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The weight of obesity

Childhood obesity

From Saturday's Globe and Mail

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The girls trudge over from their dorm rooms in robes and long T-shirts and giant furry slippers with claws on the toes. They queue up in front of the scale room for the Wednesday weigh-in. They unclasp gold chains, remove earrings and slip out of slippers. One girl wonders if she should take off her bra.

“The underwire could add to my weight,” she says. “Nah,” her friend replies. “It's your boobs that add to the weight!” They erupt in nervous laughter. But Carmen Nanninga, a big blonde from Edmonton, hardly cracks a smile. She just returned from a trip, a test to see how well she could control her eating away from school for a week. Her parents treated her to a vacation at a Mexican resort – with an all-you-can-eat buffet.

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Half an hour southeast of Fresno, Calif., in a fruit-farming region famous for its raisins, the children come to shrink. They lumber here from all over the world, with chafing knees and double chins and bellies too big for them to see their feet.

Tucked in an apron of the Sierra Nevada Mountains, and with tuition higher than at Harvard University, the Wellspring Academy bills itself as the world's first academic boarding school for overweight children. To enroll, students must have at least 30 surplus pounds. Few have trouble making the grade.

Rates of childhood obesity have soared in the past 30 years. In North America, they have tripled. One in four Canadian children is now estimated to be overweight and 1 in 10 is clinically obese.

For adults, a multibillion-dollar industry offers endless, if dubious, options for weight loss. But services to help children are so scarce that parents are taking out loans and raiding retirement savings to send their sons and daughters thousands of kilometres away to this $6,300-a-month (U.S.) institution.

“We had to take a home-equity line of credit to pay for it … but it's an investment in a human being,” says Nancy Stolk, the Edmonton-area mother of 17-year-old, 5-foot-10 Carmen Nanninga, who weighed 275 pounds when she entered Wellspring in January.

Weight-loss camps for kids have surged in popularity around the world. But officials at Wellspring insist that their year-round school is no typical “fat camp,” where kids tend to drop pounds each summer but return every year to lose the same weight again.

Founded by a Canadian entrepreneur banking on big market growth, Wellspring Academy is a certified high school that requires students to stay a minimum of four months and take part in a tough program of behaviour modification.

The goal is to help students become healthier, and yes, slimmer, but wiser too, so they can battle the dietary demons that lie beyond this rural campus. Just up the freeway, Famous Dave's Barbeque Hut in Fresno invites patrons to “eat like a pig and squeal with delight.”

“We're not going to fix the outside world from our little school here,” says headmaster Phil Obbard, 34. “But we can work on changing their behaviour so they can defend themselves.”

Like recruits to a health-conscious cult, students recite self-help codes aloud in unison, record each morsel they put in their mouths and every step they take, abide by strict curfews and agree to be nearly cut off from the outside world, including their families.

Parents balk, but officials here say it's all necessary to reprogram young minds raised on Xboxes and Big Macs. They also insist that their results are better than any other program's, with more than half their students maintaining their weight loss up to two years later, though the claim has not been verified in a controlled study.

Even before it turns a profit, Wellspring is spreading like a fast-food franchise. A second school opened in North Carolina in 2006. Two others are planned for Texas and Massachusetts and another for Britain, where the National Health Service has begun to foot the bill for children enrolled in weight-loss camps. British schools are sending “fat report cards” home this year detailing children's weight.

In total, the summer programs of Wellspring, formerly known as the Academy of the Sierras, now number 14. Next year, it is to set up camp in Canada for the first time, scouting a location just outside Vancouver.

“The obesity rates in Canada are not quite what they are in the U.S., but they're getting there,” says Ryan Craig, the Toronto-raised entrepreneur behind Wellspring. This fall, four Canadians are among the 90 students enrolled at Wellspring's California flagship location, which opened with just seven students four years ago.

“We get calls from families with obese kids younger than 5. We get calls from departments of family and social services who have to take in a child for being morbidly obese,” Mr. Craig says. “For many of these kids, we're the last stop before surgery.”

Carmen sits on a campus bench in front of the culinary-class portable where she will learn to fry bananas in a non-fat cooking spray and Splenda sweetener that afternoon. She has her golden hair pulled back.

“I want to be healthy now, and thin, and I'm not going to give that up,” she says. “I want to be a flight attendant.” She wants to lead a “jet-set lifestyle” and see the world. She just has to lose the weight first.

The weight. She has been trying to do that since she was at least 11, when her mother remarried. “Kids were mean, but I never got angry or depressed. I just shut myself out.”

She tried to starve herself at 13. “That was pretty damaging.” She tried Weight Watchers and countless other diet programs, but she could never keep the pounds off for long.

It is estimated that up to 1.6 million children in Canada need help losing weight, but the health system can provide care to no more than 2,000 of them. Experts say the problem has ballooned too quickly.

“It's not like the issue of childhood obesity has been around a long time,” says Geoff Ball, director of the Pediatric Centre for Weight and Health at the Stollery Children's Hospital in Edmonton. “The health-risk factors haven't been staring us in the face yet.”

Extra weight increases the risk of everything from cardiovascular diseases, metabolic, joint and muscular disorders to cancers. Studies now suggest that today's overweight children will be the first generation to live shorter lives than their parents.

Yet experts remain divided about the root causes of childhood obesity and the best ways to treat it. “It's easy to say it's eating too much and not moving enough, but the issues are deeper than that,” says Arya Sharma, head of the Canadian Obesity Network and medical director of the Edmonton region's Weight Wise program for children and adults. Some children overeat as “a coping strategy, to feed their emotions,” he says. In rare cases, people have biological conditions that make them overeat.

There are tough social questions too, he says. The increase in families with two working parents has spawned the growth of the takeout industry; suburbs are built for wheels, not for walking; and parents have become afraid to let kids play outside.

“Maybe we will see [childhood obesity] as a cost of doing business,” Dr. Sharma says. “Family doctors,” he adds, “have virtually no training in obesity management. They will send their patients off to a commercial weight-loss centre. … They don't view it as a chronic disease.”

But obesity is a lifelong chronic condition. “Whatever the treatment, you have to do it forever – if it's running five [kilometres] a day or whatever. … There is no cure for obesity.”

As time went on, the emotional turmoil turned into a compulsive need to injure herself. Carmen became a cutter, slicing into hidden corners of her arms and legs. Her mother, Ms. Stolk, a nurse in training, worried more by the week.

She had initially understood her daughter's plight. She had reached 300 pounds herself when she went through a painful divorce in her 20s. But her daughter's behaviour became increasingly erratic.

Gone was the sweet little girl who played the guitar and sang in the choir. She fought constantly with her stepfather. She stopped playing with her little brother and the family dog. She would fly into rages, then break into sobs. A doctor finally put her on antidepressants.

Then Ms. Stolk heard from a guidance counsellor that friends had reported Carmen felt so “ugly and fat” that she wanted to kill herself.

That drove Ms. Stolk to the Internet, where she discovered Wellspring. She signed her daughter up for its California summer camp in 2006, when Carmen was 15 and weighed 270 pounds. She lost 30 at the camp and another 30 when she came home.

“She came back a changed person,” Ms. Stolk says.

The students milling about Wellspring's low-slung, 68-acre campus of portables, dormitories and administration buildings look at first like teens at any other high school. They sport tattoos and baggy clothes and saunter slowly between classes.

Here, though, the average student carries 60 to 100 extra pounds, everyone wears a pedometer, and no one is glued to a cellphone – they're banned, along with cigarettes and televisions in the dorms. The only two TVs on campus hang on the gym wall, smack in front of the treadmills.

The school offers team sports and recommends long daily walks and 10,000 steps a day, the equivalent of five miles. (The average person takes 3,000 steps). But only the fitness class is mandatory. “For many of these kids, it's their first exposure to exercise,” says Jeremy Berumen, the tanned and buff 22-year-old who runs the program. “They run a bit and they can't breathe. … I start them with basic moves that might be as simple as sitting in a chair and standing up.”

About 10 per cent of the students battle diabetes, high cholesterol, hypertension and other weight-related conditions. A third of the students take psychotropic drugs – mostly antidepressants or anti-anxiety medication. All must attend group and individual cognitive-behavioural therapy sessions, underscoring the backbone of the program – self-monitoring.

Somewhere in every student's pocket or backpack is a journal in which they track their physical activities and their daily diets. Mr. Obbard, the headmaster, calls it “think and ink.” He says it's the key to teaching “weight-control skills, versus weight loss.”

“Most people don't think about what they eat, or even remember what they ate for lunch the day before,” he adds, reaching for his own little black book, where he recorded his 402-calorie breakfast of eggbeaters and oatmeal.

Boys and girls eat their three meals a day separately, in a windowed, cafeteria-style dining hall in the middle of the campus. They aim for around 1,200 calories a day and less than 20 grams of fat, combining “controlled” hot meals with “uncontrolled” fruit and salad selections along with the riot of condiments on the long cafeteria tables – chilies, malt vinegar, chipotle sauce, Worcestershire, hot sauce, cinnamon, salt and baskets of Splenda, the artificial sweetener 600 times sweeter than sugar.

Here, Splenda is a food group. Students rip open the little yellow packets by the dozen. They drown their cereals in it, shower their fruit with it, cook with it and lick it straight off their fingers. One boy pours more than 20 packs on his yogurt. School chef Erin Gaughan, who teaches students to read labels, stock pantries, size portions and flavour food without fat, says they “are almost like smokers. … Their tongues have dried out from all the fat they've eaten.”

The school leaves the students free to make their own dietary choices. They can eat white bread, drink unlimited amounts of diet sodas from the dispensers and devour 10 bananas for lunch. They learn at the weekly weigh-in what the consequences have been.

Still, says John Gordon, the school's marketing executive, “no balloons come floating out or anything if you lose a bunch.” It's successful self-monitoring and physical activity that earn the coveted privileges of phone time and nights off campus.

But when they do lose, Mr. Craig says, students become less homesick and more motivated to succeed. They all know success is possible. Some of the biggest losers sit right beside them in class. Chris Grayson, for example, arrived from Connecticut in April, 2007, weighing 325 pounds. He lost 145 of them in 11 months. At 18, he's slim, strong and runs a seven-minute mile.

Terry Henry of New Hampshire was the largest student Wellspring ever had. He weighed 590 pounds when he arrived in 2004 and lost 300 in one year. Terry is long gone (and has managed to keep his weight around 220 pounds) but his old denim shorts and T-shirt still hang in the hallway, stretching across the corridor wall like a victory flag.

After Wellspring camp, Carmen kept the weight off for a year. “But last summer I sat around a lot,” she admits. “I was bored and eating … ice cream, cookies, whatever was around.”

Her mother says Carmen has to learn self-control. “If I had something in the house, banana bread, say, she would find it and eat the whole thing. I couldn't keep anything in the house. But how fair is that to the rest of the family?”

By last Christmas, Carmen had regained all the weight. She pleaded with her parents to send her back to Wellspring, full-time.

“I know they had to add to their mortgage to send me here, so I feel some pressure,” she says as she heads off to her next class.

The Wellspring program was designed by Daniel Kirschenbaum, a professor of psychology and behavioural sciences at Northwestern University in Chicago. It grew out of research he had done with elite athletes – figure skaters in particular. He found those who monitored their daily efforts, their strengths and weaknesses, improved the most over time.

The 57-year-old author of The Healthy Obsession says children have to become a bit obsessive about their food, controlling their weight and remaining active. This demands that they be separated from their old lives, their families and homes.

“It has to be immersion. If they keep one foot in their old way of living and their former lives, it's not going to work.”

Only with progress through an elaborate level system are students bumped up from two 10-minute calls a week to two 20-minute calls home, followed by 60 minutes and then, in the final stages, unlimited calls.

“Students are more likely to be homesick than hungry,” Mr. Obbard says. “But we get the calls from parents every day who hear from their kids that they want to come home.”

Chris Grayson, the student from Connecticut, gripes that dealing with the immaturity of the younger kids was his one major complaint. At 12 or 13, they are away from home for the first time, he says, living in a dorm and unschooled in the matters of basic hygiene.

“Who wants to live with that smell?” When Toronto parents Audrey and Fred Guth enrolled their 16-year-old, 321-pound son, Jesse, at Wellspring in 2006, they understood that the school sought to limit family contact because “parents might be part of the problem.” But Ms. Guth did not realize the strict policies would make them feel like “parents were just getting in the way.”

“It was like a drug rehab,” she says, “we were totally cut off from him, no email, no computer.”

At one point, Jesse developed a respiratory infection at the tail end of a visit they had in San Francisco. She flew back to the school to be with him, but officials told her that she should not be there.

“I live in another country 5,000 miles away and this is my kid,” she says. “He had a really bad chest infection. … We weren't even allowed to call.” He ended up in the hospital. Still, Ms. Guth says, Jesse shed 84 pounds during his seven-month stay at Wellspring. “I can recommend it because there's nothing else out there for kids. What else is there? What are you going to do? He was missing life, he was so depressed,” she says. “I thank God there was a place like this.”

The school runs a weekend workshop every three months for parents to learn the program and help their kids make the transition back home. One of the first things Dr. Kirschenbaum tells parents, and their children, is that they are not to blame for their bulky bodies.

“Obesity is primarily and foremost a biological condition,” he says. “They have to know the enemy.” He estimates that genes account for 75 per cent of the reason people become overweight and that roughly half the parents of Wellspring students are heavy themselves.

Genetics makes them slow metabolizers who have a propensity to pack on pounds. One person might be born with 30 billion fat cells, he says, another with 200 billion.

“It's not just them being pathetic like the rest of the world might think.” And unfortunately they and their genes have been born into a lousy environment – an “obesogenic culture,” Dr. Kirschenbaum calls it. “This is a disease of affluence,” he says, and it's a cultural phenomenon spreading worldwide.

Fifteen per cent of Wellspring students come from outside the U.S. – Canada, Mexico, Europe and the Middle East. This past year, for example, three sisters arrived from Kuwait, which has one of the world's highest childhood obesity rates at more than 30 per cent.

“In Kuwait, there's not a lot for us to do. It's about shopping and food,” said Muneera, 19, the eldest. “It's also too hot to walk anywhere and we all have drivers.” McDonald's, Burger King and Pizza Hut all opened two minutes from their high school.

“This,” Dr. Kirschenbaum says, “is a clash between biology and culture.”

The first girls emerge from the weigh-in room with giant smiles. “I lost four!” one of them says. “I lost 4.8!” says another. There's a chorus of praise and high fives, but out walks a girl who utters not a single word. It sends a shiver up the line. Behind the door, in the sparse room barely bigger than a walk-in closet, Carmen steps off the shiny linoleum tiles and on to the scales with her face to the cinderblock wall.

Rachel Thomas, a model-thin woman who used to counsel for Jenny Craig, records the numbers. Carmen tries to look brave. The scale registers a gain of three pounds. She bolts out the door in silence and will not make it back to her room before the tears start.

Typical teenage dramas play out in the dorms where they live, two to a room. But Wellspring has a unique social dynamic. Back home, these were the fat kids, teased and humiliated. Here, the big boy might be the bully, or the hearthrob; a heavy girl can suddenly become the belle of this ball.

“They are normalized here. Most of them never had a girl or boy pay attention them,” says Mr. Obbard. The school works hard to keep the new-found adolescent hormones in check, in part to keep students focused on their program goals. But staff cannot keep young lovers apart any more than they can halt ice-cream cravings.

It happened to Carmen in June after a new boy arrived from upstate New York. By July, he was her boyfriend. “Things move so much faster at the school,” she says, “because you're spending all your time together.”

If students are caught in an embrace or even holding hands, they run the risk of a “72-hour, no-contact” penalty, forbidden even to speak with one another for three days. “I feel like that rule backfires,” Carmen says. “You know, it's like, ‘Distance makes the heart grow fonder.' ”

She and her beau were caught “having contact” and that, along with a few other behavioural clashes with staff, cost her dearly. All her privileges were stripped down to the level of a newcomer.

“I wish it hadn't happened,” she says. But policing affairs of the heart is not the only challenge for the staff at Wellspring. Students with emotional problems can be as creative in finding ways to self-medicate as they can be in altering their meals in the cafeteria.

“I had a roommate who inhaled Tinactin,” Jesse Guth says, explaining how the boy would shoot the spray for athlete's foot into a hat and then sniff it. “Some of the kids snorted their Ritalin too.”

Mr. Gordon says staff have never heard of such incidents. “We watch our students closely and this would be grounds for immediate dismissal.”

Jesse also says that kids sometimes ran away, usually to the burger joint a few kilometres from school. Minding the kids has proved to be the most expensive item in Wellspring's budget. The staff-to-student ratio here is nearly one-to-one, with 80 teachers, instructors and support employees. Mr. Craig argues that such intense oversight makes it unfair to compare Wellspring's fees to Harvard's. Wellspring is a health-care program first, a boarding school second, he says.

Mr. Gordon concurs: “We don't pretend to be a premiere academic institution.” The bare-bones appearance of the Wellspring campus, originally constructed as a remote mental-health facility, often surprises both parents and students.

“I felt for the amount of money it cost to send him there that it should be state-of-the-art facility with state-of-the-art-equipment – and it wasn't,” Ms. Guth says. “Even the washing machines were broken.”

The average annual income of Wellspring parents hovers around $72,000 (U.S.). A third of parents take out loans, and about 70 per cent of families have health-insurance plans that cover the costs of the cognitive therapy (about a quarter of the fees). These sums have prompted some observers to warn that students might face unhealthy pressures to lose the weight and keep it off.

During one of the group-therapy sessions, a 15-year-old girl who hobbled in on crutches, having twisted her knee exercising, confesses that she is feeling especially down. She spoke to her grandfather, who contributed to her school fees, and told him that she had lost more than 27 pounds in the previous two months.

“He said, ‘Oh, is that all?' ”

Later in the day of the weigh-in, sitting opposite Ms. Thomas in her one-on-one therapy session, Carmen says it was her own decision to join her family at the Mexican resort as part of her “off-campus challenge.” She does not regret it.

“Life can't be about a constant state of denial,” she says. “You know my body gains weight so easily, and the weigh-in could have gone so much worse. …

“It was my vacation and I didn't want to not drink pina coladas. You know - what about everything in moderation? I'm not going to make myself guilty, and think I can never have Haagen-Dazs ever again.”

“You have to stop putting certain foods on a pedestal,” Ms. Thomas answers her. “There's a whole big world out there … and when you're not here, you have to be the control.”

“Food is good. It tastes good. I want to enjoy my life,” Carmen says. “It's terrifying to think I'll never be able to eat this again or eat that again.”

Most experts agree that Wellspring's school program has several positive elements. Jean Pierre Chanoine, whoheads the pediatric division of the Canadian Obesity Network, says it might be worth sending some kids to a boarding school “to get them out of a toxic environment.” But he stresses that there is little concrete information about how long teens stick to the program after they leave the school.

After most interventions, 70 to 90 per cent of children tend to regain the weight they lose less than a year later. Dr. Ball of Stollery Children's Hospital in Edmonton saw Wellspring's Dr. Kirschenbaum speak at a Vancouver conference on childhood obesity last year and was struck: “I've never seen another program able to demonstrate that 50 per cent can keep the weight off up to two years later.”

But with no controlled study in a peer-reviewed journal, observers remain skeptical. “They should publish,” says Dr. Chanoine, who treats overweight kids at the B.C. Children's Hospital. “It's a good initiative, but it needs to be evaluated.”

The only article so far appeared last fall in the journal Obesity Management, reporting that more than half of students maintained their weight loss for 10 months.

Dr. Ball notes that weight loss with children presents particular challenges because parents have to be closely involved: They are generally the ones deciding what food is bought and prepared.

What's more, Dr. Ball says, some critics say it's inappropriate for children to count calories and focus on low-fat eating, as it may contribute to unhealthy obsessions and bad body image. “Some experts say it's better to focus on healthy eating and active living,” he says.

Mr. Gordon says school officials present their data at peer-reviewed scientific conferences regularly. But conducting a large study with a control group takes “a lot of time and a lot of money.”

Jesse Guth is one of the students Wellspring staff is happy to introduce, as the Toronto teen has maintained his weight since leaving the school in June, 2006. His 104-pound loss was so dramatic that he underwent surgery to remove the extra skin.

But he is the first to admit that his experience is extraordinary. Sprawled on the white sofa in his family's spacious North York home, he describes how his family has offered support and incentives. His parents encourage him steadily. They have a housekeeper who prepares nutritious, low-fat meals for the family. They have a gym set up in the basement. In the driveway sits a 2006 Mustang that belongs toJesse so long as he keeps off his 100 pounds.

“We're in a position financially that we could afford to offer Jesse a reward,” Ms. Guth explains. “He did once have to turn the keys in for a month.”

Jesse had initially been completely opposed to a boarding school for weight loss. He threw the brochure in the trash and snapped the DVD in half. Even as he tried and failed various weight-loss programs, he kept telling himself there were kids bigger than he was – “I never knew how overweight I was,” he said.

Ms. Guth, who runs a foreign recruitment company and holds a masters degree in nutrition, had struggled with weight for much of her life. She always made sure the house was stocked with wholesome food. But Jesse, by his own admission, was drawn to sugar “gummies and dirty, cheap-made, fake-coloured candy.” He'd buy it during school at the vending machines, after school at the convenience store, or at the subway station.

The weight had begun to overshadow his life. He didn't date. He never wanted to remove his shirt to go swimming. When he holidayed with his family in Hawaii, he was deemed too heavy to take the helicopter tour.

Then one day after school, he trudged upstairs with a bowl of ice cream and realized he was panting. He sat on his bed, scared. Doctors had already warned him he faced gastric bypass surgery: “I knew I had to do something, for my health,” he said. He decided the school was it.

“I kept picturing myself walking down the hall in my school after I'd lost all this weight and my friends turning around and smiling at the new me.”

For Jesse, who started at Dalhousie University this fall, the dream came true.

“I can't say I enjoyed the program,” Jesse says of Wellspring. “But based on my success, I would recommend it. … More than anything, it gave me knowledge about what I was putting in my mouth.”

The challenge, Jesse says, starts the second you get home and people stop weighing your food. He has stopped wearing his pedometer, though he continues to “mentally” self-monitor, he says.

Jesse has kept in touch with some former students by Facebook and estimates many of his friends have regained weight. Most troubling, he says, is the fate of a boy named Jahcobie Cosum.

Like Jesse, Jahcobie, 18, was a poster boy for the boarding school. He arrived at Wellspring in 2005 weighing 483 pounds. He lost 167 by June, 2006, and 30 more in his first month home. The TV show Extreme Makeover featured his story. But before long, Jahcobie gained it all back and then some. He now weighs 562.

Jesse calls it a tragedy: “When he got home, his family was still cooking fried chicken and buying chips.”

It's September, and Carmen leafs through the classified ads for a job at home in Calmar, Alta. She finally left Wellspring on Aug. 16, staying two months longer than she expected.

She hoped to weigh less than 200 pounds when she left. But in the end it was 210 pounds, 65 down from her starting weight.

“I reached a point where the weight loss just slowed down,” she says. “I hit some ruts. “I got a little negative at the end, sassing staff and everything. … I did do my best, but I had setbacks.” She is disheartened that her new boyfriend has lost the same weight over the summer that it took her six months to shed. She guesses boys lose faster.

Even before she arrived home, Carmen had regained a couple of pounds. She and her family toured around Los Angeles and other parts of the U.S. en route back to Canada: “I would ask the restaurant for meals prepared without oils or butters, but they never seemed to follow the request.”

Carmen says she is determined to stick to the program now. Since she is the only one in the household struggling with weight, it means making her own meals. “Mostly I have fresh fruits and salads,” she says.

She still hopes to land a job at the airport, the first step toward being a flight attendant. In the meantime, she believes she will lose more weight. She rollerblades and walks the dog. But she no longer rises for that pre-breakfast stroll as she did at the school.

And as for the pedometer, she says, “I was never really into wearing that anyway.”

Carolyn Abraham is The Globe and Mail's medical reporter.

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