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- v.3(1); 2012 Jan
Childhood Obesity: A Global Public Health Crisis
Masters of Public Health Program, American Public University, East Stroudsburg, PA, USA
1 Department of Health Studies, East Stroudsburg University of Pennsylvania, East Stroudsburg, PA, USA
Childhood obesity is a major public health crisis nationally and internationally. The prevalence of childhood obesity has increased over few years. It is caused by imbalance between calorie intake and calories utilized. One or more factors (genetic, behavioral, and environmental) cause obesity in children. Physical, psychological, and social health problems are caused due to childhood obesity. Hence, effective intervention strategies are being used to prevent and control obesity in children. The purpose of this manuscript is to address various factors influencing childhood obesity, a variety of interventions and governmental actions addressing obesity and the challenges ahead for managing this epidemic.
In order to collect materials for this review a detailed search of CINAHL, MEDLINE, ERIC, Academic Search Premier databases was carried out for the time period 1999-2011.
Some of the interventions used were family based, school based, community based, play based, and hospital based. The effective school-based interventions were seen targeting physical activity along with healthy diet education. The major challenges faced by these intervention programs are financial, along with stigmatization of obese children. Governments along with other health care organizations are taking effective actions like policy changing and environmentally safe interventions for children to improve physical activity.
In conclusion, childhood obesity can be tackled at the population level by education, prevention and sustainable interventions related to healthy nutrition practices and physical activity promotion.
Obesity is a major public health crisis among children and adults.[ 1 , 2 ] The range of weights for individuals if greater than the ideal weight, which is considered healthy for the particular height, is termed as either overweight or obese. Childhood-related obesity is an increasing concern with respect to the health and well-being of the child. Body mass index (BMI), a measure of weight with relation to height, is not only used as an outcome measure to determine obesity but also as a useful anthropometric index for cardiovascular risk.[ 3 ] For children between 2 and 19 years, BMI is plotted on the CDC growth chart to check for the corresponding age and sex related percentile. Childhood obesity is defined as a BMI at or above 95 th percentile for children of same age and sex.[ 4 ] Classifications of obesity in children depend upon the body composition of the child, as it varies with respect to age and sex of the child.[ 4 ]
MAGNITUDE OF THE PROBLEM
The prevalence of childhood obesity is increasing in developed and underdeveloped countries.[ 5 ] The development in reducing the problem of obesity and overweight is monitored nationally by using data from National Health and Nutrition Examination Survey. The report presented by NHANES for the year 2007-2008 estimated that 16.9% of children and adolescent in the age group of 2-19 years were obese.[ 6 ] Childhood obesity prevalence among preschool children between age group of 2-5-year-old girls and boys has increased from 5.0 to 10% between 1976-1980 and 2007-2008 and it has increased from 6.5 to 19.6% among age group of 6-11 year olds.[ 6 ] The data collected for the same period shows that the adolescent (age group 12-19 years) obesity has increased from 5.0 to 18.1% [ Figure 1 , Table 1 ].[ 6 ]
Graphically shows the increasing trend of obesity among children and adolescent population from 1963 to 2008. Source: CDC/NCHS, National Health Examination Surveys 11 (ages 6-11), 111 (ages 12-17), and National Health and Nutrition Examination Surveys (NHANES) 1-111 and NHANES 1999-2000, 2001-2002, 2003-2004, 2005-2006, and 2007-2008[ 6 ]
Prevalence of obesity among US children and adolescents aged 2-19, for selected years 1963-1965 through 2007-2008[ 6 ]
Healthy people 2010 have ranked obesity as number one health problem showing that prevalence of childhood obesity has increased over the years.[ 7 ] Increased prevalence of childhood obesity may have adverse morbidity and mortality implications in the adult life of the child.[ 8 ] Childhood obesity concern has increased worldwide. There has been increased prevalence of childhood obesity in England, especially among school children over last few decades.[ 9 ] Childhood obesity is common in United Kingdom and according to the health survey conducted in 2004, obesity among 2-10-year olds was 14% and among 11-15-year olds was 15%.[ 5 ]
A Boolean search strategy where the key words entered for search were “factors” and “childhood obesity” “interventions” and “governmental actions” and “economic problems” in differing orders were used to extract studies for this narrative review.
FACTORS INFLUENCING CHILDHOOD OBESITY
Childhood obesity is due to the imbalance between caloric intake of the child and the calories utilized (for growth, development, metabolism, and physical activities). Normally the amount of calories a child consumes through food or beverages, if not used for energy activities, leads to obesity.[ 10 ] Factors causing childhood obesity are genetic, behavioral, and environmental. Obesity can be multifactorial in children.
There are certain genetic factors which may lead to obesity in children. These genetic factors increase the child's susceptibility for obesity.[ 10 ] Genetic factors may influence the metabolism, by changing the body fat content and energy intake and energy expenditure. Heritability of obesity from parents also influences obesity in children.[ 11 ]
There are some behavioral factors which can cause obesity. Sometimes children eat more or consume more energy via food and beverages which are not utilized appropriately.[ 10 ] Children may eat large portions of food, foods high in sugar, and energy-rich foods. Hence, energy intake is higher than energy expenditure. So this may lead to weight gain in children.[ 10 ]
Lack of physical activity also plays an important role in obesity. Energy gained should be properly balanced by energy expenditure. It is seen that children and teens nowadays lack the required amount of physical activity; hence the calories are not used properly and can lead to obesity.[ 10 ] In a recently conducted mixed-methods study conducted in Iran, lack of safe and easy – access place for physical activity and unsupportive family were the main barriers to physical activity among adolescents.[ 12 ]
It is seen that sedentary lifestyle is an important factor for obesity, as many children spend most of their time in front of television sets, play video games, and watch computers. Children snack more in front of television and spent most of their time sitting without any physical activity.[ 10 ] All these behavioral factors are in a vicious circle with one leading to another. Children are prone to sedentary lifestyle such as watching television, consuming more energy-dense foods or snacks with large portion sizes, and having reduced physical activity, giving rise to obesity. The television advertisements of energy-rich and sugar-rich foods influence children to make unhealthy choices. These unhealthy food choices may lead to weight gain and obesity.[ 10 ]
Environmental factors are those that surround the children and influence their food intake and physical activity.[ 10 ] These factors are seen in various settings such as at home, in school, and in the community. At home, the parent-child interaction is very crucial as parents can influence children food choices and motivate them to have a healthy lifestyle. Children spend most of their time at school, so school can promote healthy food choices and physical activity among them.[ 10 ] Community's lack of accessibility and affordability of healthy food can affect the nutrition of these children. Their lack of physical activity may be because of lack of facilities like safe side walks, bike paths, and safe parks.[ 10 ]
CONSEQUENCES OF CHILDHOOD OBESITY
Much health-related problems are associated with obesity in children. Childhood obesity also leads to health risks in adulthood. Health problems related to obesity are not only physical but psychological and social as well.[ 13 ]
PSYCHOLOGICAL AND SOCIAL HEALTH ISSUES
Children who are obese have a negative body-image, which leads to lower self-esteem. Children feel depressed and are nervous about their obesity issue and this has a negative effect on their behavior. This may also reflect negatively on their academic and social progress. They feel socially discriminated and stigmatized by their peers and adults.[ 13 , 14 ]
OTHER HEALTH RISKS
Obese children have high risk of cardiovascular diseases, high blood pressure, and increased cholesterol levels.[ 13 ] Childhood obesity increases the risk of having insulin resistant type 2 diabetes.[ 14 ] Children may have high risk of having respiratory problems like asthma as well. Obesity causes shortness of breath and sleep apnea. The physical effects may also reflect on musculoskeletal system causing discomfort due to increased weight on joint, causing muscle and bone disorder.[ 14 ] Obesity may affect liver causing fatty degeneration of liver.[ 13 ]
Childhood obesity is a major public health issue. The complications caused due to childhood obesity are severe and could continue to affect the health of a child even in adulthood.[ 13 ] Hence, there is need to address this problem at every possible step through effective interventions and motivation strategies.
FAMILY-BASED LIFESTYLE INTERVENTIONS
Family bonding is a strong structure in the behavioral molding of the child. Parents and siblings are the people around the child who can influence child behavior and lifestyle.[ 15 ] Hence, effective interventions in a family setting can be beneficial to change child's behavior of overeating and unhealthy choice of food. Physical activity can be improved by small strategies like parking cars away from stores so that kids can walk and to take stairs instead of elevators or escalators. It is essential that parents are aware of the potential risk the child is facing due to obesity and take actions to control the problem. Effective measures to prevent obesity in future can be promoted by these interventions.[ 14 ] These weight-control interventions can be achieved and sustained by providing good support and a variety of strategies to parents.[ 16 ]
Children spend most of their time in schools. Hence, school plays an important role in the life of the child. There are many school-based intervention strategies. Some interventions focus on nutrition-based or physical-based aspect of weight-control independently, while others jointly focus on both aspects of nutrition and physical activity to achieve the aim of weight control in children.[ 17 ] Children take at least one meal at school. Hence, schools can encourage kids to make a healthy food choice like reducing the intake of carbonated drinks or sugary foods, encourage kids to drink healthy fruit juices, water, vegetables, and fruits. Schools which provide meals can have healthy nutritious food items with emphasis on a balanced diet.[ 18 ] Schools can involve kids in physical activity by strategies like lengthening the time of physical activity; involving them in moderate to vigorous physical activity for short durations, encouraging them to walk or active commuting, and taking stairs instead of elevators. Kids should be encouraged to participate in various physical activities like games and dance groups with more emphasis on non-competitiveness. Some school-based programs along with the help of community members can help to promote physical education skills and healthy nutrition among children, with focus on implementing this education for maintaining long-term healthy behavior. Classroom-based health education can make older children and teens aware of eating nutritious diet and engaging in regular physical activity.[ 17 ]
Community plays a crucial role in healthy lifestyle of children. The term ‘community’ includes the environment around children along with other factors like geographic location, race, ethnicity, and socioeconomic status.[ 19 ] This resource can be effectively used to promote healthy nutrition and healthy behavior. Community support is invaluable in implementing interventions and organizing social events like healthy food festivals, harvest festivals, imparting healthy messages, and educating and encouraging people to adopt healthy lifestyle. Thus, community can help children to get affordable and accessible healthy food options and encourage healthy nutrition.[ 19 ] Community organizations along with parents can promote nutrition and physical activity-based programs for children, eg., walk to school. Community can make the neighborhood safe and accessible to children and motivate them to increase physical activity.[ 20 ] Other programs like providing play groups with safe play grounds and bike paths for kids to play outside will reduce their time spent in front of television sets. Community can provide children with easy accessible facilities like gymnasiums and supervised physical education with strategies such as music for physical activities. Community can influence media or local entertainment to promote healthy educational programs for parents and children. Hence, making them aware of healthy intervention programs via the community is important to reduce childhood obesity.[ 20 ]
Instead of just advising children what to eat they can appreciate nutrition-related education in a better way when it comes to them via fun activities like playing games. Some countries are using board games for children to make them understand about balanced diet and thus leading to knowledge gain.[ 17 ] Interactive multimedia can be used for interventions. Interactive multimedia like CD ROM can promote healthy nutrition in children with the help of virtual educational games. When these games are used in real-life situations children can make healthy food choices. They can promote decision making and self-esteem for healthy eating behavior. Thus, these programs can help and motivate children to make healthy food choices and also understand the benefits of making such choices.[ 17 ] These innovative interventions can encourage children to lead a healthy life.
CHILDHOOD-OBESITY PREVENTION INTERVENTIONS
Preventive programs are conducted to control obesity in children and to modify the social and behavioral aspect of developing obesity. Some of the preventive programs revolve around educating the general population about healthy nutrition and providing information about health problems caused due to childhood obesity.[ 15 ] Health care professionals can advise their patients, especially parents, about healthy child nutrition, tackling health problems due to childhood obesity, and benefits of breast feeding among newborn children to prevent weight gain.[ 21 ] Federal or state actions to deal with childhood obesity are directing all the food vendors to provide exact calorie readable labels on their products, mentioning calories upfront on menus, restricting advertisements of unhealthy foods, and promoting healthy food making among parents. Some of the other actions are to improve transportation facility for people and children, like providing bike paths, making sidewalks, and providing safe and clean surrounding for children to walk and play eg. no-car roads.[ 15 ]
Laboratory investigations of children who are obese and at risk of complications are important. Children aged 7 years and younger with no secondary complications of obesity are advised weight management.[ 8 ] Weight-loss programs like dietary management (eating more of fiber-rich foods) and increasing physical activity are recommended for children above 7 years of age with risk of secondary complications. Pharmacological therapy for children with obesity above the age of 12 years can include drugs like orlistat (which blocks fat from the intestine thus giving negative energy balance).[ 8 ] Medical professionals are considering the benefits of bariatric surgery in extremely obese children to avoid complications of obesity in adulthood.[ 22 ]
There may be some potential barriers to these interventions, which may make the task of promoting healthy behavior and improving physical activity in children challenging. Some of these challenges are:
Financial investment in these interventions is very crucial. All the intervention-based programs need monitoring of progress and sustainability over many years, which may be costly. In today's world of economic problems funding for such programs is limited.[ 17 ] School-based intervention programs require much effort on budgeting and planning, as the cost of educating the teachers about the program, and providing facilities and infrastructure to conduct physical activities is enormous and prohibitive.[ 17 ] Communities also find it challenging to make the neighborhood safe for children to play, to organize events, and to provide adequate facilities.
STIGMATIZATION OF OBESE CHILDREN
Obese children are mostly discriminated due to their body image. This may lead to a potential challenge for these children to come forward and opt for healthy programs. Stigmatization of these children by their peers and by others acts as a mental barrier leading to negative body image and fear of food.[ 17 ]
Literature reviews of school-based interventions conducted in the past have shown mixed outcomes. According to a recent review about school-based interventions for obesity prevention, 17 out of 25 intervention studies were effective in reducing the body mass index.[ 23 ] Some interventions targeting physical activity through physical education along with nutritional education worked in reducing obesity. Interventions targeting physical activity education and television viewing were seen to be successful in this review study.[ 23 ] While another review addressed school-based interventions by conducting a meta-analysis, concluding that body mass index may not be a good outcome measure among school kids.[ 24 ]
US GOVERNMENTAL STRATEGIES TO REDUCE CHILDHOOD OBESITY
According to the Centers for Disease Control and Prevention, identifying effective intervention strategies that can target both improvements in physical activity and providing nutritious diet to reduce childhood obesity are important. These evidence-based programs can be effective in managing obesity in children.[ 21 ] Interventions encouraging mothers to breastfeed their babies can be effective in reducing the risk of obesity in children.[ 21 ] The United States government is changing the health policies involving transportation, land use, education, agriculture, and economics so that it can have an important impact on healthy environment and health of people in turn reducing obesity.[ 21 ] The United States government, along with other health organizations, is developing healthy environments like improving population access to healthy and fresh foods, building walk paths, bike paths, and playgrounds in underserved communities. State governments with the assistance of different health organizations are also getting involved in promoting healthy lifestyles for people. The First Lady has also initiated an obesity prevention and control program titled ‘Let's move’.[ 21 ]
Childhood obesity is a major public health problem. Hence, implementation of the available effective intervention programs is essential. Important data regarding evaluation of childhood obesity prevention schemes can be collected and can be used to make stronger and more effective strategies including policy building to reduce future childhood obesity rates.[ 25 ]
Childhood obesity has become a public health crisis, not just in the United States but all over the world. Childhood obesity problem can be reduced by educating children and parents about healthy nutrition and encouraging them to be physically active. There are effective interventions and government policies for prevention and control of childhood obesity. Sustainability of these interventions is a key factor, so that children can adopt these healthy behaviors as a lifelong practice and have a healthy life. This will lead to a nationwide healthy future for the kids.
Source of Support: Nil
Conflict of Interest: None declared.
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Early Childhood Obesity Prevention Policies (2011)
Chapter: 1 introduction.
The topic of this report was recommended by the Institute of Medicine’s (IOM’s) Standing Committee on Childhood Obesity Prevention. The report grew out of a recognition that early childhood has emerged as a critical period for assessing the beginnings of obesity and instituting preventive measures. Given the evidence linking excessive weight gain in the first years of life to obesity and chronic disease in later years, the Standing Committee believed it was important to bring this issue to the attention of decision makers who influence children’s early years and to recommend policies that can advance obesity prevention for young children. The Standing Committee recognized that prevention strategies focused on this early period, when intervention can affect rapidly developing metabolic and behavioral systems, have the potential to alter the risk for obesity and chronic disease in childhood and throughout the life span. The Standing Committee believed that addressing early childhood obesity offers an important pathway to reversing the childhood obesity epidemic and that, while much research and policy effort had focused on obesity prevention for school-age children and teens, there was a paucity of consistent and authoritative guidance on obesity prevention policy and practice for young children.
Accordingly, the IOM convened the Committee on Obesity Prevention Policies for Young Children. The committee was charged with reviewing the factors related to overweight and obesity in infants, toddlers, and preschool children (from birth to 5 years of age), with a focus on nutrition and physical activity and sedentary behavior, and with making recommendations for early childhood obesity
Box 1-1 Statement of Task
An ad hoc committee will review factors related to overweight and obesity in infants, toddlers, and preschool children (birth to 5 years), with a focus on nutrition, physical activity, and sedentary behavior; identify gaps in knowledge; and make recommendations on early childhood obesity prevention policies, taking into account the differences between children birth to 2 years old and 2 to 5 years old.
In conducting its task, this committee will:
- — major factors affecting obesity risk in young children, including the relationship with caregivers, physical activity opportunities and barriers, access to healthy foods, social determinants, and other important factors;
- — major factors in the first 5 years that affect attitudes, preferences, and behaviors important to overweight and obesity; and
- — relationships between elevated weight status and excess weight gain in young children and their health and well-being during childhood and risk for obesity-related comorbidities, across the life course.
- Identify settings, existing programs, and policy opportunities for childhood obesity prevention efforts in the first 5 years;
- Consider the inclusion of illustrative case studies; and
- Make recommendations on early childhood obesity prevention policies across a range of settings and types of programs, taking into account potential distinctions between policy recommendations for the first 2 years (birth to 2 years) and those developed for the next 3 years (2 to 5 years).
The primary audience of the report includes decision makers and stakeholders who have the opportunity to influence the environments in which young children develop and grow.
prevention policies. The focus of the study was on settings, existing programs, and policy opportunities for childhood obesity prevention in the first 5 years of life and on the development of recommendations across a range of settings and types of programs. The primary audience for the report is policy makers and stakeholders who have opportunities to influence the environments in which young children develop and grow. 1 The committee’s statement of task is presented in Box 1-1 .
1 In this report, the term “young children” refers to ages birth to 5 years.
OBESITY IN EARLY CHILDHOOD
Obesity takes time to develop and for symptoms to appear. Therefore, children may be at risk for childhood obesity at a very young age but not yet defined clinically as overweight or obese. When children begin to show, for example, excess weight-for-height, this should not be dismissed as something “the child will grow out of with time.” The first years of life are critically important to a child’s health, well-being, and development. Excess weight at a young age can hinder movement and normal levels of activity and ultimately compromise later health and development.
The data reveal that the problem of obesity in infancy and early childhood is pervasive and growing. Approximately 10 percent of children under age 2 years have high weight-for-length (at or above the 95th percentile) (Ogden et al., 2010). The problem persists among children over age 2. Fully 21 percent of children aged 2–5 are overweight or obese, and the proportions of overweight and obese children in this age group have doubled in 30 years (Ogden et al., 2008, 2010). These statistics are of particular concern because rapid weight gain and obesity during the first years of life increase the risk for later obesity (Freedman et al., 2005; Goodell et al., 2009; Ong et al., 2009; Stettler et al., 2003).
The prevalence of overweight and obesity has increased significantly over the past 25 years among all ethnic groups, but is higher in some groups than in others. Variations in the prevalence of overweight among different ethnic groups in the United States are measured regularly in the National Health and Nutrition Examination Survey (NHANES). The Centers for Disease Control and Prevention (CDC) has published the most recent national survey data, showing that Hispanic males and African American females have a higher prevalence of obesity than other groups, particularly in the teenage years (CDC, 2011) (see Figure 1-1 ).
Although school-based prevention is critical, it is not where awareness and action on childhood obesity should begin. The childhood obesity epidemic requires a sense of urgency and new avenues for prevention focused on the first 5 years of life. The first years of life are characterized by rapid growth and developmental change. The newborn’s behavioral repertoire is limited to sleeping, feeding, crying, and a few reflexes, but over the next months and years, development proceeds rapidly. In these early years, children will learn to sleep through the night, drink from a cup, walk, and talk; in many cases, they also will learn to drink sugar-sweetened beverages (Fox et al., 2010; Siega-Riz et al., 2010) instead of milk or water, dislike and reject vegetables (except french fries), and watch too much
FIGURE 1-1 Prevalence of obesity among children and adolescents, by sex, age group, and race/ethnicity—United States, 2007–2008. SOURCE: CDC, 2011.
television. By the time they reach ages 6 to 11, 35 percent will have become overweight or obese (Ogden et al., 2010).
Development is more rapid during these early years than at any other time after birth, and young children’s early experiences are “built into their bodies,” affecting neural, metabolic, and behavioral systems in ways that can influence obesity risk, health, and well-being throughout the life span (Birch and Anzman, 2010; Gluckman et al., 2008; NRC and IOM, 2000). Evidence now emerging reveals the potential of this early period for obesity prevention. In contrast to later stages of life, early development is a period when it is not necessary to change established dietary and activity patterns, but to promote the development of healthy patterns. Despite the critical role of early learning and development in shaping obesity risk, infancy and early childhood have not been a focus of obesity prevention efforts. Yet precisely because this early period is one of rapid development, it may afford the best opportunities for altering development in ways that can reduce obesity risk. It is during such periods of rapid change and instability that interventions can alter developmental pathways, and these alterations can
have long-term effects on the risk for obesity and related chronic disease decades later, in adulthood.
Unfortunately, many children learn lifestyles during the first years of life that contribute to excessive weight gain, the risk of obesity, and chronic disease later in life. Early in life, as children are being introduced to the adult diet, it is especially important that they have opportunities to learn to like and eat healthy foods. Recent survey data indicate that even the nation’s youngest children are consuming diets that are too high in energy and added sugar, fat, and salt and that include too few fruits, vegetables, and complex carbohydrates (Reedy and Krebs-Smith, 2010). With respect to activity patterns, many young children are developing lifestyles that include too much screen time, too little sleep, and too little active play (Christakis and Garrison, 2009; Iglowstein et al., 2003; NASPE, 2009; Perrin et al., 2007).
Children learn lifestyles from the adults who care for them. These adults have a powerful impact on children’s developing patterns of eating and activity; they structure their children’s environments through the choices they make, both within the family and through the child care arrangements they select for out-of-home care. These environments can differ in opportunities they provide for activity, for television viewing, and for the consumption of some foods and not others. In addition, adult caregivers serve as models for children’s developing eating and activity patterns. Infants and young children are dependent on their caregivers as well to create safe environments that can promote the development of healthy lifestyles.
Differences in caregivers’ responsiveness also affect children’s development. During the first years of life, both child and caregiver must learn to recognize and respond to the other’s cues. Responsive caregiving has been identified as an effective tool that can foster children’s social, emotional, cognitive, and physical growth, health, and development (Black and Aboud, 2011; Eshel et al., 2006). To be a responsive caregiver requires understanding infants’ and children’s early physical, cognitive, social, and motor development. Responsiveness is characterized by reciprocity between child and caregiver and includes promptly identifying the child’s needs and responding contingently and in ways that are appropriate to the child’s level of development. To be responsive to the child during periods of rapid development in early childhood, caregivers’ responses must change as children are developing new behaviors and abilities. For example, offering a young infant breast milk or formula in response to hunger cues is appropriate, but offering pureed foods before about 6 months of age is not (AAP, 2005). For this reason,
the recommendations and potential implementing actions presented in Chapters 3 through 6 addressing children’s eating, physical activity, media exposure, and sleep, respectively, differ according to the child’s age and developmental level.
PURPOSE AND SCOPE OF THE REPORT
Childhood obesity prevention begins with the patterns and behaviors of those who care for infants and young children and in the environments where children grow and develop in their first years of life. A number of key factors influence the weight of an infant or young child, including prenatal influences, eating patterns, environments, physical activity levels, sleep patterns, food and beverage marketing, and screen time. All of these factors come into play in the policy environment that shapes the places where children spend their time and must be addressed in a coordinated manner if progress is to be made against the early onset of childhood obesity.
A wide range of institutions and settings influences young children’s behaviors. The purpose of this report is to provide practical guidance for two primary audiences. The first is those who work with young children in settings where they spend their time outside the home. These comprise child care providers and early childhood educators, as well as others whose direct and indirect messages ultimately shape parents’ 2 knowledge about health and obesity, including health care providers and those who work in home visiting programs such as the Special Supplemental Nutrition Program for Women, Children and Infants (WIC) and the U.S. Department of Agriculture’s (USDA’s) Cooperative Extension programs. Policies and practices developed by the institutions, programs, and professional organizations with which these individuals are affiliated influence the content and frequency of their communications with parents on a number of issues related to children’s daily routines, including eating patterns, physical activity, and sleep. The second audience for the report is those who make and implement policies that directly affect children from birth to age 5.
Parents play the primary role in shaping children’s development. However, the focus of this report is on policies that are developed and implemented by policy makers and by caregivers who interact with parents and young children. The report does not make recommendations directly to parents, but rather urges these “intermediaries” to ensure that policies are implemented in a way that comple-
2 For purposes of this report, the term “parents” refers to those who have primary responsibility for a child’s welfare in the home.
ments and supports parents’ efforts to maintain healthy weight in their young children. In this model, parents are not “counseled”; rather, they are provided education, knowledge, and awareness. Caregivers and policy makers act as helpful partners in the endeavor to maintain healthy weight in young children.
It is important to remember that the role of intermediary requires what is often called “cultural competency,” or the ability to work in cross-cultural situations. Culturally competent people can act sensitively and effectively in the context of beliefs, actions, and needs of a community different from their own. On its minority health website, the Department of Health and Human Services (HHS) defines culturally competent health care services as those that are “respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients” and suggests that these types of services “can help bring about positive health outcomes” (HHS, 2011). If these beliefs, practices, and needs are not understood, or are ignored, the success of efforts to partner with parents in childhood obesity prevention will be compromised.
Parents also can play an important role beyond the direct role they play at home with their children. Working with other parents, for example, they can influence their children’s child care food environment for the better, support child care staff in making healthy changes in foods and beverages provided in young children’s educational settings, or join with their neighbors to direct local government attention to a neglected or unsafe neighborhood park.
This report briefly addresses the food and physical activity environments of the larger community in which children and families reside. However, its focus is on policy makers and caregivers of young children and their important roles in interacting with children and parents, as well as in helping to create environments and local and national policies specific to young children that can increase their chances of maintaining a healthy weight. A previous IOM publication, Local Government Actions to Prevent Childhood Obesity (IOM and NRC, 2009), addresses issues related to the food and physical activity environments of the broader community for all children and families in much greater detail. That report focuses on improving access to and consumption of healthy, safe, and affordable foods through changes in retail outlets, restaurants, community outlets, public programs, and worksites and encouraging physical activity through improvements in the built environment, initiation of programs for walking and biking, and promotion of increased recreational and routine physical activity.
Access to healthy, safe, and affordable food also is influenced by major food manufacturing decisions, as well as strategic choices made by food retailers and
restaurant industry leaders. In addition, agriculture policy and decisions made by farmers can make a difference in food availability. These decisions, processes, and policies influence the diets of all Americans to a greater or lesser extent. However, this report focuses on obesity prevention policies that are unique to children from birth to age 5 and that can be implemented through the assistance and involvement of caregivers and policy makers.
In addition, it should be noted that, although this report does not focus on pregnancy and prepregnancy, the committee decided to devote a significant portion of Chapter 2 to prenatal influences because what happens in utero may predispose young children to metabolic imbalances that lead them to gain excess weight as they grow and develop. In that chapter, the committee reaffirms prior IOM recommendations regarding healthy weight prepregnancy and healthy weight gain during pregnancy as important factors in the prevention of early childhood obesity. That chapter also comments on the need for further research in the area of prepregnancy and other influences on early childhood weight.
Finally, there is growing interest in the potential role of exogenous agents—including chemical pollutants, drugs, and microorganisms—that may disturb metabolism in a manner that promotes obesity in young children. These agents generally are thought to be potentially influential through prenatal exposure, but could also be associated with exposures in early childhood. These emerging issues in early childhood obesity prevention are covered briefly in Appendix B .
The committee’s approach to this study encompassed gathering and assessing the evidence, formulating recommendations, and exploring child care standards.
Gathering and Assessing the Evidence
The formulation of policy recommendations calls for careful consideration of the evidence associated with one course of action or another. The committee carefully considered both direct and indirect evidence regarding the likely impact of a given policy on reducing childhood obesity, as well as evidence pertaining to the potential for unintended adverse effects. The committee did not carry out a comprehensive, systematic evidence review on each important policy-related question. However, its expertise and consideration of the most pertinent studies led to recommendations that are consistent with the evidence base. Evidence on obesity prevention for young children is limited, especially for those under 2 years of age. There are multiple reasons for this lack of data. First, it is difficult and expensive
to design studies that satisfy Institutional Review Board criteria for conducting research with young children and infants. Second, both federal and private funding for research has targeted primarily school-age children. Third, most policy and environmental interventions are expensive and time-consuming, while impact is often difficult to observe in a short time period, which is the norm for many research studies. Fourth, younger children are more difficult to reach and include in primary data studies than older children. Finally, childhood obesity prevention is a relatively new area for research funding, particularly research focused on policy.
Despite the scarcity of data, the urgency of the issue of obesity in young children demands that action be taken now with the best available evidence. As noted in a previous IOM report, obesity prevention actions “should be based on the best available evidence—as opposed to waiting for the best possible evidence” (IOM, 2005, p. 3). Therefore, in addition to reviewing the published literature, the committee examined reports from organizations that work with young children; invited presentations from experts on a range of scientific, programmatic, and policy issues related to children from birth to age 5; and explored a variety of materials that have been developed for programs and practitioners.
Experimental studies testing the impact of childhood obesity prevention policies are rare. The committee gave strong observational studies serious consideration and was also receptive to evidence that a policy would be likely to affect a determinant of childhood obesity even if not studied for its direct influence on obesity. Thus, for example, policy changes that are expected to increase physical activity or promote more healthy eating in children are recommended because such intermediate outcomes are themselves associated with prevention of childhood obesity.
In reviewing the available literature, the committee drew on the extensive experience and expertise of its members. The committee’s 15 members brought to bear a broad array of knowledge and experience related to young children in the areas of
- child development,
- obesity prevention,
- child health,
- infant development,
- physical activity,
- child psychology and behavior,
- child care regulations and policy,
- food marketing and media,
- health disparities,
- family health,
- federal and state child programs, and
- community health.
In areas in which the committee identified a need for additional information, outside experts were called upon at a public workshop held on June 2, 2010, in Washington, DC, titled “Emerging Issues, Programs, and Policy Needs in Early Childhood Obesity Prevention.” These experts specialized in the areas of
- injury prevention,
- motor development,
- electronic media,
- introduction of solids and complementary feeding,
- WIC and Head Start, and
- child care practices and policy.
Appendix A provides greater detail on the study methods, while Appendix E contains the workshop agenda.
For young children, actions that promote healthy development often also support obesity prevention. In formulating its recommendations, therefore, the committee considered policies that would promote young children’s health, with a focus on the key factors linked to obesity in early childhood, such as eating patterns, physical activity levels, television viewing, marketing, and sleep. The committee formulated policy recommendations and also identified potential actions that could be taken to implement those recommendations. These actions lie within the jurisdiction of relevant decision makers, were determined to be actionable based on a combination of precedent and committee members’ judgment, and have the potential to make a positive contribution to the implementation of the recommendations.
To implement the committee’s recommendations, health and child care providers often will need education and training, implementation tools they obtain from others or create, and limited or extensive technical assistance. Identifying specific tools was beyond the scope of this study, but each chapter does contain training recommendations for different audiences that are relevant to the topic at hand. Training can take a number of forms: in-service training and continuing education provided on the job, training that is part of college and associate degree programs, clinical training in health care providers’ degree programs, and certification programs (which also require continuing education) offered by national professional organizations.
All young children share the need for healthy food, optimum physical activity, sufficient sleep, health care providers who monitor their growth for healthy patterns and who advise and assist their parents in following through, and protection from the negative influences of too much sedentary behavior and the marketing of unhealthy foods and beverages to children. Nonetheless, in developing obesity prevention recommendations and implementation strategies that will be effective for young children and their families, the committee recognized the importance of negative social and economic factors in some communities that can act as barriers to a recommendation’s success.
It is widely recognized that many low-income neighborhoods have limited access to healthy foods because of a lack of nearby supermarkets (Morland et al., 2006; Powell et al., 2007; Zenk and Powell, 2008) and that places to be physically active in these communities are in short supply (Lovasi et al., 2009). At the same time, access to less healthy foods and advertising for these foods has been shown to be higher in lower-income neighborhoods (Baker et al., 2006; Black and Macinko, 2008; Kumanyika and Grier, 2006; Yancey et al., 2009). For example, fast-food restaurants and the relatively inexpensive calorie-dense foods they sell are more available in such neighborhoods (Baker et al., 2006; Larson et al., 2009). In these same neighborhoods, many stores where food is sold are small, with limited equipment and shelf space, and lack fruits and vegetables, whole grains, and low- and nonfat dairy products (IOM and NRC, 2009; Morland et al., 2002). Families with limited resources and time who must make their food purchases in these environments face difficult choices related to cost, availability, and quality.
Moreover, affordable child care providers in low-income neighborhoods may not have the resources to offer optimal opportunities for physical activity because of a lack of space or equipment (Copeland et al., 2011; Trost et al., 2010). Likewise, low-income parents and caregivers may have limited budgets
for providing nutritious meals to young children (Ding et al., in press; Kelly and Patterson, 2006; Omar et al., 2001; Slusser et al., 2011). Parents with several jobs or unusual working hours who are picking up their young children at child care centers or bringing their children to health care centers also may have very limited time to interact with their children’s providers and learn what they have to offer. Mothers who of necessity return to work soon after giving birth may have workplaces that are not friendly to breastfeeding (Guendelman et al., 2009; Kimbro, 2006; Rojjanasrirat and Sousa, 2010).
In this context, the committee attempted to formulate recommendations to caregivers and policy makers that would be universal with respect to the optimal health of young children but also feasible in the short term through creative adaptation in many different settings with families at all socioeconomic levels.
As noted earlier, the committee’s recommendations are aimed at policy makers at all levels, as well as professionals in a variety of settings where young children receive care. Given that childhood obesity is a multidimensional problem requiring a multidimensional solution, the committee believes it will be helpful for both of these groups to examine the full report as a broad base for specific actions. Obesity prevention efforts in early childhood require consistent and common policy, practices, and information across multiple settings; innovative thinking about implementation; effective communication among caregivers; and shared concerns for healthy development and obesity prevention in young children.
Exploring Child Care Standards
Throughout this report, the committee makes recommendations for the development of standards by state child care regulatory agencies. These standards have to do with physical activity, healthy eating, screen time, and sleep. They are based on a combination of the best evidence available on actions that can support obesity prevention in young children, best practices for child care settings founded on widely recommended practices, and the judgment of the committee.
Several overall strategies could be employed to foster adoption of these standards by child care providers. They include focused outreach campaigns to child care providers and parents of young children; criteria for program accreditation; the Quality Rating and Improvement System (QRIS); and state voluntary regulations and mandatory regulations developed by state regulatory agencies, often in response to specific state legislation. Focused outreach campaigns could be conducted by both private and public entities. Several national organizations offer accreditation programs for child care providers seeking to improve the quality of
care and compete better in the child care market. QRIS is not in effect in all states, but it is usually separate from state licensing standards. Typically, as with accreditation, meeting QRIS standards can make child care providers more attractive in the market, depending on their ratings, and in some cases the level of subsidies they may receive from the state to provide child care to individual children can be based on their QRIS rating. State voluntary standards often are tied to an incentive that benefits the child care program; if a program complies, for example, its licensing fee is reduced.
The focus of the committee’s recommended strategy for child care settings is mandatory regulation. This decision was made for several reasons. All states already have child care regulations of some type; thus the impact of state regulations reaches all preschool children in licensed care in a state, regardless of their geographic location or socioeconomic status. These regulations have the force of law and the potential to reach young children in an efficient and timely manner (National Association for Regulatory Administration, 2011). The reach of voluntary standards, guidelines, and criteria, by their nature, will not be as broad or thorough.
There is currently a national thrust, including among national health and child care organizations and at HHS, toward encouraging state child care regulations that will contribute to obesity prevention in young children (AAP et al., 2010; National Resource Center for Health Safety in Child Care and Early Education, 2011). For example, in Healthy People 2020 (HHS, 2010), the physical activity objectives include “increase the number of states with licensing regulations for physical activity provided in child care,” and under that objective are the sub-objectives of requiring children to engage in vigorous or moderate physical activity and requiring a certain number of minutes of physical activity per day or length of time in care. In addition, the recently passed Healthy, Hunger-Free Kids Act of 2010 (Public Law 111-296 [December 13, 2010]), through which Congress reauthorized funding for federal school meal and child nutrition programs for the next 5 years and provided new funding for these programs over 10 years, includes a requirement for interagency coordination to promote health and wellness in child care licensing. The act requires the Secretary of Agriculture to “coordinate with the Secretary of Health and Human Services to encourage state licensing agencies to include nutrition and wellness standards within licensing standards that ensure, to the maximum extent practicable, that licensed child care centers and family or group day care homes provide to all children under their supervision daily opportunities for age-appropriate physical activity,” “limit the use of electronic media
and the time spent in sedentary activity to an appropriate level,” “serve meals and snacks that are consistent with the requirements of the Child and Adult Care Food Program,” and “promote such other nutrition and wellness goals as the Secretaries determine to be necessary.”
Over the past 2 years, a number of states, including Arizona, Delaware, Massachusetts, North Carolina, Tennessee, and Texas, as well as Washington, DC, have adopted mandatory regulations related to obesity prevention in child care settings related to breastfeeding, nutrition, physical activity and inactivity, and screen time. (These and other state standards can be found on the website of the National Resource Center for Health and Safety in Child Care and Early Education at http://www.nrckids.org .) The committee recognizes that a regulatory requirement may take time to implement in some states. In the interim, this report’s recommendations could be used in developing and encouraging voluntary standards in those states.
ORGANIZATION OF THE REPORT
Chapter 2 addresses the importance of beginning growth monitoring at birth in order to gauge and respond to a child’s risk of developing obesity, as well as the usefulness of understanding the major prenatal influences on early childhood weight. Chapters 3 through 6 are organized around the key factors that play a role in early childhood obesity development and prevention: physical activity ( Chapter 3 ), eating patterns ( Chapter 4 ), food and beverage marketing and screen time ( Chapter 5 ), and sleep ( Chapter 6 ). Each of these chapters begins with one or more goals that underlie the recommendations on that topic, which are then presented along with their rationale and potential actions for implementation.
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Childhood obesity is a serious health problem that has adverse and long-lasting consequences for individuals, families, and communities. The magnitude of the problem has increased dramatically during the last three decades and, despite some indications of a plateau in this growth, the numbers remain stubbornly high. Efforts to prevent childhood obesity to date have focused largely on school-aged children, with relatively little attention to children under age 5. However, there is a growing awareness that efforts to prevent childhood obesity must begin before children ever enter the school system.
Early Childhood Obesity Prevention Policies reviews factors related to overweight and obese children from birth to age 5, with a focus on nutrition, physical activity, and sedentary behavior, and recommends policies that can alter children's environments to promote the maintenance of healthy weight. Because the first years of life are important to health and well-being throughout the life span, preventing obesity in infants and young children can contribute to reversing the epidemic of obesity in children and adults. The book recommends that health care providers make parents aware of their child's excess weight early. It also suggests that parents and child care providers keep children active throughout the day, provide them with healthy diets, limit screen time, and ensure children get adequate sleep.
In addition to providing comprehensive solutions to tackle the problem of obesity in infants and young children, Early Childhood Obesity Prevention Policies identifies potential actions that could be taken to implement those recommendations. The recommendations can inform the decisions of state and local child care regulators, child care providers, health care providers, directors of federal and local child care and nutrition programs, and government officials at all levels.
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- Published: June 2007
Obesity in Childhood: Introduction and General Considerations
- Charles H Hennekens 1 , 2 , 4 ,
- Wendy R Schneider 1 &
- E Joan Barice 1 , 3 , 4
Pediatric Research volume 61 , pages 634–635 ( 2007 ) Cite this article
Obesity in childhood is perhaps the most major clinical and public health problem in the United States and most developed countries and is rapidly becoming so in developing countries. The National Health and Nutrition Examination Survey (NHANES) is a federally funded periodic survey of a random sample of the U.S. population. In NHANES data over the past several decades, there is a 3-fold increase in the prevalence of obesity in childhood ( 1 – 4 ). These data are alarming but, perhaps not surprising.
The landmark Framingham Heart Study, which enrolled and followed over 5000 residents of a single community in Massachusetts for over 40 years, has demonstrated that in middle age the average American gains about seven pounds per decade of life. Thus, for these and other cogent reasons, it appears that, at present, the adult population of the U.S. is the fattest society in the world and likely to be the fattest in the history of the world ( 5 ). Further, there are even more alarming trends in obesity in childhood in developing countries ( 6 , 7 ). Thus, the epidemic of obesity in childhood in the United States and most developed countries is now becoming a pandemic.
This emerging pandemic results from genetic and environmental factors, chiefly increased caloric intake and physical inactivity ( 3 , 6 , 8 – 12 ). Further, and also not surprisingly, childhood obesity has contributed to marked increases in metabolic syndrome and type 2 diabetes in U.S. children ( 13 – 15 ). The increasing prevalence of metabolic syndrome and type 2 diabetes in childhood has also been well documented in developing countries, including China ( 16 , 17 ).
Among most middle-aged adult populations, smokers tend to be thinner due to the effects of smoking on decreasing appetite and increasing basal metabolic rate. Among adolescents in both developed and developing countries, the rise in cigarette consumption is associated with increasing obesity perhaps due, at least in part, to increasing levels of physical inactivity ( 12 , 18 – 20 ).
At present, most of the remarkable decline in mortality from coronary heart disease in the United States over the past several decades is currently due to diagnosis and treatment rather than primary prevention. Further, the rate of decline is decreasing and coronary heart disease will increase as the current generation of U.S. children and adolescents reach middle age ( 18 ). For all these reasons, cardiovascular disease (CVD) is and will remain the leading killer in the United States and most developed countries. Thus, the long-term consequences of childhood obesity could cause our current generation of children to become the first in the history of the United States to have a decreased life expectancy than their parents ( 13 , 21 ). In addition, however, the alarming increases in obesity and tobacco consumption in developing countries has led the World Health Organization to estimate that CVD will rise from number 5 to number 1, the leading killer in the entire world after another decade ( 6 , 7 ).
There is increasing evidence that atherosclerosis begins in childhood. In the Bogalusa Heart Study, autopsy studies of children showed a clear relationship between the number and severity of risk factors, principally obesity, with atherosclerosis in both the aorta and coronary arteries ( 14 , 22 ). Thus, the need for primary prevention of cardiovascular disease beginning in childhood is clear (7,13–15,23), but there is no consensus regarding the best approach that includes therapeutic lifestyle changes as well as pharmacologic therapies. While further research is certainly warranted, so too are clinical and health policy measures ( 24 – 29 ).
In this issue of the journal, new predictors of metabolic syndrome in children, epidemiology of childhood obesity, and the relation to subsequent cardiovascular disease are addressed. All these issues underscore the crucial need for primary prevention of obesity in children throughout the world.
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Authors and affiliations.
Department of Biomedical Science, Center of Excellence, FL Atlantic University, Boca Raton, 33431, FL
Charles H Hennekens, Wendy R Schneider & E Joan Barice
Departments of Medicine & Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, 33136, FL
Charles H Hennekens
Psychiatry and Behavioral Science, University of Miami Miller School of Medicine, Miami, 33136, FL
E Joan Barice
Department of Preventive Medicine, NOVA Southeastern University, Fort Lauderdale, 33328, FL
Charles H Hennekens & E Joan Barice
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Hennekens, C., Schneider, W. & Barice, E. Obesity in Childhood: Introduction and General Considerations. Pediatr Res 61 , 634–635 (2007). https://doi.org/10.1203/PDR.0b013e3180686cf1
Received : 19 March 2007
Accepted : 23 March 2007
Issue Date : June 2007
DOI : https://doi.org/10.1203/PDR.0b013e3180686cf1
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Actions Needed to Prevent Childhood Obesity in The USA
The roles of parents, schools, and the media in child obesity, a discussion of whether parents are responsible for childhood obesity, childhood obesity as a nutritional issue in new zealand, the influence of obesogenic environment on the rise of child obesity in the united states, the issue of consumer manipulation responsible for child obesity, childhood obesity outbreak: a challenge on parenting, problems, and inference, the nationwide epidemic of child obesity and its prevention, the factors contributing to child obesity in the united states, the contributions of the nature versus nurture theories in child obesity, research on lifestyle and diet of students.
Childhood obesity is a condition where excess body fat negatively affects a child's health or well-being.
Childhood obesity can be brought on by a range of factors which often act in combination. "Obesogenic environment" is the medical term set aside for this mixture of elements. The greatest risk factor for child obesity is the obesity of both parents. This may be reflected by the family's environment and genetics. Other reasons may also be due to psychological factors and the child's body type.
The first problems to occur in obese children are usually emotional or psychological. However it can also lead to life-threatening conditions including diabetes, high blood pressure, heart disease, sleep problems, cancer, and other disorders. Some of the other disorders would include liver disease, early puberty or menarche, eating disorders such as anorexia and bulimia, skin infections, and asthma and other respiratory problems.
Black and Latino youths have substantially higher rates of overweight and obesity than do their White peers. An overweight adolescent has a 70 percent chance of becoming an overweight or obese adult. Since 1980, the obesity prevalence among children and adolescents has almost tripled. Children with obesity have three times more healthcare expenditures than children at healthy weights, costing an estimated $14 billion every year.
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Epidemiology of childhood overweight, obesity and their related factors in a sample of preschool children from Central Iran
- Bahram Armoon 1 &
- Mahmood Karimy ORCID: orcid.org/0000-0002-8413-1942 1
BMC Pediatrics volume 19 , Article number: 159 ( 2019 ) Cite this article
Childhood overweight and obesity are strongly associated with the psychological and physical health of those for the duration of the lifetime. The purpose of this study was to assess the epidemiology of childhood overweight and obesity and their related factors in Zarandieh city, of Iran, in 2017.
In a cross-sectional study, 572 preschool-mother dyads from primary care Clinics were selected by multi-stage sampling method. BMI of the children and mothers were calculated using standard method and the demographic, children nutrition and physical activity habits; the mothers perceived threat toward obesity, and their life style data were collected by self-report questionnaires for the literate mothers and interviewing for illiterate mothers.
The prevalence of overweight and obesity in mothers was 30.8 and 20.3% respectively. This rate in children was 15.5 and 9.9% respectively. The multiple logistic regression analysis showed that variables of mother’s BMI, Birth weight, Mother’s employment, watching TV > 2 h/day, Computer games> 2 h/day and daily breakfast eating (≥4/week), perceived threat, health responsibility, stress management, physical activity, and healthy eating were the significant predictors of the child’s BMI respectively.
Our results indicated that the prevalence of overweight and obesity are high in preschool children and their mothers. It seems that necessary to have suitable intervention programs to help mothers understand the serious risk of childhood obesity and the importance of creating a healthy lifestyle by them in childhood.
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Childhood overweight (OW) and obesity (OB) is the global public health problem since it increases the risk of premature death, as well as developing Diabetes, cancer, heart diseases, and many other physical or social diseases and complications in adulthood [ 1 ]. It also causes undesirable psychological consequences, such as anxiety, depression, sleep disorders and low self-esteem, which affects the social and educational relationships of children [ 2 , 3 ]. Researchers estimate that 79% of obese adolescents will become obese adults who are at increased risk of developing hypertension, and cardiovascular disease [ 4 ]. According to the WHO report, in 2016, over 340 million children and adolescents aged 5–19 years old were diagnosed as overweight/obese [ 5 ]. Researchers believe that the increased prevalence of obesity is the result of changes in the lifestyle of societies, such as the inactivity, collapse of energy balance, increased use of fast food and animal proteins, and increased use of technology [ 2 , 6 ]. Several studies have shown that there is a relationship between lifestyle and health, and today, lifestyle changes are considered as an essential strategy for solving chronic health problems such as obesity [ 7 , 8 ]. Most Asian countries, including Iran, are at a transition from traditional to western lifestyles. Lifestyle changes have increased the prevalence of overweight /obesity in these societies [ 9 ]. The study by Agha-Alinejad indicated the prevalence of overweight/obesity in Iranian preschool as 12% in boys and 22.5% in girls [ 10 ]. In 2017, non-communicable diseases accounted for 76% of total mortality in Iran [ 6 ]. The main risk factor for these diseases is the unhealthy lifestyle (e.g., getting extra calories, inactivity, and unhealthy nutrition). Healthy lifestyle plays a vital role in improving life expectancy and is associated with a reduction in the risk of death and recurrence of many diseases [ 11 ].
The construct of perceived threat is an individual’s perception about the seriousness of health problem [ 12 ], and their attitudes to one’s vulnerability to its problem [ 13 , 14 ]. Previous studies demonstrated that perceived threat has a vital role in predictive to health behavior [ 13 , 15 ]. Health professionals recognize children’s lifestyle as a function of parents’ behavior, belief and life styles [ 14 ]. Health professionals recognize children’s lifestyle as a function of parents’ behavior. Parents are considered to be the causes of the child’s BMI in the community, considering the rules for watching TV, Computer games, nutrition and using the car instead of walking [ 16 , 17 ]. Children that have low levels of physical activity are more likely to watch TV than the others, and much-watching TV may cause to increase snacking and using up of high-fat, high-sugar, or high-calorie foods and the decrease of fruit and vegetable consumption and this lifestyle may cause to greater BMI among children [ 40 ]. Excessive use of computer and TV causes sedentary behavior in children, which is an essential determinant for developing OW/OB [ 8 ]. The role of mother for children is highlighted because the mother directly determines the social and physical environment of the child and indirectly affects their attitude, habits, and behaviors [ 14 , 18 ]. The mother is the closest person to the child and the first person to shape their behavior and lifestyle. In multigenerational families that grandmothers have roles in preparing food for family members, even if mothers are employed the eating patterns have no significant transitions. Besides, in these situations, young children may have insufficient access to dense energy food. In the contexts that the mean of BMI Z-score is negative, the income should be dedicated to goods that are currently associated with healthy weight gain in LMIC. Because of the rapid growth in children aged 0–5 years, they require a high amount of energy. Following this, the growth of household food charges may cause only modest alterations in energy balance [ 34 ].
Meanwhile, the mother decides on the type and amount of household food [ 19 ]. Therefore, the mother plays an essential role in determining the weight of the child. Because people’s perception of health threats leads them to health behaviors, the present study is aimed to assess the effects of the perceived threat from obesity and mothers’ lifestyles on children’s BMI.
Subjects and methods
Design and sample.
The present study is a descriptive, analytical cross-sectional study and the research community includes 576 mothers with 6-7 year-old children having medical records in the primary care clinics of Zarandieh city, placed in the Markazi Province of Iran, in 2017. After obtaining permission from the authorities of Saveh University of Medical Sciences and providing a list of all primary care clinics in the city, the research samples were selected through multi-stage sampling and entered into the study. The sampling method was as follows: in the first stage, all primary care clinics of the city including eight bases were selected by the census method. In the next stage, 72 children (36boys and 36 girls) were randomly selected from each center based on the family file number available in each base and entered the study with their mothers. In the third stage, the chosen mothers were called using the telephone number in the family file, and they were invited to the primary care clinics. The goals of the study were explained to the mothers, and self-administered questionnaires were completed by them in a separate room. After collecting the questionnaires, four questionnaires were deleted due to incomplete information, and the final analysis was done on 572 questionnaires. The inclusion criteria included mothers with records in primary care clinics and have children aged 6–7 years; exclusion criteria were the absence of informed agreement in the study. The heights and weight of the selected children and mothers were measured, and their BMIs were calculated. Height without shoes was measured using height gauge (SECA model) with a precision of 0.5 cm, and body weight was measured with clothes and without shoes with a digital scale of 500 g sensitivity, and finally, the BMI was calculated. For children, the obesity criterion was BMI ≥ 95, the overweight criterion was BMI between 85 and 95 percentiles, and normal weigh criterion was BMI between 50 and 85 percentiles [ 20 ]. For mothers, the overweight criterion was BMI between 25–29.99, and the obesity criterion was BMI ≥ 30 [ 16 ]. The reliability of the scale and meter used were confirmed using the test-retest method in three stages.
Data were collected using written self-report questionnaires for the literate (middle/High school/university) and through interviews with the help of trained instructors for the low-literate (Illiterate/ Elementary). To design the questionnaire, the sample questionnaires used in similar studies were used [ 9 , 13 , 14 , 18 , 21 ]. The questionnaire included the following sections: 1. Demographics; this section provided descriptive information about the research samples such as mother’s age, child’s age, child’s birth weight, mother’s education, and mother’s occupation. 2. Perceived threat; this Scale is a 6 item tool that assesses the perceived threat of mothers towards childhood obesity (i.e., I am worried about the additional weight of my child). In this section, mothers’ answers were set based on the Likert 5-point scale ranging from 1 “ strongly disagree” to 5 “ strongly agree.” Therefore, the acquired score in this structure ranged between 6 and 30. Cronbach’s Alpha reliability of the Perceived threat was 0.82. A panel of 12 experts helped to evaluate the validity of this section; the technique of content validity ratio (CVR) and content validity index (CVI) was used. CVR value > 0.56 and a CVI value > 0.79 were considered “satisfactory.” In the next step, face validity was evaluated. For this purpose, 20 mothers who would not join later in the research was requested to score the importance of each question on the 5-point Likert scale from ‘1’ (not important at all) to ‘5’ (completely important). Only the questions with impact scores of 1.5 or above were accepted.
3. Child’s behavior by mother report: The child’s behavior in the two areas of “Nutrition and Physical Activity” was assessed through 16 items. Mother was asked about child’s intake of dietary indicators (Food habits, fast foods, fruit, and vegetables), physical activity habits, Duration of TV watching/computer games and sleep during the past 30 days. The reliability of this section was obtained by Cronbach’s Alpha as 0.78. 4. Health Promoting Lifestyle Profile II; this instrument consists of 52 items and six subscales (nutrition9 items, physical activity 8 items, health responsibility 9 items, stress management 8 items, interpersonal relationships 9 items, and spiritual growth 9 items) that assesses the health-promoting behavior of mothers. In this section, the mothers’ answers were set on a Likert scale ranging from 1 (Never) to 4 (always). The Iranian version of this scale was reliable by Taheri et al. [ 22 ]. In our study, the Cronbach’s alpha was determined as 0.81. The validity of the questionnaire was performed using Content Validity Index (CVI) and Content Validity Rate (CVR) with the assistance of 10 experts in the field of health sciences, nutrition, and behavioral sciences, and it was confirmed with CVI 81% and CVR 75%.
The data were analyzed using SPSS 18. One-way analysis of variance (ANOVA) and T-Test were used to determine significant differences between the mean score of perceived threat, behavior and Health Promoting Lifestyle structures in two or more independent groups of demographic variables.
Multiple Logistic regression analysis was used to determine the factors affecting childhood obesity. At first, the variables were entered into the Univariate analysis, and the variables that became significant associations with childhood obesity ( P ≤ 0.05) in this test, were entered into a multiple logistic regression model. The child’s BMI that was entered into the regression model as a dependent variable was classified as binary variables with code 0 for “normal,” and code 1 for “overweight/obese.”
The ethics committee of Saveh University of Medical Science approved this study and permission to conduct the research was obtained from this committee. Moreover, written consent from was taken from the mothers. Also, the teach-back method and interview were used to get informed consent in mothers with low levels of literacy.
Demographic variables and obesity
The mean age of children and mothers was 6.3 ± 1.1 years and 32.6 ± 4.7 years, respectively. The prevalence rate of overweight and obesity in mothers based on the BMI index was 30.8% ( n = 176) and 20.3% ( n = 116), respectively. This rate in boys’ was 8.9 and 6.1%, as well as in girls was 6.6 and 3.8% respectively. About 36% ( n = 189) of the mothers had a high school educational level, while the levels of elementary school, middle school, and the university had the following places with 23.8%( n = 125), 23%( n = 122) and 16.9%( n = 89). About 26% of the mothers were working, while the rest were homemakers. 287 children were boys, and the rest were girls. A total of 80 obese/overweight children (54.7%), and 175 normal weight children (46%) had a birth weight of more than 3000 g. The average number of children in families was 2.1 ± 1.6. The multiple logistic regression analysis showed that demographic variables of mother BMI, Birth weight, Mother’s employment were the most significant predictors of the child’s BMI respectively (Tables 1 , 3 ). In the survey of perceived treats towards childhood obesity, 66.7% of mothers of children with normal weight worried about hazardous of OW in their children. This rate was 28% in mothers of OW/OB children (Table 2 ).
The perceived threat of mothers and child behavior
The results revealed that the perceived threat was a significant variable in predicting of child’s BMI. Also, the mean score of perceived threat for mothers having children with normal BMI was higher than that for mothers having children with OB/OW, and the difference was statistically significant ( p < 0.05). Also, the correlation coefficient indicated that behavior has a moderate positive and significant correlation with a perceived threat ( r = 0.41, p < 0.001). In the “behavior” section, 58.6% of the mothers did not know how to calculate the BMI. 65 and 52% of the mothers set no time limit for their children’s watching TV or playing Computer games respectively. 61 and 54% of the children watched TV and played games for more than 2 h a day respectively. In the behavior section, Watching TV > 2 h/day, Computer games> 2 h/day and daily breakfast eating (≥4/week) were significant elements in predicting children’s BMI.
In the “Health Promoting Lifestyle” section, the mean scores of all the structures for mothers having children with normal BMI were significantly higher than mothers having children with OB/OW. The structures of health responsibility, stress management, physical activity, and healthy eating were the most important of significant predictors of child obesity respectively ( p < 0.05) (Table 3 ).
Factors associated with childhood overweight and obesity
Our result showed that there was about fourfold increase overweight children in mothers with BMI ≥25, (AOR = 3.91, 95% CI: 1.35, 6.86). Also, working mothers had two times likely to have overweight offspring’s (AOR = 2.37, 95% CI: 1.18, 4.21). The likelihood that birth weight ≥ 3000 g leads to overweight was two times (AOR = 3.91, 95% CI: 1.24, 5. 17).
Regarding children who spent their free time; by watching TV > 2 h/day (AOR = 3.51, 95% CI: 1.20, 8.66), and playing computer> 2 h/day (AOR = 3.4, 95% CI: 1.24, 7.32) were almost three times more likely to be overweight. Children who did not eat daily breakfast (≥4/week) were almost three times more likely to be overweight (AOR = 2.88, 95% CI: 1.19, 86.67).
Regarding to psychological factor and health promoting lifestyle constructs; perceived threat (AOR = 0.90, 95% CI: 0.85, 0.94), healthy eating (AOR = 0.83, 95% CI: 0.75, 0.89), health responsibility (AOR = 0.80, 95% CI: 0.72, 0.93), physical activity (AOR = 0.77, 95% CI: 0.65, 0.82) and stress management (AOR = 0.69, 95% CI: 0.44, 0.79) were almost less likely to be overweight (Table 3 ).
We can take a significant step towards preventing obesity by studying and analyzing the causes and predictors of obesity. In the present study, the mother OB/OW is an important variable affecting childhood obesity since children having mothers with obesity are more likely to be affected by obesity. The observed relationship between the mother’s weight and the child’s weight in the present study was similar to the results from other studies [ 2 , 23 ]. For instance, in Bider-Canfield et al. study, the mother’s obesity increased the risk of the child’s obesity by 2.34 times [ 24 ]. In a similar survey of Danielzik et al. on 5–7-year-old German children, parent’s obesity was as the most important predictor of childhood obesity [ 2 ]. In consistent with our result, the effect of the mother’s BMI on the child’s BMI depends on both the genetics and the process of learning the mother’s behaviors and unhealthy lifestyles of children [ 3 ]. In recent decades, there is an increase in adults BMI because of changes in nutritional style. These changes are due to taking the high amount of saturated fats, sugar and refined foods (for example Fast-food) and low fiber in the daily diet, in addition to the decline in the daily physical activity [ 25 , 26 ].
Our results indicate that the birth weight was a significant variable for predicting the preschool child’s BMI. The relationship between high birth weight and the increased risk of childhood obesity is also proven in the study of He et al. in China [ 27 ]. The similar finding has been reported by Gulliford et al. study in Trinidad and Tobago [ 28 ]. The relationship between high birth weight and the increased risk of childhood obesity is attributed to metabolic and endocrine activities or autonomic pathways. Furthermore, high birth weight remains a risk for obesity in children [ 29 , 30 , 31 , 32 ]. Based on meta-analysis research, high birth weight (> 4000 g) in comparison with normal birth weights (2500–4000 g), there is a high probability of childhood overweight (OR 1.66; 95% CI: 1.55–1.77). Accordingly, increased birth weight is associated with increased overweight risk, later on, proposing prenatal overfeeding as a key risk factor that leads to long-term obesity susceptibility [ 31 ]. Similarly, Qiao et al. [ 29 ], found that the full range of birth weights and the association of it with childhood obesity risk demonstrated that the birth weight > 3000 g increases the OR of overweight plus obesity during childhood. Consistent with previous studies [ 23 , 33 ], in our study, a significant relationship was diagnosed between the child’s BMI and the mother’s employment. This means that the family income is likely to increase, which leads to increased purchasing power as well as increased diversity in purchasing food products. Moreover, the mother’s employment leads to the change in the child’s dietary pattern and increases the use of ready-made meals and high-calorie snacks, which consequently leads to an increased risk of developing obesity. Therefore, to illustrate the null findings several studies have specifications [ 34 ].
Our study showed mother’s perceived threat towards obesity was a significant factor in predicting for child’s BMI. The study of Azizi et al. [ 35 ] in tuberculosis patients revealed that effective threat perceptions are related to health decision-making. Similarly, Moore et al. [ 13 ] indicated that perceived threat could create motivation for losing weight and having more physical activity. In another study by Kim, found that that perceived threat is a crucial structure for motivating to prevention and improve the behaviors related to obesity in boys [ 36 ]. A recent meta-analysis of interventional studies highlights the role of perceived threat to facilitate behavior change [ 37 ]. It seems perceived threat is a critical determinant in adopting healthy behaviors since people react well to healthy messages only when they believe they are susceptible to risk such as obesity.
In this study, the period spent on watching TV and Computer game was a significant factor in predicting of child’s BMI. This finding is in line with the study of Brug’s et al. among school children in Europe [ 38 ], also, study of Hajian and Heidari [ 9 ] among preschool children in Iran, both of which showed that there was a positive and significant relationship between overweight and TV viewing and playing Computer games. Similar result have been reported in Katzmarzyk et al. [ 8 ], study in 9–11-year-old children from 12 countries, found that there was a significant relationship between childhood obesity and high TV viewing. [ 8 ]. Moreover, A study by Kelly et al. [ 39 ], indicated that children were exposed and influenced to high rates of TV advertising about unhealthy nutritional behaviors, which that can facilitate the consumption of unhealthy foods in children such as increased use of chips and cheese puffs [ 40 ].
As regards Health Promoting lifestyle variables, researchers have found significant relations between dietary habits and obesity. Similarly, our result indicated that dietary habits such as daily breakfast eating were a significant factor in predicting OW/OB. In line with this finding, a study by Vanhala on Finnish children proved that skipping breakfast is an important risk factor for developing childhood obesity [ 41 ]. The relationship between regular breakfast eating and fit weight for children could be justified by the fact that by regular eating of this main meal, the child’s appetite is full and they refuse to eat fatty snacks and junk food like chips and puffs. We also recognized that breakfast skipping and overweight/ obesity have a weak association with each other. Based on this finding the relationship between breakfast skipping, eating pathology, and obesity is not simple. For example, it is possible that eating pathology intervene in the relationship between breakfast skipping and overweight [ 42 ].
Previous studies have shown that Health responsibility is an important factor in promoting people’s health [ 43 , 44 ]. In the present study, likewise, mothers who showed greater responsibility towards health were more likely to have normal weight children. Indeed, it seems that people who do not hold themselves responsible for their health and believe in the effect of fate, chance, and other factors on the development of diseases or health, do not try to correct their families’ unhealthy lifestyle, which consequently leads to the increased risk of developing diseases and complications like OW/OB in their families.
In this study, stress management was a significant factor in predicting of child’s BMI. Psychologists believe stress-induced overeating could be a contributing factor for obesity. In other words, when someone is stressed, they usually automatically and unconsciously look for ways to relieve their stress; the most common behavior of these people is eating, and children can learn this behavior from their mothers since parents are the children’s first role models. The study of Ng and Jeffery showed that there was a positive relationship between stress and fatty diets [ 45 ]. In a study Harding et al. [ 46 ], observed that people who are exposed to stress, are more likely to develop obesity. Also, Rydon et al. [ 47 ]. Showed that women with obesity were significantly more stressed.
Some studies reported that parent unhealthy lifestyles such as physically inactive, unhealthy eating practice are among the causes of childhood obesity [ 14 , 18 ]. Similarly, in our study, mothers’ low physical activity could significantly predict the probability of developing childhood obesity. This is in line with the study of Rutledge et al. [ 48 ], found preschoolers’ weights were related to parent lifestyles. In another study, Etelson et al. [ 49 ], reported that parents lifestyle influence children in shaping dietary and physical activity habits. Also, an unhealthy lifestyle might increase the risk of childhood obesity. A study by Davis in Kansas City, USA showed that the parents’ healthy diet and physical activity has a vital role in creating the child’s ideal weight [ 50 ]. This finding should be taken seriously, since reduced physical activity leads to serious consequences, such as cardiovascular diseases, cancer, hypertension, diabetes, overweight, and obesity for the public health of people around the world, and it requires special attention of health workers to change the lifestyle of individuals and encourage to sports and physical activity. Indeed, this finding shows the importance of a healthy lifestyle in the parents. The present study had several limitations: Firstly, This data was collected only from the children’s mother. Secondly, the analysis of this study was based on cross-sectional data, thus does not enable to investigate the causal relationships.
The results of the present study indicate that unhealthy behaviors and lifestyles are prevalent in children and their mothers. This problem could be a major risk to children’s weight loss programs in Iranian society. It seems necessary to have suitable intervention programs to help mothers understand the serious risk of childhood obesity and the importance of creating a healthy lifestyle by them in childhood. Accordingly, we recommend that encouraging active lifestyles and healthy diets should be considered as a public health priority. In addition, to improve our knowledge about genetic factors, educational and nutritional programs about obesity and related health outcomes should incept early in childhood that may prevent the increasing prevalence of childhood obesity and may reduce the frequency of obesity in children.
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We gratefully acknowledge the very helpful participation of the women, without whose contribution the present study would not have been completed.
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Armoon, B., Karimy, M. Epidemiology of childhood overweight, obesity and their related factors in a sample of preschool children from Central Iran. BMC Pediatr 19 , 159 (2019). https://doi.org/10.1186/s12887-019-1540-5
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DOI : https://doi.org/10.1186/s12887-019-1540-5
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Review article, childhood and adolescent obesity: a review.
- 1 Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
- 2 Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, United States
- 3 Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
Obesity is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors; it is a significant public health problem. The most common cause of obesity throughout childhood and adolescence is an inequity in energy balance; that is, excess caloric intake without appropriate caloric expenditure. Adiposity rebound (AR) in early childhood is a risk factor for obesity in adolescence and adulthood. The increasing prevalence of childhood and adolescent obesity is associated with a rise in comorbidities previously identified in the adult population, such as Type 2 Diabetes Mellitus, Hypertension, Non-alcoholic Fatty Liver disease (NAFLD), Obstructive Sleep Apnea (OSA), and Dyslipidemia. Due to the lack of a single treatment option to address obesity, clinicians have generally relied on counseling dietary changes and exercise. Due to psychosocial issues that may accompany adolescence regarding body habitus, this approach can have negative results. Teens can develop unhealthy eating habits that result in Bulimia Nervosa (BN), Binge- Eating Disorder (BED), or Night eating syndrome (NES). Others can develop Anorexia Nervosa (AN) as they attempt to restrict their diet and overshoot their goal of “being healthy.” To date, lifestyle interventions have shown only modest effects on weight loss. Emerging findings from basic science as well as interventional drug trials utilizing GLP-1 agonists have demonstrated success in effective weight loss in obese adults, adolescents, and pediatric patients. However, there is limited data on the efficacy and safety of other weight-loss medications in children and adolescents. Nearly 6% of adolescents in the United States are severely obese and bariatric surgery as a treatment consideration will be discussed. In summary, this paper will overview the pathophysiology, clinical, and psychological implications, and treatment options available for obese pediatric and adolescent patients.
Obesity is a complex issue that affects children across all age groups ( 1 – 3 ). One-third of children and adolescents in the United States are classified as either overweight or obese. There is no single element causing this epidemic, but obesity is due to complex interactions between biological, developmental, behavioral, genetic, and environmental factors ( 4 ). The role of epigenetics and the gut microbiome, as well as intrauterine and intergenerational effects, have recently emerged as contributing factors to the obesity epidemic ( 5 , 6 ). Other factors including small for gestational age (SGA) status at birth, formula rather than breast feeding in infancy, and early introduction of protein in infant's dietary intake have been reportedly associated with weight gain that can persist later in life ( 6 – 8 ). The rising prevalence of childhood obesity poses a significant public health challenge by increasing the burden of chronic non-communicable diseases ( 1 , 9 ).
Obesity increases the risk of developing early puberty in children ( 10 ), menstrual irregularities in adolescent girls ( 1 , 11 ), sleep disorders such as obstructive sleep apnea (OSA) ( 1 , 12 ), cardiovascular risk factors that include Prediabetes, Type 2 Diabetes, High Cholesterol levels, Hypertension, NAFLD, and Metabolic syndrome ( 1 , 2 ). Additionally, obese children and adolescents can suffer from psychological issues such as depression, anxiety, poor self-esteem, body image and peer relationships, and eating disorders ( 13 , 14 ).
So far, interventions for overweight/obesity prevention have mainly focused on behavioral changes in an individual such as increasing daily physical exercise or improving quality of diet with restricting excess calorie intake ( 1 , 15 , 16 ). However, these efforts have had limited results. In addition to behavioral and dietary recommendations, changes in the community-based environment such as promotion of healthy food choices by taxing unhealthy foods ( 17 ), improving lunch food quality and increasing daily physical activity at school and childcare centers, are extra measures that are needed ( 16 ). These interventions may include a ban on unhealthy food advertisements aimed at children as well as access to playgrounds and green spaces where families can feel their children can safely recreate. Also, this will limit screen time for adolescents as well as younger children.
However, even with the above changes, pharmacotherapy and/or bariatric surgery will likely remain a necessary option for those youth with morbid obesity ( 1 ). This review summarizes our current understanding of the factors associated with obesity, the physiological and psychological effects of obesity on children and adolescents, and intervention strategies that may prevent future concomitant issues.
Definition of Childhood Obesity
Body mass index (BMI) is an inexpensive method to assess body fat and is derived from a formula derived from height and weight in children over 2 years of age ( 1 , 18 , 19 ). Although more sophisticated methods exist that can determine body fat directly, they are costly and not readily available. These methods include measuring skinfold thickness with a caliper, Bioelectrical impedance, Hydro densitometry, Dual-energy X-ray Absorptiometry (DEXA), and Air Displacement Plethysmography ( 2 ).
BMI provides a reasonable estimate of body fat indirectly in the healthy pediatric population and studies have shown that BMI correlates with body fat and future health risks ( 18 ). Unlike in adults, Z-scores or percentiles are used to represent BMI in children and vary with the age and sex of the child. BMI Z-score cut off points of >1.0, >2.0, and >3.0 are recommended by the World Health Organization (WHO) to define at risk of overweight, overweight and obesity, respectively ( 19 ). However, in terms of percentiles, overweight is applied when BMI is >85th percentile <95th percentile, whereas obesity is BMI > 95th percentile ( 20 – 22 ). Although BMI Z-scores can be converted to BMI percentiles, the percentiles need to be rounded and can misclassify some normal-weight children in the under or overweight category ( 19 ). Therefore, to prevent these inaccuracies and for easier understanding, it is recommended that the BMI Z-scores in children should be used in research whereas BMI percentiles are best used in the clinical settings ( 20 ).
As BMI does not directly measure body fat, it is an excellent screening method, but should not be used solely for diagnostic purposes ( 23 ). Using 85th percentile as a cut off point for healthy weight may miss an opportunity to obtain crucial information on diet, physical activity, and family history. Once this information is obtained, it may allow the provider an opportunity to offer appropriate anticipatory guidance to the families.
Pathophysiology of Obesity
The pathophysiology of obesity is complex that results from a combination of individual and societal factors. At the individual level, biological, and physiological factors in the presence of ones' own genetic risk influence eating behaviors and tendency to gain weight ( 1 ). Societal factors include influence of the family, community and socio-economic resources that further shape these behaviors ( Figure 1 ) ( 3 , 24 ).
Figure 1 . Multidimensional factors contributing to child and adolescent obesity.
There is a complex architecture of neural and hormonal regulatory control, the Gut-Brain axis, which plays a significant role in hunger and satiety ( Figure 2 ). Sensory stimulation (smell, sight, and taste), gastrointestinal signals (peptides, neural signals), and circulating hormones further contribute to food intake ( 25 – 27 ).
Figure 2 . Pictorial representation of the Hunger-Satiety pathway a and the various hormones b involved in the pathway. a, Y1/Y5R and MC3/4 are second order neuro receptors which are responsible in either the hunger or satiety pathway. Neurons in the ARC include: NPY, Neuropeptide Y; AgRP, Agouti-Related Peptide; POMC, Pro-Opiomelanocortin; CART, Cocaine-and Amphetamine-regulated Transcript; α-MSH, α-Melanocyte Stimulating Hormone. b, PYY, Peptide YY; PP, Pancreatic Polypeptide; GLP-1, Glucagon-Like Peptide- I; OMX, Oxyntomodulin.
The hypothalamus is the crucial region in the brain that regulates appetite and is controlled by key hormones. Ghrelin, a hunger-stimulating (orexigenic) hormone, is mainly released from the stomach. On the other hand, leptin is primarily secreted from adipose tissue and serves as a signal for the brain regarding the body's energy stores and functions as an appetite -suppressing (anorexigenic) hormone. Several other appetite-suppressing (anorexigenic) hormones are released from the pancreas and gut in response to food intake and reach the hypothalamus through the brain-blood barrier (BBB) ( 28 – 32 ). These anorexigenic and orexigenic hormones regulate energy balance by stimulating hunger and satiety by expression of various signaling pathways in the arcuate nucleus (ARC) of the hypothalamus ( Figure 2 ) ( 28 , 33 ). Dysregulation of appetite due to blunted suppression or loss of caloric sensing signals can result in obesity and its morbidities ( 34 ).
Emotional dysfunction due to psychiatric disorders can cause stress and an abnormal sleep-wake cycles. These modifications in biological rhythms can result in increased appetite, mainly due to ghrelin, and can contribute to emotional eating ( 35 ).
Recently, the role of changes in the gut microbiome with increased weight gain through several pathways has been described in literature ( 36 , 37 ). The human gut serves as a host to trillions of microorganisms, referred to as gut microbiota. The dominant gut microbial phyla are Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria, Fusobacteria, and Verrucomicrobia, with Firmicutes and Bacteroidetes representing 90% of human gut microbiota ( 5 , 38 ). The microbes in the gut have a symbiotic relationship within their human host and provide a nutrient-rich environment. Gut microbiota can be affected by various factors that include gestational age at birth, mode of infant delivery, type of neonatal and infant feeding, introduction of solid food, feeding practices and external factors like antibiotic use ( 5 , 38 ). Also, the maturation of the bacterial phyla that occurs from birth to adulthood ( 39 ), is influenced by genetics, environment, diet, lifestyle, and gut physiology and stabilizes in adulthood ( 5 , 39 , 40 ). Gut microbiota is unique to each individual and plays a specific role in maintaining structural integrity, and the mucosal barrier of the gut, nutrient metabolism, immune response, and protection against pathogens ( 5 , 37 , 38 ). In addition, the microbiota ferments the indigestible food and synthesizes other essential micronutrients as well as short chain fatty acids (SCFAs') ( 40 , 41 ). Dysbiosis or imbalance of the gut microbiota, in particularly the role of SCFA has been linked with the patho-physiology of obesity ( 36 , 38 , 41 , 42 ). SCFAs' are produced by anaerobic fermentation of dietary fiber and indigestible starch and play a role in mammalian energy metabolism by influencing gut-brain communication axis. Emerging evidence has shown that increased ratio of Firmicutes to Bacteroidetes causes increased energy extraction of calories from diets and is evidenced by increased production of short chain fatty acids (SCFAs') ( 43 – 45 ). However, this relationship is not affirmed yet, as a negative relationship between SCFA levels and obesity has also been reported ( 46 ). Due to the conflicting data, additional randomized control trials are needed to clarify the role of SCFA's in obese and non-obese individuals.
The gut microbiota also has a bidirectional interaction with the liver, and various additional factors such as diet, genetics, and the environment play a key role in this relationship. The Gut- Liver Axis is interconnected at various levels that include the mucus barrier, epithelial barrier, and gut microbiome and are essential to maintain normal homeostasis ( 47 ). Increased intestinal mucosal permeability can disrupt the gut-liver axis, which releases various inflammatory markers, activates an innate immune response in the liver, and results in a spectrum of liver diseases that include hepatic steatosis, non-alcoholic steatohepatitis (NASH), cirrhosis, and hepatocellular carcinoma (HCC) ( 48 , 49 ).
Other medical conditions, including type 2 Diabetes Mellitus, Metabolic Syndrome, eating disorders as well as psychological conditions such as anxiety and depression are associated with the gut microbiome ( 50 – 53 ).
Genetic causes of obesity can either be monogenic or polygenic types. Monogenic obesity is rare, mainly due to mutations in genes within the leptin/melanocortin pathway in the hypothalamus that is essential for the regulation of food intake/satiety, body weight, and energy metabolism ( 54 ). Leptin regulates eating behaviors, the onset of puberty, and T-cell immunity ( 55 ). About 3% of obese children have mutations in the leptin ( LEP ) gene and the leptin receptor (LEPR) and can also present with delayed puberty and immune dysfunction ( 55 , 56 ). Obesity caused by other genetic mutations in the leptin-melanocortin pathway include proopiomelanocortin (POMC) and melanocortin receptor 4 (MC4R), brain-derived neurotrophic factor (BDNF), and the tyrosine kinase receptor B (NTRK2) genes ( 57 , 58 ). Patients with monogenic forms generally present during early childhood (by 2 years old) with severe obesity and abnormal feeding behaviors ( 59 ). Other genetic causes of severe obesity are Prader Willi Syndrome (PWS), Alström syndrome, Bardet Biedl syndrome. Patients with these syndromes present with additional characteristics, including cognitive impairment, dysmorphic features, and organ-specific developmental abnormalities ( 60 ). Individuals who present with obesity, developmental delay, dysmorphic features, and organ dysfunction should receive a genetics referral for further evaluation.
Polygenic obesity is the more common form of obesity, caused by the combined effect of multiple genetic variants. It is the result of the interplay between genetic susceptibility and the environment, also known as the Gene-Environment Interaction (GEI) ( 61 – 64 ). Genome-wide association studies (GWAS) have identified gene variants [single nucleotide polymorphism (SNPs)] for body mass index (BMI) that likely act synergistically to affect body weight ( 65 ). Studies have identified genetic variants in several genes that may contribute to excessive weight gain by increasing hunger and food intake ( 66 – 68 ). When the genotype of an individual confers risk for obesity, exposure to an obesogenic environment may promote a state of energy imbalance due to behaviors that contribute to conserving rather than expending energy ( 69 , 70 ). Research studies have shown that obese individuals have a genetic variation that can influence their actions, such as increased food intake, lack of physical activity, a decreased metabolism, as well as an increased tendency to store body fat ( 63 , 66 , 67 , 69 , 70 ).
Recently the role of epigenetic factors in the development of obesity has emerged ( 71 ). The epigenetic phenomenon may alter gene expression without changing the underlying DNA sequence. In effect, epigenetic changes may result in the addition of chemical tags known as methyl groups, to the individual's chromosomes. This alteration can result in a phenomenon where critical genes are primed to on and off regulate. Complex physiological and psychological adjustment occur during infancy and can thereafter set the stage for health vs. disease. Developmental origins of health and disease (DOHaD) shows that early life environment can impact the risk of chronic diseases later in life due to fetal programming secondary to epigenetic changes ( 72 ). Maternal nutrition during the prenatal or early postnatal period may trigger these epigenetic changes and increase the risk for chronic conditions such as obesity, metabolic and cardiovascular disease due to epigenetic modifications that may persist and cause intergenerational effect on the health children and adults ( 58 , 73 , 74 ). Similarly, adverse childhood experiences (ACE) have been linked to a broad range of negative outcomes through epigenetic mechanisms ( 75 ) and promote unhealthy eating behaviors ( 76 , 77 ). Other factors such as diet, physical activity, environmental and psychosocial stressors can cause epigenetic changes and place an individual at risk for weight gain ( 78 ).
Eating behaviors evolve over the first few years of life. Young children learn to eat through their direct experience with food and observing others eating around them ( 79 ). During infancy, feeding defines the relationship of security and trust between a child and the parent. Early childhood eating behaviors shift to more self-directed control due to rapid physical, cognitive, communicative, and social development ( 80 ). Parents or caregivers determine the type of food that is made available to the infant and young child. However, due to economic limitations and parents having decreased time to prepare nutritious meals, consumption of processed and cheaper energy-dense foods have occurred in Western countries. Additionally, feeding practices often include providing large or super-sized portions of palatable foods and encouraging children to finish the complete meal (clean their plate even if they do not choose to), as seen across many cultures ( 81 , 82 ). Also, a segment of parents are overly concerned with dietary intake and may pressurize their child to eat what they perceive as a healthy diet, which can lead to unintended consequences ( 83 ). Parents' excessive restriction of food choices may result in poor self-regulation of energy intake by their child or adolescent. This action may inadvertently promote overconsumption of highly palatable restricted foods when available to the child or adolescent outside of parental control with resultant excessive weight gain ( 84 , 85 ).
During middle childhood, children start achieving greater independence, experience broader social networks, and expand their ability to develop more control over their food choices. Changes that occur in the setting of a new environment such as daycare or school allow exposure to different food options, limited physical activity, and often increased sedentary behaviors associated with school schedules ( 24 ). As the transition to adolescence occurs, physical and psychosocial development significantly affect food choices and eating patterns ( 25 ). During the teenage years, more independence and interaction with peers can impact the selection of fast foods that are calorically dense. Moreover, during the adolescent years, more sedentary behaviors such as video and computer use can limit physical exercise. Adolescence is also a period in development with an enhanced focus on appearance, body weight, and other psychological concerns ( 86 , 87 ).
Environmental changes within the past few decades, particularly easy access to high-calorie fast foods, increased consumption of sugary beverages, and sedentary lifestyles, are linked with rising obesity ( 88 ). The easy availability of high caloric fast foods, and super-sized portions, are increasingly common choices as individuals prefer these highly palatable and often less expensive foods over fruits and vegetables ( 89 ). The quality of lunches and snacks served in schools and childcare centers has been an area of debate and concern. Children and adolescents consume one-third to one-half of meals in the above settings. Despite policies in place at schools, encouraging foods, beverages, and snacks that are deemed healthier options, the effectiveness of these policies in improving children's dietary habits or change in obesity rate has not yet been seen ( 90 ). This is likely due to the fact that such policies primarily focus on improving dietary quality but not quantity which can impact the overweight or obese youth ( 91 ). Policies to implement taxes on sugary beverages are in effect in a few states in the US ( 92 ) as sugar and sugary beverages are associated with increased weight gain ( 2 , 3 ). This has resulted in reduction in sales of sugary drinks in these states, but the sales of these types of drinks has risen in neighboring states that did not implement the tax ( 93 ). Due to advancements in technology, children are spending increased time on electronic devices, limiting exercise options. Technology advancement is also disrupting the sleep-wake cycle, causing poor sleeping habits, and altered eating patterns ( 94 ). A study published on Canadian children showed that the access to and night-time use of electronic devices causes decreased sleep duration, resulting in excess body weight, inferior diet quality, and lower physical activity levels ( 95 ).
Infant nutrition has gained significant popularity in relation to causing overweight/obesity and other diseases later in life. Breast feeding is frequently discussed as providing protection against developing overweight/obesity in children ( 8 ). Considerable heterogeneity has been observed in studies and conducting randomized clinical trials between breast feeding vs. formula feeding is not feasible ( 8 ). Children fed with a low protein formula like breast milk are shown to have normal weight gain in early childhood as compared to those that are fed formulas with a high protein load ( 96 ). A recent Canadian childbirth cohort study showed that breast feeding within first year of life was inversely associated with weight gain and increased BMI ( 97 ). The effect was stronger if the child was exclusively breast fed directly vs. expressed breast milk or addition of formula or solid food ( 97 ). Also, due to the concern of poor growth in preterm or SGA infants, additional calories are often given for nutritional support in the form of macronutrient supplements. Most of these infants demonstrate “catch up growth.” In fact, there have been reports that in some children the extra nutritional support can increase the risk for overweight/obesity later in life. The association, however, is inconsistent. Recently a systemic review done on randomized controlled trials comparing the studies done in preterm and SGA infants with feeds with and without macronutrient supplements showed that macronutrient supplements may increase weight and length in toddlers but did not show a significant increase in the BMI during childhood ( 98 ). Increased growth velocity due to early introduction of formula milk and protein in infants' diet, may influence the obesity pathways, and can impact fetal programming for metabolic disease later in life ( 99 ).
General pediatricians caring for children with overweight/obesity, generally recommend endocrine testing as parents often believe that there may be an underlying cause for this condition and urge their primary providers to check for conditions such as thyroid abnormalities. Endocrine etiologies for obesity are rarely identified and patients with underlying endocrine disorders causing excessive weight gain usually are accompanied by attenuated growth patterns, such that a patient continues to gain weight with a decline in linear height ( 100 ). Various endocrine etiologies that one could consider in a patient with excessive weight gain in the setting of slow linear growth: severe hypothyroidism, growth hormone deficiency, and Cushing's disease/syndrome ( 58 , 100 ).
Clinical-Physiology of Pediatric Obesity
It is a well-known fact that early AR(increased BMI) before the age of 5 years is a risk factor for adult obesity, obesity-related comorbidities, and metabolic syndrome ( 101 – 103 ). Typically, body mass index (BMI) declines to a minimum in children before it starts increasing again into adulthood, also known as AR. Usually, AR happens between 5 and 7 years of age, but if it occurs before the age of 5 years is considered early AR. Early AR is a marker for higher risk for obesity-related comorbidities. These obesity-related health comorbidities include cardiovascular risk factors (hypertension, dyslipidemia, prediabetes, and type 2 diabetes), hormonal issues, orthopedic problems, sleep apnea, asthma, and fatty liver disease ( Figure 3 ) ( 9 ).
Figure 3 . Obesity related co-morbidities a in children and adolescents. a, NAFLD, Non-Alcoholic Fatty Liver Disease; SCFE, Slipped Capital Femoral Epiphysis; PCOS, Polycystic Ovary Syndrome; OSA, Obstructive Sleep Apnea.
Clinical Comorbidities of Obesity in Children
Growth and puberty.
Excess weight gain in children can influence growth and pubertal development ( 10 ). Childhood obesity can cause prepubertal acceleration of linear growth velocity and advanced bone age in boys and girls ( 104 ). Hyperinsulinemia is a normal physiological state during puberty, but children with obesity can have abnormally high insulin levels ( 105 ). Leptin resistance also occurs in obese individuals who have higher leptin levels produced by their adipose tissue ( 55 , 106 ). The insulin and leptin levels can act on receptors that impact the growth plates with a resultant bone age advancement ( 55 ).
Adequate nutrition is essential for the typical timing and tempo of pubertal onset. Excessive weight gain can initiate early puberty, due to altered hormonal parameters ( 10 ). Obese children may present with premature adrenarche, thelarche, or precocious puberty (PP) ( 107 ). The association of early pubertal changes with obesity is consistent in girls, and is well-reported; however, data is sparse in boys ( 108 ). One US study conducted in racially diverse boys showed obese boys had delayed puberty, whereas overweight boys had early puberty as compared to normal-weight boys ( 109 ). Obese girls with PP have high leptin levels ( 110 , 111 ). Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) is a cross-sectional study and suggested an indirect relationship between elevated leptin levels, early puberty, and cardiometabolic and inflammatory markers in obese girls ( 112 ). Additionally, obese girls with premature adrenarche carry a higher risk for developing polycystic ovary syndrome (PCOS) in the future ( 113 , 114 ).
Obesity is an independent risk factor for obstructive sleep apnea (OSA) in children and adolescents ( 12 , 115 ). Children with OSA have less deleterious consequences in terms of cardiovascular stress of metabolic syndrome when compared to adolescents and adults ( 116 , 117 ). In children, abnormal behaviors and neurocognitive dysfunction are the most critical and frequent end-organ morbidities associated with OSA ( 12 ). However, in adolescents, obesity and OSA can independently cause oxidative systemic stress and inflammation ( 118 , 119 ), and when this occurs concurrently, it can result in more severe metabolic dysfunction and cardiovascular outcomes later in life ( 120 ).
Obesity is related to a clinical spectrum of liver abnormalities such as NAFLD ( 121 ); the most important cause of liver disease in children ( 122 – 124 ). NAFLD includes steatosis (increased liver fat without inflammation) and NASH (increased liver fat with inflammation and hepatic injury). While in some adults NAFLD can progress to an end-stage liver disease requiring liver transplant ( 125 , 126 ), the risk of progression during childhood is less well-defined ( 127 ). NAFLD is closely associated with metabolic syndrome including central obesity, insulin resistance, type 2 diabetes, dyslipidemia, and hypertension ( 128 ).
Obese children are also at risk for slipped capital femoral epiphysis (SCFE) ( 129 ), and sedentary lifestyle behaviors may have a negative influence on the brain structure and executive functioning, although the direction of causality is not clear ( 130 , 131 ).
Clinical Comorbidities of Obesity in Adolescents
Menstrual irregularities and pcos.
At the onset of puberty, physiologically, sex steroids can cause appropriate weight gain and body composition changes that should not affect normal menstruation ( 132 , 133 ). However, excessive weight gain in adolescent girls can result in irregular menstrual cycles and puts them at risk for PCOS due to increased androgen levels. Additionally, they can have excessive body hair (hirsutism), polycystic ovaries, and can suffer from distorted body images ( 134 , 135 ). Adolescent girls with PCOS also have an inherent risk for insulin resistance irrespective of their weight. However, weight gain further exacerbates their existing state of insulin resistance and increases the risk for obesity-related comorbidities such as metabolic syndrome, and type 2 diabetes. Although the diagnosis of PCOS can be challenging at this age due to an overlap with predictable pubertal changes, early intervention (appropriate weight loss and use of hormonal methods) can help restore menstrual cyclicity and future concerns related to childbearing ( 11 ).
Metabolic Syndrome and Sleep Disorders
Metabolic syndrome (MS) is a group of cardiovascular risk factors characterized by acanthosis nigricans, prediabetes, hypertension, dyslipidemia, and non-alcoholic steatohepatitis (NASH), that occurs from insulin resistance caused by obesity ( 136 ). Diagnosis of MS in adults requires at least three out of the five risk factors: increased central adiposity, hypertension, hyperglycemia, hypertriglyceridemia, or low HDL level. Definitions to diagnose MS are controversial in younger age groups, and many definitions have been proposed ( 136 ). This is due to the complex physiology of growth and development during puberty, which causes significant overlap between MS and features of normal growth. However, childhood obesity is associated with an inflammatory state even before puberty ( 137 ). In obese children and adolescents, hyperinsulinemia during puberty ( 138 , 139 ) and unhealthy sleep behaviors increase MS's risk and severity ( 140 ). Even though there is no consensus on diagnosis regarding MS in this age group, when dealing with obese children and adolescents, clinicians should screen them for MS risk factors and sleep behaviors and provide recommendations for weight management.
Social Psychology of Pediatric Obesity in Children and Adolescents
Obese children and adolescents may experience psychosocial sequelae, including depression, bullying, social isolation, diminished self-esteem, behavioral problems, dissatisfaction with body image, and reduced quality of life ( 13 , 141 ). Compared with normal-weight counterparts, overweight/obesity is one of the most common reasons children and adolescents are bullied at school ( 142 ). The consequence of stigma, bullying, and teasing related to childhood obesity are pervasive and can have severe implications for emotional and physical health and performance that can persist later in life ( 13 ).
In adolescents, psychological outcomes associated with obesity are multifactorial and have a bidirectional relationship ( Figure 4 ). Obese adolescents due to their physique may have a higher likelihood of psychosocial health issues, including depression, body image/dissatisfaction, lower self-esteem, peer victimization/bullying, and interpersonal relationship difficulties. They may also demonstrate reduced resilience to challenging situations compared to their non-obese/overweight counterparts ( 9 , 143 – 146 ). Body image dissatisfaction has been associated with further weight gain but can also be related to the development of a mental health disorder or an eating disorder (ED) or disorder eating habits (DEH). Mental health disorders such as depression are associated with poor eating habits, a sedentary lifestyle, and altered sleep patterns. ED or DEH that include anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED) or night eating syndrome (NES) may be related to an individual's overvaluation of their body shape and weight or can result during the treatment for obesity ( 147 – 150 ). The management of obesity can place a patient at risk of AN if there is a rigid focus on caloric intake or if a patient overcorrects and initiates obsessive self-directed dieting. Healthcare providers who primarily care for obese patients, usually give the advice to diet to lose weight and then maintain it. However, strict dieting (hypocaloric diet), which some patients may later engage in can lead to an eating disorder such as anorexia nervosa ( 151 ). This behavior leads to a poor relationship with food, and therefore, adolescents perseverate on their weight and numbers ( 152 ).
Figure 4 . Bidirectional relationship of different psychological outcomes of obesity.
Providers may not recognize DEHs when a morbidly obese patient loses the same weight as a healthy weight individual ( 149 ). It may appear as a positive result with families and others praising the individual without realizing that this youth may be engaging in destructive behaviors related to weight control. Therefore, it is essential to screen regarding the process of how weight loss was achieved ( 144 , 150 ).
Support and attention to underlying psychological concerns can positively affect treatment, overall well-being, and reduce the risk of adult obesity ( 150 ). The diagram above represents the complexity of the different psychological issues which can impact the clinical care of the obese adolescent.
Eating family meals together can improve overall dietary intake due to enhanced food choices mirrored by parents. It has also may serve as a support to individuals with DEHs if there is less attention to weight and a greater focus on appropriate, sustainable eating habits ( 148 ).
Prevention and Anticipatory Guidance
It is essential to recognize and provide preventive measures for obesity during early childhood and adolescence ( 100 , 153 , 154 ). It is well-established that early AR is a risk factor for adult obesity ( 66 – 68 ). Therefore, health care providers caring for the pediatric population need to focus on measures such as BMI but provide anticipatory guidance regarding nutritional counseling without stigmatizing or judging parents for their children's overweight/obesity ( 155 ). Although health care providers continue to pursue effective strategies to address the obesity epidemic; ironically, they frequently exhibit weight bias and stigmatizing behaviors. Research has demonstrated that the language that health care providers use when discussing a patient's body weight can reinforce stigma, reduce motivation for weight loss, and potentially cause avoidance of routine preventive care ( 155 ). In adolescents, rather than motivating positive changes, stigmatizing language regarding weight may negatively impact a teen and result in binge eating, decreased physical activity, social isolation, avoidance of health care services, and increased weight gain ( 156 , 157 ). Effective provider-patient communication using motivational interviewing techniques are useful to encourage positive behavior changes ( 155 , 158 ).
Anticipatory guidance includes educating the families on healthy eating habits and identifying unhealthy eating practices, encouraging increased activity, limiting sedentary activities such as screen time. Lifestyle behaviors in children and adolescents are influenced by many sectors of our society, including the family ( Figure 1 ) ( 3 , 24 ). Therefore, rather than treating obesity in isolation as an individual problem, it is crucial to approach this problem by focusing on the family unit. Family-based multi-component weight loss behavioral treatment is the gold standard for treating childhood obesity, and it is having been found useful in those between 2 and 6 years old ( 150 , 159 ). Additionally, empowering the parents to play an equal role in developing and implementing an intervention for weight management has shown promising results in improving the rate of obesity by decreasing screen time, promoting healthy eating, and increasing support for children's physical activity ( 160 , 161 ).
When dietary/lifestyle modifications have failed, the next option is a structured weight -management program with a multidisciplinary approach ( 15 ). The best outcomes are associated with an interdisciplinary team comprising a physician, dietician, and psychologist generally 1–2 times a week ( 15 , 162 ). However, this treatment approach is not effective in patients with severe obesity ( 122 ). Although healthier lifestyle recommendations for weight loss are the current cornerstone for obesity management, they often fail. As clinicians can attest, these behavioral and dietary changes are hard to achieve, and all too often is not effective in patients with severe obesity. Failure to maintain substantial weight loss over the long term is due to poor adherence to the prescribed lifestyle changes as well as physiological responses that resist weight loss ( 163 ). American TV hosts a reality show called “The Biggest Loser” that centers on overweight and obese contestants attempting to lose weight for a cash prize. Contestants from “The Biggest Loser” competition, had metabolic adaptation (MA) after drastic weight loss, regained more than they lost weight after 6 years due to a significant slow resting metabolic rate ( 164 ). MA is a physiological response which is a reduced basal metabolic rate seen in individuals who are losing or have lost weight. In MA, the body alters how efficient it is at turning the food eaten into energy; it is a natural defense mechanism against starvation and is a response to caloric restriction. Plasma leptin levels decrease substantially during caloric restriction, suggesting a role of this hormone in the drop of energy expenditure ( 165 ).
The role of pharmacological therapy in the treatment of obesity in children and adolescents is limited.
Orlistat is the only FDA approved medication for weight loss in 12-18-year-olds but has unpleasant side effects ( 166 ). Another medicine, Metformin, has been used in children with signs of insulin resistance, may have some impact on weight, but is not FDA approved ( 167 ). The combination of phentermine/topiramate (Qsymia) has been FDA approved for weight loss in obese individuals 18 years and older. In studies, there has been about 9–10% weight loss over 2 years. However, caution must be taken in females as it can lead to congenital disabilities, especially with use in the first trimester of pregnancy ( 167 ).
GLP-1 agonists have demonstrated great success in effective weight loss and are approved by the FDA for adult obesity ( 168 – 170 ). A randomized control clinical trial recently published showed a significant weight loss in those using liraglutide (3.0 mg)/day plus lifestyle therapy group compared to placebo plus lifestyle therapy in children between the ages of 12–18 years ( 171 ).
Recently during the EASL conference, academic researchers and industry partners presented novel interventions targeting different gut- liver axis levels that include intestinal content, intestinal microbiome, intestinal mucosa, and peritoneal cavity ( 47 ). The focus for these therapeutic interventions within the gut-liver axis was broad and ranged anywhere from newer drugs protecting the intestinal mucus lining, restoring the intestinal barriers and improvement in the gut microbiome. One of the treatment options was Hydrogel technology which was shown to be effective toward weight loss in patients with metabolic syndrome. Hydrogel technology include fibers and high viscosity polysaccharides that absorb water in the stomach and increasing the volume, thereby improving satiety ( 47 ). Also, a clinical trial done in obese pregnant mothers using Docosahexaenoic acid (DHA) showed that the mothers' who got DHA had children with lower adiposity at 2 and 4 years of age ( 172 ). Recently the role of probiotics in combating obesity has emerged. Probiotics are shown to alter the gut microbiome that improves intestinal digestive and absorptive functions of the nutrients. Intervention including probiotics may be a possible solution to manage pediatric obesity ( 173 , 174 ). Additionally, the role of Vitamin E for treating the comorbidities of obesity such as diabetes, hyperlipidemia, NASH, and cardiovascular risk, has been recently described ( 175 , 176 ). Vitamin E is a lipid- soluble compound and contains both tocopherols and tocotrienols. Tocopherols have lipid-soluble antioxidants properties that interact with cellular lipids and protects them from oxidation damage ( 177 ). In metabolic disease, certain crucial pathways are influenced by Vitamin E and some studies have summarized the role of Vitamin E regarding the treatment of obesity, metabolic, and cardiovascular disease ( 178 ). Hence, adequate supplementation of Vitamin E as an appropriate strategy to help in the treatment of the prevention of obesity and its associated comorbidities has been suggested. Nonetheless, some clinical trials have shown contradictory results with Vitamin E supplementation ( 177 ). Although Vitamin E has been recognized as an antioxidant that protects from oxidative damage, however, a full understanding of its mechanism of action is still lacking.
Bariatric surgery has gained popularity since the early 2000s in the management of severe obesity. If performed earlier, there are better outcomes for reducing weight and resolving obesity-related comorbidities in adults ( 179 – 182 ). Currently, the indication for bariatric in adolescents; those who have a BMI >35 with at least one severe comorbidity (Type 2 Diabetes, severe OSA, pseudotumor cerebri or severe steatohepatitis); or BMI of 40 or more with other comorbidities (hypertension, hyperlipidemia, mild OSA, insulin resistance or glucose intolerance or impaired quality of life due to weight). Before considering bariatric surgery, these patients must have completed most of their linear growth and participated in a structured weight-loss program for 6 months ( 159 , 181 , 183 ). The American Society for Metabolic and Bariatric Surgery (AMBS) outlines the multidisciplinary approach that must be taken before a patient undergoing bariatric surgery. In addition to a qualified bariatric surgeon, the patient must have a pediatrician or provider specialized in adolescent medicine, endocrinology, gastroenterology and nutrition, registered dietician, mental health provider, and exercise specialist ( 181 ). A mental health provider is essential as those with depression due to obesity or vice versa may have persistent mental health needs even after weight loss surgery ( 184 ).
Roux-en-Y Gastric Bypass (RYGB), laparoscopic Sleeve Gastrectomy (LSG), and Gastric Banding are the options available. RYGB and LSG currently approved for children under 18 years of age ( 166 , 181 , 185 ). At present, gastric banding is not an FDA recommended procedure in the US for those under 18y/o. One study showed some improvements in BMI and severity of comorbidities but had multiple repeat surgeries and did not believe a suitable option for obese adolescents ( 186 ).
Compared to LSG, RYGB has better outcomes for excess weight loss and resolution of obesity-related comorbidities as shown in studies and clinical trials ( 183 , 184 , 187 ). Overall, LSG is a safer choice and may be advocated for more often ( 179 – 181 ). The effect on the Gut-Brain axis after Bariatric surgery is still inconclusive, especially in adolescents, as the number of procedures performed is lower than in adults. Those who underwent RYGB had increased fasting and post-prandial PYY and GLP-1, which could have contributed to the rapid weight loss ( 185 ); this effect was seen less often in patients with gastric banding ( 185 ). Another study in adult patients showed higher bile acid (BA) subtype levels and suggested a possible BA's role in the surgical weight loss response after LSG ( 188 ). Adolescents have lower surgical complication rates than their adult counterparts, hence considering bariatric surgery earlier rather than waiting until adulthood has been entertained ( 180 ). Complications after surgery include nutritional imbalance in iron, calcium, Vitamin D, and B12 and should be monitored closely ( 180 , 181 , 185 ). Although 5-year data for gastric bypass in very obese teens is promising, lifetime outcome is still unknown, and the psychosocial factors associated with adolescent adherence post-surgery are also challenging and uncertain.
Obesity in childhood and adolescence is not amenable to a single easily modified factor. Biological, cultural, and environmental factors such as readily available high-density food choices impact youth eating behaviors. Media devices and associated screen time make physical activity a less optimal choice for children and adolescents. This review serves as a reminder that the time for action is now. The need for interventions to change the obesogenic environment by instituting policies around the food industry and in the schools needs to be clarified. In clinical trials GLP-1 agonists are shown to be effective in weight loss in children but are not yet FDA approved. Discovery of therapies to modify the gut microbiota as treatment for overweigh/obesity through use of probiotics or fecal transplantation would be revolutionary. For the present, ongoing clinical research efforts in concert with pharmacotherapeutic and multidisciplinary lifestyle programs hold promise.
AK, SL, and MJ contributed to the conception and design of the study. All authors contributed to the manuscript revision, read, and approved the submitted version.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: obesity, childhood, review (article), behavior, adolescent
Citation: Kansra AR, Lakkunarajah S and Jay MS (2021) Childhood and Adolescent Obesity: A Review. Front. Pediatr. 8:581461. doi: 10.3389/fped.2020.581461
Received: 08 July 2020; Accepted: 23 November 2020; Published: 12 January 2021.
Copyright © 2021 Kansra, Lakkunarajah and Jay. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Alvina R. Kansra, firstname.lastname@example.org
This article is part of the Research Topic
Pediatric Obesity: From the Spectrum of Clinical-Physiology, Social-Psychology, and Translational Research