Spanish with their mother. The children are here for Rocky Mountain Youth Clinics’ Get Fit program, but White addresses other medical issues as they arise.

Gabby, 9, and Laila, 6, bring their water bottles to a Get Fit group appointment. Behind them is medical cart full of shiny red apples.

The oldest boy has a cut on his forehead from an accident during a trip to Mexico.

“Have you been wearing your bike helmet?” White asks. The boy admits he hasn’t. She gives her standard plug: “Wear your helmet!”

They discuss whether he’s eating less late at night.

“Is that helping?” she says as she examines his little sister and finds that she has an infection from a virus that can give her blisters on her hands and in her mouth.

Altogether, Dr. White examines about a dozen children who come to this appointment with their siblings, parents and grandparents. Group appointments represent one of the newest trends in health care. They help medical practitioners save time and create support communities for patients.

In this case, White and nutritionist Beth Ondrako found that they could give the same information to multiple people at once.  And, if some “no shows” forget to come, the providers haven’t wasted their time. On this day, the turnout is great and the conference room is packed. Organizers have encouraged family members to attend since getting fit is a family affair. The group meeting also helps take away the stigma of coping with weight issues.

“It lets the kids be in an atmosphere where they understand that there are a lot of kids who struggle with the exact same thing,” Ondrako said.

“You touch more people’s lives in a group,” said White. “They get to interact with each other. It’s more fun. We want them to follow through. These kids are not thinking, ‘Oh, I have to be worried about diabetes someday.’ We try to find what inspires them. Why is this better for me? Maybe it’s so I can run faster.”

Obesity among children ‘an epidemic’

Dr. Cheryl Saipe, a pediatrician at Rocky Mountain Youth Clinics, created the Get Fit Clinic in 2006 because she and other providers were seeing so many children who were overweight and obese. Ondrako later came up with the idea of giving kids a written prescription to get fit. Now, during well-child visits, providers can give any family the prescription and invite them to join the Get Fit Clinic.

Not everyone will follow up, but providers found that when they invited families to contact them, rather than the other way around, motivated parents and children reached out for help and were more likely to follow through. Interest has been spiking recently.

Nearly 650 children have participated in Get Fit since 2007 and another 147 have enrolled so far this year. Interest has been so high recently that Ondrako, the nutritionist, has doubled the time she spends each month at clinics in Denver, Thornton and Aurora. Organizers hope to expand funding next year to reach children at their mobile and school based clinics.

White attributes increased demand both to rising rates of obesity and a new system that makes it easier for families to come for their first visit. The program includes six visits spread out over six months to a year. But the program is flexible and care can continue if necessary.

Dr. Kim White, a pediatrician at Rocky Mountain Youth Clinics, examines a patient and speaks with her mother before a group Get Fit nutrition class.

A grant from Aetna pays some of the program costs while clinic managers bill insurance providers – public or private – when they can. While obesity is a major health threat, insurance rarely covers care for it. Providers instead must find associated health issues like sleep apnea and diabetes and bill for those instead. Regardless of ability to pay, Rocky Mountain Youth Clinics will welcome any motivated patient to the program.

Altogether, the nonprofit provides care for more than 35,000 children during 55,000 visits a year. There are traditional pediatric clinics like this one in Denver along with non-traditional sites throughout the Denver area.

Most of the patients – 85 percent – come from low-income families whose children qualify for public health programs like Medicaid and CHP+. White estimates that more than half of all the kids she sees are obese.

Among children ages 10 to 15, the numbers are even more staggering.

“My guess is that over 85 percent are obese. It’s an epidemic,” White said. “Patients and parents are finally beginning to realize it’s a problem. In the past, we’d hear, ‘He’s fine. He’ll outgrow it.’”

Yet, even when parents are willing to tackle obesity, they need help. And medical providers can’t do much to reverse the complex problem in short annual well-child visits.

Without intensive follow-up care, children and families stick with the same old patterns and come back year after year with ever-increasing weights that forecast lifelong health problems from diabetes to heart disease.

Many Coloradans have the misguided notion that the state is far removed from the obesity epidemic that is fast surpassing smoking as the No. 1 health problem in the country. In fact, while Colorado remained the leanest state for adult obesity rates in the country again this year, nearly 20 percent of Colorado adults are now obese according to the F is for Fat Study (add link). Colorado is now merely the best of the worst and our current adult obesity rates would have made us the fattest state in the nation as recently as 1995.

For children, Colorado’s outlook is even more alarming. Childhood obesity in Colorado is increasing at the second fastest rate in the country. And the epidemic is especially pronounced among children of color and low-income kids.

The latest statistics from the Colorado Department of Public Health and Environment show that 27 percent of children in the state are either overweight or obese. Problems with obesity escalate in adulthood. More than 54 percent of adults in Colorado are now overweight or obese.

At its core, solving obesity issues should be simple. The formula should be as basic as this: move more and eat less.

But, the reasons that people become obese are varied and complex. Experts believe low-income people and racial minorities have much higher rates of obesity in part because some have less money to spend on healthy foods and access to fresh foods is often drastically worse in poor neighborhoods.

“Eating really healthily is more expensive and it takes more time. The McDonald’s dollar menu is very tempting,” White said.

Sometimes there are complex psychological links to obesity. (Add link to sidebar). Or it can be as simple as bad habits. Many children drink far too much soda and juice. Some families eat giant servings of unhealthy foods in front of the TV, a recipe for disaster over the long run.

In order to succeed, the Get Fit program very deliberately does not focus on weight loss. Rather, it’s much more about making incremental changes that promote a healthy lifestyle.

“They’re not going to change because we tell them to do it. No one can do it for the child. You want them empowered with knowledge to change their lives,” White said.

Lasting results are measured in small steps.  Providers at Rocky Mountain tell children that every person’s body looks different and that’s fine. They encourage family members to focus on maintaining their current weight. Then, over time, as children grow taller, they will almost certainly grow leaner. And, healthy habits can last a lifetime.

“It’s a hard, hard thing,” White concedes. “We don’t see a bunch of kids who improve their BMIs (body mass index) overnight. But if they trade all their sugar cereals for non-sugar cereals or if they’re drinking water instead of juice or soda, that’s progress.”

It’s about lifestyle, not weight-loss

Teresa Jammal’s children are on Medicaid. She did some research and learned about the Get Fit Clinic and eagerly signed on to get help.

“My children are overweight and I am as well. I wanted a lifestyle change for us,” she said.

Jammal is a busy single mom who works and goes to school. She’s studying nursing and lives in Denver.

“This semester, I committed myself to my children more. This was the perfect time for us to join,” Jammal said.

Nutritionist Beth Ondrako works with Laila to understand "Stoplight Nutrition." Children learn how to decide whether foods are healthy "green-light foods," "go slow yellow-light foods" or unhealthy "red-light" choices.

“In the past, I’ve gone to other doctors who do accept Medicaid. They automatically made me feel terrible that my children are overweight. I would walk out in tears like I was the worst parent in the world.

“Dr. White has not judged me and she’s willing to help,” Jammal said. “She said to Gabby, ‘It’s not about losing weight because we’re all different shapes and sizes. It’s about a healthy lifestyle.’ That meant a lot to me.”

Jammal’s mother, Mary, helps care for the children and does quite a bit of the cooking.

“She’s very old school. She’s Middle Eastern, from Jordan,” Teresa Jammal explained. “She’s one of those who would say, ‘Finish your plate or you can’t leave the table.’”

But at the group appointment, Mary Jammal expresses her willingness to learn how to prepare and serve healthier food.

“I’m the cook,” she said. “It’s up to me to change.”

In the conference room, the children sit with their families in a circle. At the center, Ondrako gives them a PowerPoint presentation about nutrition. Again and again, she emphasizes that it’s important to make gradual changes and not to focus on weight loss.

“Our focus is for all of us to get fit and healthy. We’re going to start slowly and keep learning. Everyone is setting goals.”

Later, Ondrako pulls out a colorful board with bright sections on it. She plays games with the kids to teach them “stoplight nutrition.” It’s a simple way to categorize foods and remember to put the brakes on unhealthy “red light” choices, like desserts, soda, chips and fatty fried proteins, while eating more “green light” foods such as vegetables, whole grains and lean protein.

Ondrako hands out pictures of foods like pasta, rice, ice cream and bacon. The children go up to the poster and figure out where their food belongs. Most are quick to pick up on the categories.

“There are not good and bad foods,” Ondrako tells everyone.

She knows it’s unrealistic to think that people will always skip dessert. Rather, she encourages parents not to keep red light foods around the house.

“If we as family members set up a healthy kitchen, then it’s easier to make a healthy choice,” she said. “We’ll get desserts at family parties. We’ll get them at schools. We’re not going to deprive ourselves. We’re just not going to keep them in the house. Maybe every once in a while, you go out for a special treat and you get a smaller portion. It’s better to pay a little more for a treat but not have a big tub of ice cream and eat it all in two days.”

Both the children and adults ask lots of questions. “What do you do when you don’t feel like doing anything?” “Is sorbet better than ice cream?” “Are Cliff Bars good for you?” “What are the best vegetables to eat?”

Ondrako tries to get the children excited about colorful foods.

“Eat a rainbow of colors. Each different color provides different nutrition. We can eat orange pumpkins and orange peppers, green broccoli and purple eggplant. We want lots and lots of dark colors,” she said.

Ondrako tells the children that food in the green light category will give them more energy and that they won’t get sick as much if they eat it.

“This isn’t a diet. It’s not a quick fix. It’s about being healthy. All of us want to live longer and feel better.”

Ondrako then teaches children how to figure out proper portion sizes using their fists. She talks about how plates in America have grown bigger and bigger. As portion sizes have gone up, so has obesity. She gives hints. Use salad plates instead of dinner plates. Find old plates at second-hand shops and use those instead. Fill half your plate with vegetables. Don’t keep food on the table. Serve everyone the right size portion, then wait 10 minutes before getting seconds.

“A lot of times you’ll realize you’re full and you don’t want it,” she said.

In the days after the nutrition appointment, Teresa Jammal noticed changes right away. The girls were working hard to drink their water.

“I used to give them juice every day. We’ve eliminated that,” Teresa said.

Laila, 6, has been asking if foods she wants are healthy choices while Teresa and her mom are brainstorming about changes they can make. The family eats a lot of white rice. The girls like brown rice and Teresa is eager to eat more bulgur, a nutritious wheat grain.

The family also switched from white pita bread to wheat.

“I am making them smaller lunches. I think they’re doing great. At school they’re so active,” Teresa Jammal says.

Dinner takes more creativity.

“We’re trying to eliminate carbs at dinner. I’ve done turkey sausages and a huge salad or lettuce wraps with ground chicken. They love vegetables, but if you put out a big bowl of rice, they love that too.”

Most of all, Teresa is trying to remember to be active with the children, to take them for a walk or go to the playground. The Get Fit program is giving the whole family a new start.

“I used to beat myself up and say it’s all my fault. Now, I think I can change it while they’re still young.”