On June 27th, 2017, Tanya Verstak interviewed Dr. Webb Smith about how his clinic uses exercise as medicine to treat pediatric obesity at Le Bonheur Children’s Hospital in Memphis, TN. He speaks about his extensive background and training in exercise physiology has led him to develop a clinical program that focuses on preventing and treating diseases associated with obesity in a part of the country that desperately needs it.
About the interviewee:
Dr. Webb Smith completed his Doctorate in Health and Kinesiology at the University of Mississippi and his Master’s and Bachelor’s degrees in Human Movement Science from the University of Memphis. Dr. Smith spent 7 years managing the Human Performance Laboratory at St. Jude Children’s Research Hospital. Dr. Smith has over 20 scientific publications and has presented his research at over 40 professional conferences. Dr. Smith currently serves a Clinical Exercise Physiologist and Director of the Human Performance Lab in the Healthy Lifestyles Clinic at Le Bonheur Children’s Hospital and an Assistant Professor in the Department of Pediatrics at the University of Tennessee Health Science Center.
About the interviewer:
Tanya Verstak moved from the Bay Area to Memphis, TN to work at the Epidemiology Department at St. Jude Children’s Research Hospital three years ago. She then fell in love with clinical trials after working at the University of Tennessee Health Science Center and completing a M.S. in Clinical Research Organization and Management through Drexel University. Tanya continues to reside in Memphis attending pharmacy school with hopes of pursuing a career as a Medical Science Liaison.
Tanya Verstak: So what exactly do you do at Le Bonheur Children’s Hospital?
Dr. Webb Smith: I’m a clinical exercise physiologist at Le Bonheur and I’m an Assistant Professor in the Department of Pediatrics at the University of Tennessee. So I work at Le Bonheur and my work is primarily focused on pediatric obesity. We are interested in using exercise as a medical treatment and using it as a way to prevent disease or to slow down disease progression.
Also, specifically in the pediatric obesity realm, I’m really interested in preserving physical function and physical fitness in children that have some impairment based on excess weight and metabolic consequence.
Tanya Verstak: When you say “use exercise as medical treatment,” what sorts of diseases would you use it for?
Dr. Webb Smith: As I mentioned, pediatric obesity is the largest population that I work with here; it makes up probably 80% of the patients that I see. So obesity is a tricky disease: especially in kids: from literature and research that is now getting to be several decades old, we know that the longer you are obese, the more medical consequences you have.
Children with obesity generally grow up to be adults with obesity, so they have been obese a long time and there are a lot of medical consequences to that: diabetes, heart disease, and all the big things that you want to avoid.
One of the focuses of my work is to try to intervene when they are children to prevent them from getting more severely obese but to also hopefully help them develop the skills that they need to be lifelong exercisers.
The other thing that we know is that obesity is also a mental health concern: you are more fit if you think you are, regardless of what your physical outcome is. So if you are more physically fit, then you have a lower risk of developing heart disease or you have better outcomes if you do develop heart disease. Same with diabetes.
What I tend to do and what my lab focuses on at Le Bonheur is to develop exercise programs that will target the biggest need for that particular patient to try to improve whatever weaknesses they have so hopefully that will result in them being more active and getting more benefit from improved physical fitness and also try to guard off some of the diseases that come from obesity.
Tanya Verstak: You mentioned that you are in clinical some days, so do you do studies? Or what is the protocol that you follow for treating patients?
Dr. Webb Smith: So I am a researcher and a clinician here. On the clinical side, we evaluate all the pediatric obesity patients that come in so we do a very diverse set of screenings tests to evaluate physical fitness.
We focus on five sort of traditional areas of physical fitness that you think about: muscle strength, muscular endurance, aerobic capacity, flexibility, and body composition. Those are all the areas that are sort of traditional that you see in literature. In kids, I also like to get a sense of overall proficiency, which is really just to get a sense of overall how well they can coordinate their body and how well they can move as they are developing.
In children who are obese, what comes up a lot is that they are not as proficient with movement: part of that is related to how they have a bigger body that is more challenging to move around, and they also don’t have very developed skills for moving themselves around.
If you think of athletes as being really skilled movers, they move lots of directions, they can move really fast, and they react to things quickly. Not surprisingly, the way they do this is through training. They put themselves in these situations where they learn to adopt and grow and respond. What we see in children who are obese is the opposite: they aren’t very active so they don’t develop the skills to move well, and then they are heavy so it’s actually more challenging for them to move. This under-prepared child that has this extra weight has to figure out how to move in order to become a proficient mover.
Traditionally you counsel people to be more active and to exercise, and in kids you tell them well you should be outside playing with your friends. But one scenario that presents itself a lot to us is that if there are these kids are not very active, we encourage them to be active. Kids that have some kind of physical fitness or performance deficit are going to go out and try to be active with their friends: they are not going to perform well and so that is a negative experience for the child. They go out and play, they aren’t very good at whatever the sport or the game is, so then it is a negative experience.
What we try to do is actually find out what their strengths and weaknesses are and we try to design workouts for them that can try to bring their weaknesses up so we train them the same way that an athlete trains to be faster. We would try to train them so that they are closer to what their peers are. And we would also highlight their strengths.
For instance, if we have a kid with childhood obesity, we would not recommend running because that activity would not be very good for them. But we might recommend basketball, where they would have to use their body to get in position and create space. So we would actually highlight some of these strengths that they would be good at and explain to them why there are certain activities that they might want to avoid for right now or try at a later time when they get a chance to develop the skills that they need.
So from both of the clinical and research side, that is part of the focus: we try to identify the strengths and weaknesses and figure out ways to make them stronger.
Then there’s the exercise prescription focus of my work; and we talked a second ago about some of the physiologic things like the metabolic consequences of obesity that I research. So I really try to balance: I devote a little more time to research than I do to the clinical side but I try to balance both.
Tanya Verstak: How did this program get started? Has it been around for awhile or did you kind of bring it here?
Dr. Webb Smith: It’s very interesting how this came about. Before here, I worked at St. Jude on childhood survivorship research where obesity is one of the secondary concerns to cancer because a result of their therapy and maybe having the cancer itself, they gain weight. So I really became interested in obesity because of that and also with my training in exercise physiology. I worked in town and I think that I see this sort of need in this area, and interestingly as I was completing my doctorate training, the Pediatric Obesity Foundation here, which is a joint effort between Le Bonheur Children’s Hospital and University of Tennessee Health Science Center, was starting off.
This program actually started in 2014 and I was one of the original faculty members that was pulled in to really work on the exercise physiology piece. We have an inter-multidisciplinary team which includes quite a few bit of specialists, including a nutritionist, behavior therapist, pediatric endocrinologist, medical obesity treatment specialists, and my group with the exercise piece. I was recruited to do that part of it and I already had an interest and training in the area so it all just sort of came together.
Tanya Verstak: When you say cancer survivorship research, was that the St. Jude Life program?
Dr. Webb Smith: Yes, so I worked there for seven years. I was the manager of the human performance lab there. It was really interesting because it made me think of obesity totally differently. It was one of the first experiences I had where it really made me think that obesity is not just eating too much and not being active enough.
In a lot of cases that is true: it is the bad nutrition and poor lifestyle and that leads to obesity. But, once you are obese, that is different: that’s why there are not a lot of studies of profound treatment that helps with that. There are a lot of studies that it is easy to gain weight but hard to lose it.
That is what got me so interested: we know that is is easy to gain the weight but once you gain the weight, your physiology changes and it makes it harder to lose weight again. That’s why you can always hear that sort of anecdotal that it is easier to lose it than keep the weight off. And I think that is true, because when you are morbidly obese, then your physiology is against you: from an evolutionary standpoint, it makes sense for your body to pull all of these excess calories in and conserve. That made sense: not too many times in history, there were not too many times with too many calories. So as a physiologist, I find it very interesting that when you gain weight, things change.
Especially again looking at severely obese kids: they have lots of things that physiologically make it challenging. So it’s not just eat less, it’s more complex than that and we don’t understand that very well. That is the very intriguing part of it: if your physiology is working against you, how can we manipulate an environment that makes your physiology work towards you again? So I think that’s one of the things that I find really intriguing about obesity as a disease.
Tanya Verstak: Do you think that there is a big mental and social component to obesity as well?
Dr. Webb Smith: There is absolutely no doubt that there is a very large component of all this that is social and environmental. For example, when I travel to California, I love it because I get to ride a bike around and it’s normal. Here, you ride a bike and people think you are crazy and going to get hit by a car.
So there are certainly environmental things that play into this, and with behavioral health, and just mindfulness.
One of my close collaborators clinically is Dr. Burton, who is a clinical psychologist. From an exercise standpoint, if someone comes in and they are extremely motivated and do exactly what we say, then we know exactly what to do to help them lose weight. But, that’s in a perfect world like animal research: if we lock them in a box and we do the right things, then we will make them lose weight. That is mostly true but that’s not real world: which is an added level of complexity with the social and emotional levels.
In kids especially we see a lot of bullying, a lot of problems like that which we have to be mindful with. That is why when I mentioned how we strategically try to design scenarios where they can be successful and feel successful because the severely obese kid out playing on the playground is a source of emotional negativity.
You have this emotional stress, there’s a whole lot of things that play into it so it’s definitely not an easy fix and I think in a lot of ways the social and emotional things are difficult to deal with: this is a person after all, right? They have thoughts, they aren’t happy that they are morbidly obese so there’s a lot of feelings around that.
Tanya Verstak: What do you think about the future of this program? Do you think other hospitals will start opening programs like this or do you think the future it will be a more prominent thing to focus more on exercise and nutrition in the hospital?
Dr. Webb Smith: I certainly hope so. One of the things that interest me in exercise physiology and especially the clinical side of it, is coming up with plans that take a little bit more of a broader scope; we’re thinking of the person as a whole. Not only to be healthy, but to get an idea of what kind of activities they would like to do.
I would like to see exercise and these types of programs being incorporated into medical treatments because from adult studies at least, exercise is equally as effective as medical treatment. So I think it is a shame, because we focus a lot on treating a specific thing and almost without exception those treatments also have side effects. There are very few side effects to exercise, mostly positive, which is not the case for most drugs.
For instance, to help regulate blood sugar, you give Metformin. In this study, you give Metformin to regulate blood sugar but you could also exercise to regulate blood sugar. However, exercise also helps manage depression and trains the body to be more functional.
When we think about it, GI upset is common with Metformin but the side effects from exercise are that you might get more functional skills, gain more muscle, might actually have lower depression: lots of positive things.
So as a medical treatment, I would certainly hope to see exercise more closely integrated with drug regimen. This is one of my interests working here.
I also work with other clinics that are not only for patients with pediatric obesity. Exercise is not a treatment for everything; there are circumstances where it is contraindicated and you do need surgery or a medication because you are deficient in something.
As a whole, I think exercise in underutilized when it could really have some positive benefits. But it is not something that is reimbursed through insurance and it is not something that is commonly done from a weight loss perspective since it has had moderate success. I think that is what works against us: I hope that from my work and work from my group here we can find some more cost effective ways to include exercise so that it becomes more palliative, makes families a little more interested, and makes the physicians and other medical teams think of it as a treatment that is so important you can’t leave it out. Unfortunately we have not gotten there yet.
Tanya Verstak: I feel like it might be challenging because of how specific you are; as you mentioned you design workouts that focus on your patients’ unique strengths and weaknesses, which takes a lot more time than prescribing a pill and telling someone to take it once a day, with a full glass of water, etc. You definitely have to put in a lot more time and effort to treat your patients.
From my experience, you can counsel someone on how much weight to lose and over what specific time, but you don’t really tell them how. What if they don’t like walking, they are self conscious, or they don’t want to be outside?
Dr. Webb Smith: You are right, one of the things I hear people say who are trying to improve their lifestyles is that they visited their doctor and they were told to lose weight and exercise, but they really don’t know what to do. Its really that “I don’t know what to do” that is a lot of my focus: you are right, it is very time consuming and in order for it to make sense, it has to have a lot of impact. A lot of my work has been focused on trying to package it so it does make sense.
When we work with patients, I really try to treat exercise in the same way that I treat medication: I have to think a lot of about dose. I think about frequency, intensity, time spent doing it, and all of those things are measurable and they are dosed so you can generate dose response curves in the same way that you do in pharmacy school: you can think okay if I give this dose, it won’t have the impact that I need to get in the therapeutic range.
If our goal is to try to help build bone, we need a lot of jumping and high impact to the bones to stimulate osteoblasts that will build some bone. If we want to improve cardiac function, I do some work with the Heart Institute with heart transplant patients: we need to challenge it in the right way. When I work with heart transplant patients, we need to be careful with how far we push because we don’t want to damage it. If you do too much you can damage, and if you do not do enough than you do not see results.
It is just in the same way that you use medication. If you do too little, you do not get your result, and if you do too much, there can be harmful effects. So you have to look at the dosage range.
One of my biggest pet peeves is when people say that if you want to get in better shape, then just go for a walk. In some cases, going for a walk could give you enough stimulus to generate a result. Just like how half a dose of medication may be enough stimulus to get your desired biological effect.
In most cases, that’s not true. It is just another stimulus that provokes a response in the body: be active, it’s easy to go be active. What we’re telling patients who have never been active, in the case of obesity, those kids have never been active. They wouldn’t even know where to begin.
You wouldn’t start a kindergartener out with a book and tell them to read. So just like we want kids to be literate in math, science, and reading, we want to do the same thing with physical literacy. We want them to learn how to move their body; we can’t throw them out in the middle of a soccer game with more experienced players and expect them to do well and enjoy it. It needs to be measured, dosed, and tailored to what they can do and what they’re interested in doing.
That’s an interesting area where I feel like a lot of exercise research has not shown much of an effect. But again, why would we think that going for a walk makes you much more stronger? It doesn’t do that; that’s not the stimulus we are providing. So we provide a better stimulus that gives a better response. That’s the part where I think in the medical setting we can do a lot better job integrating those things.
Tanya Verstak: So how do you usually get your patients here? I cannot imagine a parent thinking that their child is getting too big so they decided to take them to this hospital. Is it usually for another thing?
Dr. Webb Smith: They are referred by a PCP for weight management. So our referral criteria are that children must be in 85th percentile or higher for their weight with a co-morbidity. So for example, 85th percentile and a diabetic or hypertension or something related to their obesity. Or 95th percentile and no co-morbidities. We started in October 2014 we currently have over 700 kids that have been referred which we have assessed that are needing some level of our program.
And, we actually don’t have to worry about the 95th percentile because they are all really well above to the point where we have actually had to think of different ways of describing obesity. So, within the 95th percentile or above: our mean cohort is 99.8. So 95th percentile is kind of like our line so I think of how to manipulate that data.
So let’s turn it to Z-scores: our average Z-score in our population is 2.5 so 2.5 represents the standard deviation of change above the mean. Also becoming not very helpful because we just know that percentile-wise they are very out there on the tail so another way that we commonly describe them is percent of the 95th percentile. In that sense,with that reference, our patients are about 160% of the 95th percentile so they meet the 95th percentile criteria once and about 60% of the time they meet that criteria again.
We are really not dealing with slightly overweight children here, these are really medically complex patients that have very severe obesity. So I think that in these patients recommending peer-based activity is not good advice and also just telling them to lose weight is also not going to be successful because of how complex this is.
Tanya Verstak: Do you see patients up to 18 years old?
Dr. Webb Smith: We see kids up to their mid 20’s, depending on when they start in this program. We can track them until they are 25 but we take patients anywhere from 0 to 25. The mean for our patients is around 12, with the majority of our patients being between 8 to 16. About 75% of our patients fit in that range; so they are really obese and we can try to intervene.
We do medical screenings to see if maybe there is a medical reason why they are obese like an endocrinology defect or genetic predisposition. We also perform health evaluations on them, exercise evaluations which I have already described, nutritional intakes, and those sort of things.
So we look for multiple sorts of obvious causes, such as are they drinking two liters of regular soda every day, or are there other issues? Then we can try to think of a treatment plan to address the concerns that come up.
Tanya Verstak: Do you educate the family as well? Such as the siblings and the caretakers. Do you think that this has an impact on success rate?
Dr. Webb Smith: There is no doubt that family plays a big role. I think that in general we try to engage as much of the family as possible. When I write workouts for people, if mom wants to do it, then we include mom in there so we come up with exercises that mom can do. And if the sibling is interested, we try to get him or her involved. These are children: they don’t buy their food, they don’t set their own schedules so in a lot of ways we focus on trying to do whole family based intervention.
It has varying levels of success trying to engage the families: some families are not interested or not able to commit that much time and effort, so we try to tailor around that. That was one of the factors we consider when we try to personalize exercise for the patient.
If we have a really motivated sibling that wants to help, of course we try to encourage that. I think that also brings up another interesting point with our population especially. Majority of our patients are obese, majority of their family is also obese, and so from an exercise standpoint, that means that the child has not been active, mostly sedentary. The person they are going to look up to is the parent: well what if the parent is also obese, also sedentary and also probably not very experienced with exercise? So it’s not like the parent is a personal trainer that has not been helping, but I think that’s an interesting situation that we end up in because we try to intervene with the child, but actually it is important to educate the parent too so that both the parent and the child can work on this.
Tanya Verstak: I feel like I learned so much of this stuff in school. Are these kids home-schooled or do they just not get this education in school? I feel like a lot of what I learned about nutrition, grooming, and taking different physical tests was in PE classes; is that not something that your patients do not get taught here?
Dr. Webb Smith: The last couple of decades, PE is something that has been cut from a lot of schools. I am an exercise physiologist so I think that is bad; I think physical education should be just as important as being math and science literate. And I am a scientist, I think that is important but somehow we have just cut that physical education component out of our public school curriculum.
A lot of times what happens in school is that we want to do better, we need to get better scores in academia and there is only so much time in the day and instruction time. Well, the common thing that has been removed or dramatically cut from the curriculum is PE. This is really something that has been studied: PE time has declined, and obesity has gone up and I think that just stating that cutting PE is causal of obesity is naive but at the same time, one of the treatments for obesity is physical activity and we are removing education about physical health from our schools.
Old school PE taught you how to play games and physically how to do things, really focusing on those physical skills that we talked about. That has been removed in favor of more academic instruction. There is a massive debate about which way to go. I think a balance would be nice, but I think most of the schools and school systems favor more towards academic with the thought that kids would play when they go home…but they don’t.
They don’t and we also then have that kids do want to play but they don’t know the skills because they haven’t been taught: PE teachers aren’t just out there rolling balls on the court, they are trained educators as well and part of what they’re trained to do is how to teach kids how to be physically literate, how to move their body and actually do these things.
That is maybe a little unfair for parents to say surely you can figure out how to teach your kids to be active, we wouldn’t expect them to teach their kids how to do math or science. I think that’s underselling the role of a lot of our educators whose subject is PE, health, and wellness. I think they are underappreciated for their skills on teaching children these skills on how to make healthy decisions and those things. It has been de-emphasized in school and causes a problem.
It’s also an interesting area because a lot of research recently has shown that kids who do get PE during the day actually perform better academically because it creates kind of an information mismatch, where the intuitive thing is that if we want them to get better at math, we should do more math instruction. But there is only so much math instruction that you can do, so maybe some of these other things can make a comeback: then back to education.
We need to give kids basic skills on physical education, because I think the basic notion is that they’ll figure it out; they’ll figure out how to play and how to do this. There is some instruction that needs to be had out there and these are skills that need to be learned.
Tanya Verstak: There are also situations where either both parents are working or there is only one parent who is working two jobs so when the child comes home, that’s it. They might be told to not go outside by themselves. They are told this, then then have this TV and these video games and this iPad that eat away at their attention.
Dr. Webb Smith: Another scenario is that our clinic primarily sees African Americans and a lot of families with low-economic status. That is not limited to African Americans, but these things are very commonly overlapping. So, if they live in South Memphis and when they get home from school and it is not particularly safe to be out, and those parents are working multiple jobs because that is what’s required of them to meet ends meet, and the child has to come home and they get home at 3 but mom doesn’t get home until 7 because they work 12-hour shifts. So from 3-7 the rules are that they have to be in the house because that’s the safest place and how much activity can you really do there?
Tanya Verstak: Unless you get a Wi-Fit or something like that!
Dr. Webb Smith: Actually, all of these laptops that are stacked in front of you are from another grant that I am working on where we designed an active gaming system which the Xbox Connect camera there does body tracking so we can actually have them exercise in front of the computer game system so essentially when they wave their arms, the computer character does.
We’ve really developed this game with exercise in mind so they have to really jump and move and do all of the things that they need to do to really navigate their character through a maze or through the forest or race around a track to deal with exactly those problems that you are talking about because if they are locked inside, because that’s what is safe, then what intervention can we really deliver?
So with something like this, we could set this system up at home so they can potentially play it at home as a viable exercise option. Plus, it’s an easy sell because kids love video games. This has been one of our solutions to the scenario that you mentioned earlier: I have a grant where I work with computer programmers at a local small business where we actually built a video game that was designed to be exercise so they have to run to navigate and do all that.
We tested it in the lab and found that we were able to get them to exercise quite intensely and they did not think it was that bad. They enjoyed playing the game, and they actually reported that the activity was moderately strenuous because they were focused on the game, although we measured the activity as very strenuous. Now this is something that we are looking to push out into kids’ homes. Maybe for $300 or $400 they can have a system that goes home with them and they can do their exercises there.
The system would communicate back to one of the trainers in my lab or the research assistants that work here and we could look and say okay, this individual did five workouts this week and we asked them to do five workouts this week, so they did all of the exercises that we asked them to do. Or, maybe they weren’t able to: they did three, which we can prompt the phone call to say, “Hey, great job you did three sessions, but what happened on those other two days?” This way we can figure out what we could do to get them to the recommendations of 60 minutes every day.
So we try to solve some of the barriers that these families encounter by coming up with some innovative solutions in the form of a video game system.