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Wednesday, January 23, 2013

Childhood Obesity: A Serious Public Health Concern

Obesity means having too much body fat. It is different from being overweight, which means weighing too much. Both terms mean that a person's weight is greater than what is considered healthy for his or her height. Children grow at different rates, so it isn't always easy to know when a child is obese or overweight. Ask your doctor to measure your child's height and weight to determine if he or she is in a healthy range.

If a weight loss program is necessary, involve the whole family in healthy habits so your child doesn't feel singled out. You can encourage healthy eating by serving more fruits and vegetables and buying fewer sodas and high-calorie, high-fat snack foods. Physical activity can also help your child overcome obesity or being overweight. Kids need about 60 minutes each day
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Source: NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Photo Credit: Jim Gathany. Public Health Image Library, Centers for Disease Control and Prevention ID#5708
Childhood obesity is a condition where excess body fat negatively affects a child's health or wellbeing. As methods to determine body fat directly are difficult, the diagnosis of obesity is often based on BMI. Due to the rising prevalence of obesity in children and its many adverse health effects it is being recognized as a serious public health concern.[1] The term overweight rather than obese is often used in children as it is less stigmatizing.[2]

Classification

Body mass index (BMI) is acceptable for determining obesity for children two years of age and older.[3] The normal range for BMI in children vary with age and sex.

Childhood obesity BMI Boys (above). CDC Growth Charts: United States, Boys 2 - 20 years old, 2000. BMI for age percentiles for boys 2 to 20 years of age. For larger image see Centers for Disease Control and Prevention (CDC).
Childhood obesity BMI Girls. CDC Growth Charts: United States, Girls 2 - 20 years old, 2000. BMI for age percentiles for girls 2 to 20 years of age. For larger image see Centers for Disease Control and Prevention (CDC).

The Centers for Disease Control and Prevention defines obesity as a BMI greater than or equal to the 95th percentile. It has published tables for determining this in children.[4]


Effects on Health

The first problems to occur in obese children are usually emotional or psychological.[5] Childhood obesity however can also lead to life-threatening conditions including diabetes, high blood pressure, heart disease, sleep problems, cancer, and other disorders.[6][7] 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.[8] Studies have shown that overweight children are more likely to grow up to be overweight adults.[7] Obesity during adolescence has been found to increase mortality rates during adulthood.[9]

Obese children often suffer from teasing by their peers.[10][11] Some are harassed or discriminated against by their own family.[11] Stereotypes abound and may lead to low self-esteem and depression.[12]

A 2008 study has found that children who are obese have carotid arteries which have prematurely aged by as much as thirty years as well as abnormal levels of cholesterol.[13]

Per the Centers for Disease Control and Prevention (CDC), the percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 20% in 2008. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to 18% over the same period. http://www.cdc.gov/healthyyouth/obesity/facts.htm

Effects of obesity on body systems:

Endocrine
  • Impaired glucose tolerance
  • Diabetes mellitus
  • Metabolic syndrome
  • Hyperandrogenism
  • Effects on growth and puberty
  • Nulliparity and nulligravidity[14]

Gastrointestinal:
  • Nonalcoholic fatty liver disease
  • Cholelithiasis

Musculoskeletal:
  • Slipped capital femoral epiphysis (SCFE)
  • Tibia vara (Blount disease)

Psychosocial:
  • Distorted peer relationships
  • Poor self-esteem [15]
  • Anxiety
  • Depression

Cardiovascular:
  • Hypertension
  • Hyperlipidemia
  • Increased risk of coronary heart disease as an adult

Respiratory:
  • Obstructive sleep apnea
  • Obesity hypoventilation syndrome

Neurological:
  • Idiopathic intracranial hypertension

Skin:
  • Furunculosis
  • Intertrigo 

Long Term Effects on Health

Children who are obese are likely to be obese as adults.Thus, they are more at risk for adult health problems[16] such as heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis.One study showed that children who became obese as early as age 2 were more likely to be obese as adults.[17]

Obesity now affects 17% of all children and adolescents in the United States - triple the rate from just one generation ago. Source: Centers for Disease Control and Prevention (CDC)

Causes

Childhood obesity can be brought on by a range of factors which often act in combination.[18][19][20][21][22] The greatest risk factor for child obesity is the obesity of both parents. This may be reflected by the family's environment and genetics.[23] Other reasons may also be due to psychological factors and the child's body type. A 2010 review stated that childhood obesity likely is the result of the interaction of natural selection favouring those with more parsimonious energy metabolism and today's consumerist society with easy access to energy dense cheap foods and less energy requirements in daily life.[24]

Prevention

"Obesity of mothers predisposes their offsprings to obesity by epigenetic, prenatal effects." Prevention and awareness programs should target children as early as kindergarten with the involvement of parents. The approaches include changing the environment children are in. For example, the banning of pop being sold at vending machines in school.[25]

Dietary

The effects of eating habits on childhood obesity are difficult to determine. A three year randomized controlled study of 1,704 3rd grade children which provided two healthy meals a day in combination with an exercise program and dietary counsellings failed to show a significant reduction in percentage body fat when compared to a control group. This was partly due to the fact that even though the children believed they were eating less their actual calorie consumption did not decrease with the intervention. At the same time observed energy expenditure remained similar between the groups. This occurred even though dietary fat intake decreased from 34% to 27%.[26] A second study of 5,106 children showed similar results. Even though the children ate an improved diet there was no effect found on BMI.[27] Why these studies did not bring about the desired effect of curbing childhood obesity has been attributed to the interventions not being sufficient enough. Changes were made primarily in the school environment while it is felt that they must occur in the home, the community, and the school simultaneously to have a significant effect.[28]

Calorie-rich drinks and foods are readily available to children. Consumption of sugar-laden soft drinks may contribute to childhood obesity. In a study of 548 children over a 19 month period the likelihood of obesity increased 1.6 times for every additional soft drink consumed per day.[29]

Calorie-dense, prepared snacks are available in many locations frequented by children. As childhood obesity has become more prevalent, snack vending machines in school settings have been reduced by law in a small number of localities. Eating at fast food restaurants is very common among young people with 75% of 7th to 12th grade students consuming fast food in a given week.[30] The fast food industry is also at fault for the rise in childhood obesity. This industry spends about $4.2 billion on advertisements aimed at young children. McDonald's alone has thirteen websites that are viewed by 365,000 children and 294,000 teenagers each month. In addition, fast food restaurants give out toys in children's meals, which helps to entice children. Forty percent of children ask their parents to take them to fast food restaurants on a daily basis. To make matters worse, out of 3000 combinations created from popular items on children's menus at fast food restaurants, only 13 meet the recommended nutritional guidelines for young children.[31] Some literature has found a relationship between fast food consumption and obesity.[32] Including a study which found that fast food restaurants near schools increases the risk of obesity among the student population.[33]

Whole milk consumption verses 2% milk consumption in children of one to two years of age had no effect on weight, height, or body fat percentage. Therefore, whole milk continues to be recommended for this age group. However the trend of substituting sweetened drink for milk has been found to lead to excess weight gain.[34]

Physical Activity

Physical inactivity of children has also shown to be a serious cause, and children who fail to engage in regular physical activity are at greater risk of obesity. Researchers studied the physical activity of 133 children over a three week period using an accelerometer to measure each child's level of physical activity. They discovered the obese children were 35% less active on school days and 65% less active on weekends compared to non-obese children.

Physical inactivity as a child could result in physical inactivity as an adult. In a fitness survey of 6,000 adults, researchers discovered that 25% of those who were considered active at ages 14 to 19 were also active adults, compared to 2% of those who were inactive at ages 14 to 19, who were now said to be active adults.[35] Staying physically inactive leaves unused energy in the body, most of which is stored as fat. Researchers studied 16 men over a 14 day period and fed them 50% more of their energy required every day through fats and carbohydrates. They discovered that carbohydrate overfeeding produced 75–85% excess energy being stored as body fat and fat overfeeding produced 90–95% storage of excess energy as body fat.[36]

Many children fail to exercise because they are spending time doing stationary activities such as computer usage, playing video games or watching television. TV and other technology may be large factors of physically inactive children. Researchers provided a technology questionnaire to 4,561 children, ages 14, 16, and 18. They discovered children were 21.5% more likely to be overweight when watching 4+ hours of TV per day, 4.5% more likely to be overweight when using a computer one or more hours per day, and unaffected by potential weight gain from playing video games.[36] A randomized trial showed that reducing TV viewing and computer use can decrease age-adjusted BMI; reduced calorie intake was thought to be the greatest contributor to the BMI decrease.[37]

Technological activities are not the only household influences of childhood obesity. Low-income households can affect a child's tendency to gain weight. Over a three week period researchers studied the relationship of socioeconomic status (SES) to body composition in 194 children, ages 11–12. They measured weight, waist girth, stretch stature, skinfolds, physical activity, TV viewing, and SES; researchers discovered clear SES inclines to upper class children compared to the lower class children.[38]

Childhood inactivity is linked to obesity in the United States with more children being overweight at younger ages. In a 2009 preschool study 89% of a preschoolers' day was found to be sedentary while the same study also found that even when outside, 56 percent of activities were still sedentary. One factor believed to contribute to the lack of activity found was little teacher motivation,[39] but when toys, such as balls were made available, the children were more likely to play.[39]

Genetics

Childhood obesity is often the result of an interplay between many genetic and environmental factors. Polymorphisms in various genes controlling appetite and metabolism predispose individuals to obesity when sufficient calories are present. As such obesity is a major feature of a number of rare genetic conditions that often present in childhood.

In children with early-onset severe obesity (defined by an onset before ten years of age and body mass index over three standard deviations above normal), 7% harbor a single locus mutation.[40] One study found that 80% of the offspring of two obese parents were obese in contrast to less than 10% of the offspring of two parents who were of normal weight.[1][28] The percentage of obesity that can be attributed to genetics varies from 6% to 85% depending on the population examined.[41] 

Developmental Factors

Various developmental factors may affects rates of obesity. Breast-feeding for example may protect against obesity in later life with the duration of breast-feeding inversely associated with the risk of being overweight later on.[45] A child's body growth pattern may influence the tendency to gain weight. Researchers measured the standard deviation (SD [weight and length]) scores in a cohort study of 848 babies. They found that infants who had an SD score above 0.67 had catch up growth (they were less likely to be overweight) compared to infants who had less than a 0.67 SD score (they were more likely to gain weight).[46] A child's weight may be influenced when he/she is only an infant. A nationally representative sample of US preschoolers found that infants whose early weight status was normal tended to retain a normal weight status and not to develop an unfavorable status (at-risk, obese). In contrast, children who were obese at an early age were more likely to have an at-risk or obese weight category at a later age.[47] Researchers also did a cohort study on 19,397 babies, from their birth until age seven and discovered that fat babies at four months were 1.38 times more likely to be overweight at seven years old compared to normal weight babies. Fat babies at the age of one were 1.17 times more likely to be overweight at age seven compared to normal weight babies.[48] 

Medical Illness

Cushing's syndrome (a condition in which the body contains excess amounts of cortisol) may also influence childhood obesity. Researchers analyzed two isoforms (proteins that have the same purpose as other proteins, but are programmed by different genes) in the cells of 16 adults undergoing abdominal surgery. They discovered that one type of isoform created oxo-reductase activity (the alteration of cortisone to cortisol) and this activity increased 127.5 pmol mg sup when the other type of isoform was treated with cortisol and insulin. The activity of the cortisol and insulin can possibly activate Cushing's syndrome.[49] Hypothyroidism is a hormonal cause of obesity, but it does not significantly affect obese people who have it more than obese people who do not have it. In a comparison of 108 obese patients with hypothyroidism to 131 obese patients without hypothyroidism, researchers discovered that those with hypothyroidism had only 0.077 points more on the caloric intake scale than did those without hypothyroidism.[50] 

Psychological Factors

Researchers surveyed 1,520 children, ages 9–10, with a four year follow up and discovered a positive correlation between obesity and low self-esteem in the four year follow up. They also discovered that decreased self-esteem led to 19% of obese children feeling sad, 48% of them feeling bored, and 21% of them feeling nervous. In comparison, 8% of normal weight children felt sad, 42% of them felt bored, and 12% of them felt nervous.[51] Stress can influence a child's eating habits. Researchers tested the stress inventory of 28 college females and discovered that those who were binge eating had a mean of 29.65 points on the perceived stress scale, compared to the control group who had a mean of 15.19 points.[52] This evidence may demonstrate a link between eating and stress.
Feelings of depression can cause a child to overeat. Researchers provided an in-home interview to 9,374 adolescents, in grades seven through 12 and discovered that there was not a direct correlation with children eating in response to depression. Of all the obese adolescents, 8.2% had said to be depressed, compared to 8.9% of the non-obese adolescents who said they were depressed.[53] Antidepressants, however, seem to have very little influence on childhood obesity. Researchers provided a depression questionnaire to 487 overweight/obese subjects and found that 7% of those with low depression symptoms were using antidepressants and had an average BMI score of 44.3, 27% of those with moderate depression symptoms were using antidepressants and had an average BMI score of 44.7, and 31% of those with major depression symptoms were using antidepressants and had an average BMI score of 44.2.[54] 

Management

The escalation of obese children is due to the upsurge of technology, increase in snacks and portion size of meals, and the decrease in the physical activity of children. If children were more mobile and less sedentary, the rate of obesity would decrease. Children have to put down the electronic devices and spend more time outside playing or exploring other options of physical acitvity. A study found kids that use electronic devices 3 or more hours a day had between a 17- 44% increased risk of being overweight, or a 10- 61% increased risk of obese (Cespedes 2011). Parents have to recognize the signs and encourage their children to be more physically active. There are many programs designed to encourage activities such as Letsmove.gov, a program launched by the first lady, Michelle Obama to help combat problems with this epidemic of obesity. 

Lifestyle

Exclusive breast-feeding is recommended in all newborn infants for its nutritional and other beneficial effects.[45] Parents could change the diet and lifestyle of their offspring by offering appropriate food portions, increasing physical activity, and keeping sedentary behaviors at a minimum. This may also decrease the obesity levels in children.[55] 

Medications

There are no medications currently approved for the treatment of obesity in children. Orlistat and sibutramine may however be helpful in managing moderate obesity in adolescence.[45] Sibutramine is approved for adolescents older than 16. It works by altering the brain's chemistry and decreasing appetite. Orlistat is approved for adolescents older than 12. It works by preventing the absorption of fat in the intestines.[56] 

Epidemiology

Rates of childhood obesity have increased greatly between 1980 and 2010.[55] Currently 10% of children worldwide are either overweight or obese.[2] 

Canada
The rate of overweight and obesity among Canadian children has increased dramatically in recent years. In boys, the rate increased from 11% in 1980s to 30% in 1990s.[57] 

Brazil
The rate of overweight and obesity in Brazilian children increased from 4% in the 1980s to 14% in the 1990s.[57] 

United States
The rate of obesity among children and adolescents in the United States has nearly tripled between the early 1980s and 2000. It has however not changed significantly between 2000 and 2006 with the most recent statistics showing a level just over 17 percent.[58] In 2008, the rate of overweight and obese children in the United States was 32%, and had stopped climbing.[59]

Childhood obesity Diagram-trends in obesity. Prevalence of overweight among children 2 to 19 years in the U.S.A. Author: Cynthia Ogden, Ph.D., and Margaret Carroll, M.S.P.H. For larger image see Centers for Disease Control and Prevention (CDC).
In 2011, a national cohort study of infants and toddlers found that nearly one-third of US children were overweight or obese at 9 months and 2 years old.[60] Infant weight status was strongly associated with preschool weight status.[61] 

Australia
Since the onset of the 21st Century, Australia has found that childhood obesity has followed trend with the United States. Information garnered has concluded that the increase has occurred in the lower socioeconomic areas where poor nutritional education has been blamed. 

Research

A study of 1800 children aged 2 to 12 in Colac, Australia tested a program of restricted diet (no carbonated drinks or sweets) and increased exercise. Interim results included a 68% increase in after school activity programs, 21% reduction in television viewing, and an average of 1 kg weight reduction compared to a control group.[62]

A survey carried out by the American Obesity Association into parental attitudes towards their children's weight showed the majority of parents think that recess should not be reduced or replaced. Almost 30% said that they were concerned with their child's weight. 35% of parents thought that their child's school was not teaching them enough about childhood obesity, and over 5% thought that childhood obesity was the greatest risk to their child's long term health.[63]

A Northwestern University study indicates that inadequate sleep has a negative impact on a child's performance in school, their emotional and social welfare, and increases their risk of being overweight. This study was the first nationally represented, longitudinal investigation of the correlation between sleep, Body Mass Index (BMI) and overweight status in children between the ages of 3 and 18. The study found that an extra hour of sleep lowered the children's risk of being overweight from 36% to 30%, while it lessened older children's risk from 34% to 30%.[64]

Obese children and adolescents are more likely to become obese as adults. For example, one study found that approximately 80% of children who were overweight at aged 10–15 years were obese adults at age 25 years. Another study found that 25% of obese adults were overweight as children. The latter study also found that if overweight begins before 8 years of age, obesity in adulthood is likely to be more severe.[65]

A study has also found that tackling childhood obesity will not necessarily lead to eating disorders later in life.[66]

A review of secular trends in the number of overweight or obese children have come to the conclusion that prevalence had increased during the past two decades in the most industrialised countries, apart from Russia and Poland, and in several low-income countries, especially in urban areas. Prevalence doubled or tripled between the early 1970s and late 1990s in Australia, Brazil, Canada, Chile, Finland, France, Germany, Greece, Japan, the UK, and the USA. By 2010, more than 40% of children in the North American and eastern Mediterranean WHO regions, 38% in Europe, 27% in the western Pacific, and 22% in southeast Asia were predicted to be overweight or obese. However, that 2006 review pre-dates recent data, which, although still too soon to be certain, suggest that the increase in childhood obesity in the USA, the UK, and Sweden might be abating.3–5[67] 

External Links 

Children’s Food Environment State Indicator Report, 2011 - Centers for Disease Control and Prevention (CDC).
A Growing Problem: What causes childhood obesity? - Centers for Disease Control and Prevention (CDC).
Childhood Obesity - Mayo Foundation for Medical Education and Research.
Childhood Obesity: Common Misconceptions - American Academy of Pediatrics.
Obesity and Overweight Overview - National Institute of Child Health and Human Development.
Overweight and Obesity: Strategies and Solutions - Centers for Disease Control and Prevention (CDC).
BMI Percentile Calculator for Child and Teen English Version - Centers for Disease Control and Prevention (CDC).
Tips for Parents – Ideas to Help Children Maintain a Healthy Weight - Centers for Disease Control and Prevention (CDC).

Diagnosis/Symptoms
About BMI for Children and Teens - Centers for Disease Control and Prevention.

Treatment
Medical Measures to Treat Childhood Obesity - American Academy of Pediatrics.

Prevention/Screening
Balance Food and Activity - National Heart, Lung, and Blood Institute.
Healthy, Active Living for Families - American Academy of Pediatrics.
Families Finding the Balance: A Parent Handbook - National Heart, Lung, and Blood Institute.

Nutrition
Dietary Recommendations for Healthy Children - American Heart Association.

Coping
The Emotional Toll of Obesity - American Academy of Pediatrics.
Teasing and Bullying of Obese and Overweight Children: How Parents Can Help - American Academy of Pediatrics.

Specific Conditions
Fact Sheet: Pediatric Obesity and Ear, Nose, and Throat Disorders - American Academy of Otolaryngology-Head and Neck Surgery.

Related Issues
Common Weight Loss Challenges - American Academy of Pediatrics.
Is My Child's Appetite Normal? - Food and Nutrition Service.
Organic Causes of Weight Gain and Obesity - American Academy of Pediatrics.
 
Video
Making Health Easier: Healthy Changes Start in Preschool - Centers for Disease Control and Prevention (CDC).
BMI Rebound: An Obesity Clue - American Academy of Pediatrics.

Clinical Trials
ClinicalTrials.gov: Obesity and Children, Overweight and Children - National Institutes of Health.

Research
Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation - Institute of Medicine.
Nutrition/Obesity Research Centers (NORCs) - Weight Control Information Network (WIN), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
Obesity Research funded by NIDDK - National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
Strategic Plan for NIH Obesity Research - National Institutes of Health (NIH).
Office of Obesity Research - National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Directories
Find a Registered Dietitian - Academy of Nutrition and Dietetics.

Organizations
Physical Activity for Everyone: How much physical activity do you need?. Provides information about physical activity for you and your children.
Nutrition for Everyone: Fruits and Vegetables. Great recipes and information about how to incorporate fruits and vegetables in your daily meals.
How to Avoid Portion Size Pitfalls to Help Manage Your Weight. Confused about portion sizes? Play the CDC's portion control game!
Let's Move!. Program developed by First Lady Michelle Obama to solve the epidemic of childhood obesity within a generation.
Choose My Plate.gov. Provides a tailored explanation of how to balance your meals and includes an interactive game for kids.
We Can! This national education program is designed for parents and caregivers to help children 8-13 years old stay at a healthy weight. The booklet Families Finding the Balance: A Parent Handbook offers an array of easy to use practical tips and tools for parents and guardians to help their children and families eat healthy, increase physical activity, and decrease screen time.

Children
For Parents: Body Mass Index (BMI) Charts - Nemours Foundation.
What "Being Overweight" Means - Nemours Foundation. 
Is Dieting OK for Kids? - Nemours Foundation.
Keeping Portions Under Control - Nemours Foundation.
Low Fat Diets for Babies - American Academy of Pediatrics.

For Kids Only
BAM! Body and Mind. Have fun, stay active and healthy.
Blast Off Game. Learn what it takes to blast off in the food pyramid space shuttle!
Best Bones Forever! A bone health campaign for girls and their BFFs to "grow strong together and stay strong forever!"
Eat Smart, Play Hard: Power Panther Sticker and Activity Book Hey! It's what you do.

Teenagers
Dealing With Feelings When You're Overweight - Nemours Foundation.
Emotional Eating - Nemours Foundation.
Obesity's Impact on Teen Health - American Academy of Pediatrics.
How Can I Lose Weight Safely? - Nemours Foundation.
Should I Gain Weight? - Nemours Foundation.
Take Charge of Your Health: A Guide for Teenagers - National Institute of Diabetes and Digestive and Kidney Diseases.

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