Childhood overweight and obesity are increasing in prevalence and are a growing health concern. The diseases and their comorbidities have devastating consequences to children and adults as well as families, communities, and the nation. Comorbidities are cardiorespiratory, endocrinologic, gastrointestinal, orthopedic, and psychosocial. Health care providers are facing this crisis with limited medical, community, and federal resources and insufficient reimbursement. This article reviews recent trends in the assessment and treatment of this disease as well as trends in reimbursement, financial implications, and the need for further research and advocacy.
Key points
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Childhood overweight and obesity are increasing in prevalence and are a growing health concern.
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The diseases and their comorbidities have devastating consequences to children and adults as well as families, communities, and the nation. Comorbidities are cardiorespiratory, endocrinologic, gastrointestinal, orthopedic, and psychosocial.
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Health care providers are facing this crisis with limited medical, community, and federal resources and insufficient reimbursement.
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This article reviews recent trends in the assessment and treatment of this disease as well as trends in reimbursement, financial implications, and the need for further research and advocacy.
Introduction
According to the latest statistics from the Centers for Disease Control and Prevention, more than one-third (34.9% or 78.6 million) of US adults are obese, with an estimated annual medical cost of $147 billion in 2008. The prevalence of obesity in children increased 300% over approximately the past 40 years. The National Health and Nutrition Examination Survey, 2009 to 2010, found 32% of children, 2 to 19 years old, to be overweight or obese, with 17% in the obese range. Children’s risk varies significantly by race/ethnicity. In 2009 to 2010, 24% of non-Hispanic black, 21% of Hispanic, and greater than 20% of American Indian/Alaskan Native children and adolescents were obese compared with 14% of white children. For children and adolescents aged 2 to 19 years, the prevalence of obesity has remained fairly stable at approximately 17% and affects approximately 12.7 million children and adolescents for the past decade; however, the prevalence of severe obesity in children continues to rise.
Childhood overweight and obesity and their comorbidities threaten to prevent a significant portion of US children and adolescents from reaching their full potential and contributing to society on personal and community levels. Comorbidities of pediatric overweight and obesity are cardiovascular, endocrinologic, orthopedic, gastrointestinal, neurologic, pulmonary, and psychosocial ( Table 1 ). Children of underrepresented ethnic minority groups and those living at or below the poverty level are at increased risk. Communities of lower socioeconomic levels are burdened with obstacles concerning physical activity. Children of parents with lower education levels, who are more likely to live in low-income/high-crime neighborhoods, are at increased risk for overweight and obesity. School districts in these communities are less likely to have adequate funding to maintain physical education programs. Also, gym and recess are less likely to be supported during efforts to improve academic outcomes in failing schools.
| Cardiovascular |
| The overall prevalence of dyslipidemia in the pediatric population has been reported as 20.3%, whereas that in overweight children is reported to be 42.9%. The prevalence of clinically identified hypertension in United States children (estimates: prehypertension — 10%; hypertension — 3.7%) is directly correlated with increasing waist-circumference and BMI. In a study by Gidding et al, 48 children, 8–17 years old, with BMI of at least 40 kg/m 2 (obese by adult BMI measures) were studied using a graded stationary bicycle test. The subjects were noted to have deconditioning consistent with congestive heart failure. |
| Endocrinologic |
| The prevalence of metabolic syndrome among pediatric patients, according to a systematic review of population-based studies, is 3.3% in nonobese, 11.9% in overweight, and 29.2% of obese children. In another study, 50% of severely obese subjects had metabolic syndrome, whereas none of the normal-weight or overweight subjects did. Up to 25% of severely obese adolescents are noted to have impaired glucose tolerance. The prevalence of pediatric type 2 diabetes mellitus is increased with obesity (one US sample noted a prevalence of 0.24/1000), and increases with age. |
| Respiratory | Obstructive sleep apnea has been associated with childhood obesity. | Noted in 5.7%–36% of obese children and adolescents, this exceeds that noted in normal-weight children and adolescents, where the prevalence is estimated at 2%–3%. |
| Gastrointestinal |
| One study of adolescents with mean BMI of 59 kg/m 2 undergoing gastric bypass surgery noted liver involvement as follows :
|
| Musculoskeletal |
| More than 80% of the children diagnosed with slipped capital femoral epiphysis are reportedly obese (BMI greater than the 95th percentile). |
| Psychosocial |
| One study found that obesity in 10- and 11-year-old children independently predicted self-esteem 2 and 4 y later; obese children were 1.8 times more likely than normal-weight children to report low self-esteem at 4 y. |
| Adult Obesity | Cumulative exposure to the risk factors for cardiovascular insults and the other components of the metabolic syndrome. | The Bogalusa Heart Study, a longitudinal analysis of children and later those same children as adults, helps demonstrate the risk of high BMI tracking into adulthood. Of the 26 children in 1 component of the study with BMI greater than the 99th percentile, 88% of those had an adult BMI of at least 35 kg/m 2 , and 65% had an adult BMI of at least 40 kg/m 2 . |
Parents in low-income neighborhoods with high crime rates may be reluctant to allow children to play outside of the home. Both parents may be required to work, or single parents may need to work long hours to make ends meet, limiting their ability to eat together with their children and supervise food choices. Families living in food deserts face limitations in access to healthy foods, relying heavily on small community grocery stores or bodegas, where healthy choices are few and prices are high. Fast food restaurants are more prevalent in these communities, with the price of unhealthy fast food meals much less than that of local fruits and vegetables. Also, parents living in poverty are more likely to choose calorie-rich foods high in fat and simple carbohydrates and low in nutritional value, which they may consider more filling and more likely to maintain their children’s satiety until the next meal can be obtained.
Pediatricians and other health care providers to children are faced with the daunting task of addressing this epidemic. They must identify those children and adolescents who are, or are at risk for becoming, overweight or obese, in addition to preventing the chronic illness of obesity in all children and adolescents and identifying those at increased risk. Primary care providers must accomplish this in the face of growing demands for relative value units, shrinking ancillary services and other support systems (such as social workers and nutritionists), decreasing or absent insurance reimbursement for obesity-related office visits, and unreasonably short time slots for patients.
This article has been written in an effort to provide necessary information and tools to health providers in dealing with the health crises of childhood overweight and obesity in the face of prevailing obstacles and limitations in medical practice. The pathophysiology, current theories, and trends in treatment, such as motivational interviewing, research, politics and policy, and specific needs for advocacy, are reviewed.
Introduction
According to the latest statistics from the Centers for Disease Control and Prevention, more than one-third (34.9% or 78.6 million) of US adults are obese, with an estimated annual medical cost of $147 billion in 2008. The prevalence of obesity in children increased 300% over approximately the past 40 years. The National Health and Nutrition Examination Survey, 2009 to 2010, found 32% of children, 2 to 19 years old, to be overweight or obese, with 17% in the obese range. Children’s risk varies significantly by race/ethnicity. In 2009 to 2010, 24% of non-Hispanic black, 21% of Hispanic, and greater than 20% of American Indian/Alaskan Native children and adolescents were obese compared with 14% of white children. For children and adolescents aged 2 to 19 years, the prevalence of obesity has remained fairly stable at approximately 17% and affects approximately 12.7 million children and adolescents for the past decade; however, the prevalence of severe obesity in children continues to rise.
Childhood overweight and obesity and their comorbidities threaten to prevent a significant portion of US children and adolescents from reaching their full potential and contributing to society on personal and community levels. Comorbidities of pediatric overweight and obesity are cardiovascular, endocrinologic, orthopedic, gastrointestinal, neurologic, pulmonary, and psychosocial ( Table 1 ). Children of underrepresented ethnic minority groups and those living at or below the poverty level are at increased risk. Communities of lower socioeconomic levels are burdened with obstacles concerning physical activity. Children of parents with lower education levels, who are more likely to live in low-income/high-crime neighborhoods, are at increased risk for overweight and obesity. School districts in these communities are less likely to have adequate funding to maintain physical education programs. Also, gym and recess are less likely to be supported during efforts to improve academic outcomes in failing schools.
| Cardiovascular |
| The overall prevalence of dyslipidemia in the pediatric population has been reported as 20.3%, whereas that in overweight children is reported to be 42.9%. The prevalence of clinically identified hypertension in United States children (estimates: prehypertension — 10%; hypertension — 3.7%) is directly correlated with increasing waist-circumference and BMI. In a study by Gidding et al, 48 children, 8–17 years old, with BMI of at least 40 kg/m 2 (obese by adult BMI measures) were studied using a graded stationary bicycle test. The subjects were noted to have deconditioning consistent with congestive heart failure. |
| Endocrinologic |
| The prevalence of metabolic syndrome among pediatric patients, according to a systematic review of population-based studies, is 3.3% in nonobese, 11.9% in overweight, and 29.2% of obese children. In another study, 50% of severely obese subjects had metabolic syndrome, whereas none of the normal-weight or overweight subjects did. Up to 25% of severely obese adolescents are noted to have impaired glucose tolerance. The prevalence of pediatric type 2 diabetes mellitus is increased with obesity (one US sample noted a prevalence of 0.24/1000), and increases with age. |
| Respiratory | Obstructive sleep apnea has been associated with childhood obesity. | Noted in 5.7%–36% of obese children and adolescents, this exceeds that noted in normal-weight children and adolescents, where the prevalence is estimated at 2%–3%. |
| Gastrointestinal |
| One study of adolescents with mean BMI of 59 kg/m 2 undergoing gastric bypass surgery noted liver involvement as follows :
|
| Musculoskeletal |
| More than 80% of the children diagnosed with slipped capital femoral epiphysis are reportedly obese (BMI greater than the 95th percentile). |
| Psychosocial |
| One study found that obesity in 10- and 11-year-old children independently predicted self-esteem 2 and 4 y later; obese children were 1.8 times more likely than normal-weight children to report low self-esteem at 4 y. |
| Adult Obesity | Cumulative exposure to the risk factors for cardiovascular insults and the other components of the metabolic syndrome. | The Bogalusa Heart Study, a longitudinal analysis of children and later those same children as adults, helps demonstrate the risk of high BMI tracking into adulthood. Of the 26 children in 1 component of the study with BMI greater than the 99th percentile, 88% of those had an adult BMI of at least 35 kg/m 2 , and 65% had an adult BMI of at least 40 kg/m 2 . |
Parents in low-income neighborhoods with high crime rates may be reluctant to allow children to play outside of the home. Both parents may be required to work, or single parents may need to work long hours to make ends meet, limiting their ability to eat together with their children and supervise food choices. Families living in food deserts face limitations in access to healthy foods, relying heavily on small community grocery stores or bodegas, where healthy choices are few and prices are high. Fast food restaurants are more prevalent in these communities, with the price of unhealthy fast food meals much less than that of local fruits and vegetables. Also, parents living in poverty are more likely to choose calorie-rich foods high in fat and simple carbohydrates and low in nutritional value, which they may consider more filling and more likely to maintain their children’s satiety until the next meal can be obtained.
Pediatricians and other health care providers to children are faced with the daunting task of addressing this epidemic. They must identify those children and adolescents who are, or are at risk for becoming, overweight or obese, in addition to preventing the chronic illness of obesity in all children and adolescents and identifying those at increased risk. Primary care providers must accomplish this in the face of growing demands for relative value units, shrinking ancillary services and other support systems (such as social workers and nutritionists), decreasing or absent insurance reimbursement for obesity-related office visits, and unreasonably short time slots for patients.
This article has been written in an effort to provide necessary information and tools to health providers in dealing with the health crises of childhood overweight and obesity in the face of prevailing obstacles and limitations in medical practice. The pathophysiology, current theories, and trends in treatment, such as motivational interviewing, research, politics and policy, and specific needs for advocacy, are reviewed.
Overview
Obesity and its major comorbidities have become a major global health challenge affecting children and adolescents of all ages. The hope of ending its affects is through early identification and management, which are facilitated by the recognition of risk factors.
In addition to the socioeconomic factors discussed previously, epidemiologic and animal studies suggest potential links between intrauterine and postnatal factors and childhood obesity. Among these are the following.
Intrauterine
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Maternal diabetes mellitus (gestational or type 1)
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Maternal hypertension
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Maternal gestational weight gain
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Fetal growth (small for gestational age and large for gestational age)
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Fetal exposure to tobacco and cocaine
Postnatal
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Early introduction of solid foods (before age 4 months)
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Delayed weaning from bottles
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Breastfeeding less than 6 months
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Low strength of maternal-child relationship
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Increased screen time
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Parental obesity
Parental and family history of obesity may be linked to childhood obesity through genetic as well as environmental variables. Evidence for a significant role of gene-environment interactions has been demonstrated, where a genetic profile influences the ability to deal with the obesogenic impact of some environmental factors. Children with obese parents and family members are likely to share similar patterns of diet, screen time, and physical activity and to be influenced by perspectives and attitudes concerning diet and activity that lead to overweight and obesity.
Studies have also suggested a link between changes of the microbiome (bacteria in the gut, which influence the processing of nutrients as well as immune and inflammatory responses) and the development of childhood obesity. Changes of this microbiome caused by perinatal antibiotic exposure seem to program the host to an obesity-prone metabolic phenotype, which persists even after the discontinuance of antibiotics and the recovery of the native gut flora. These changes may also be induced by the method of delivery (vaginal vs cesarean section) and antibiotic use during the first 2 years after birth.
Definition and Identification
Obesity is most purely defined as excess fat. The manner in which a clinician identifies obesity usually relies on anthropometric measurements, such as height and weight. Other methods, such as underwater weighing (densitometry), multifrequency bioelectrical impedance analysis, and MRI used in research studies, are not practical in an office-based setting, where methods, such as body mass index (BMI) and measurements of skinfold thickness and waist circumference are almost exclusively used.
BMI is calculated using the weight in kilograms divided by height in meters squared and can be reliably used in children over 2 years of age. The normal standards of BMI for children and adolescents vary by age and gender and must be plotted on growth curves. A BMI between the 85th and 95th percentiles defines overweight. A BMI above the 95th percentile defines obesity.
BMI does not distinguish between excess fat, muscle mass, or bone density nor can it be used to define severe obesity, which is defined as a calculated BMI greater than 99th percentile (the 2000 Centers for Disease Control and Prevention growth charts are unable to accurately define and display BMI percentiles beyond the 97th percentile). Although BMI does have its limitations and does not directly measure an individual’s body fat, it can be correlated with body fat and is useful and practical as a diagnostic measure in identifying children and adolescents at increased risk of adult-onset obesity.
As a clinician, it is important to recognize the social stigma of overweight and obesity. The term, fat , can be associated with concepts of laziness, unattractiveness, and even stupidity. It cannot be stressed enough that care must be taken in the disclosure of these diagnoses to patients and parents. Patients and families may be sensitive to this personal diagnosis and may feel emotions of embarrassment, shame, hopelessness, or even depression by the diagnosis and development of its comorbidities. Some patients and families may even feel judged by their primary provider and team. In addition, providers must be aware that patients and families of different cultures may hold different values regarding weight and body image, which must be taken into account. During these discussions, care must be taken to ascertain patients’ and families’ explanatory models regarding the diagnosis of overweight or obesity. The explanatory model includes not only the concept of the disease but also the expectations regarding management and outcomes. If differences between the explanatory models of the clinician and the patient/family are not discovered and addressed early on in the therapeutic relationship, the clinical outcome is likely to be poor. Cultural humility must always be the basis of any clinical encounter, because all clinical encounters with patients and families are cross-cultural.
To give a global perspective of the obesity epidemic, more than 50% of the 671 million obese individuals in the world live in 10 countries. As of 2013, the United States of America accounted for 13% of obese people worldwide, with China and India together accounting for 15%. No single country has had any recent significant decline in the rate of obesity.
As discussed previously, in the United States, approximately 17% of children 2 to 19 years old are obese. That amounts to approximately 12.7 million obese children and adolescents. Aside from the ethnic distinctions, prevalence of overweight and obesity in female children and adolescents was directly correlated with the education level of the adult head of the household. Similar findings were not noted in male children.
Multiple studies have shown that vulnerable populations do benefit from public health initiatives to reduce the rate of rise in the obesity epidemic, suggesting this epidemic is controllable with efforts starting with early identification and prevention.
Obesity is a major cause of preventable diseases, such as diabetes, hypertension, cardiovascular disease, sleep apnea, osteoarthritis, cancer, gallbladder disease, and mental health issues. Many of these comorbidities are becoming more prevalent in childhood, particularly among those children in the severe obesity category, who make up 4% to 6% of all youth in the United States.
Assessment
In 2007 an American Academy of Pediatrics Expert Committee developed recommendations for the assessment of child and adolescent overweight and obesity. The latest update of these recommendations was published in October of 2015 ( Box 1 ).
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