Professional Documents
Culture Documents
a
BHSc ,
Catherine Birken,
b
MD, FRCPC ,
Jill Hamilton,
MD, FRCPC
a,
KEYWORDS
Childhood Adolescent Obesity Cardiometabolic risk Lifestyle interventions
Prevention
KEY POINTS
Routine body mass index (BMI) screening of children on age-appropriate growth charts is
necessary to identify those requiring further assessment.
Central adiposity is associated with increased risk for type 2 diabetes (T2DM), dyslipidemia, hypertension, sleep-disordered breathing, nonalcoholic fatty liver disease, and polycystic ovarian syndrome (PCOS).
Family-centered behavior therapy should focus on small goals to improve nutritional
intake and physical activity and reduce sedentary behaviors.
Studies demonstrate modest weight loss of 5% to 10% with improvement in cardiometabolic parameters.
Psychosocial stressors and comorbidities may make behavior change difficult; empathetic counseling using techniques such as motivational interviewing may be useful adjuncts to therapy.
Prevention strategies must be implemented across various domains, as children are influenced in the context of their families, cultures, communities, and on a broader population
level.
BACKGROUND
Obesity prevalence has increased during the past decades in children and adolescents, leading to a significant current and future health burden.1 In North America,
approximately one-third of children are either overweight or obese.2,3 Although the
overall proportion of children with obesity may be plateauing, the rates of severe
obesity in children continue to rise, particularly in very young children.25 Furthermore,
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the incidence of overweight/obesity for children younger than 5 years in low- and
middle-income countries is higher than the rates of wasting.6 As obesity tends to track
into adulthood, especially for those with the most severe degrees of obesity and in
older age groups, prevention and intervention strategies should begin at the earliest
age possible.7
Overweight and obesity in children are assessed clinically by calculation of BMI, obtained by dividing weight (in kilograms) by height squared (square meters). BMI values
can be plotted on age- and sex-specific growth charts. Several definitions of pediatric
obesity exist, as defined by growth charts compiled by the Centers for Disease Control
(CDC), the World Health Organization (WHO), and the International Obesity Task
Force.8 Most commonly, overweight is defined as BMI 85th to 95th percentile (CDC)
or 85th to 97th percentile (WHO) and obesity as greater than or equal to 95th percentile
(CDC) or greater than or equal to 97th percentile (WHO).9,10
ETIOLOGY/RISK FACTORS
Several dietary factors including higher caloric food intake during infancy, introduction
of solid foods before 6 months of age, higher consumption of sweetened drinks (juice,
soda), increased fast food consumption, eating while watching television (TV), skipping breakfast, reduced family meal times eating together, and lower daily milk, fruit,
Childhood Obesity
and vegetable intake have all been associated with increased rates of childhood
obesity.12,13,23,24
Most guidelines recommend 60 minutes of moderate to vigorous daily physical activity for children and adolescents. In Canada, approximately 93% and 96% of Canadian children aged 5 to 11 and 12 to 17 years, respectively, fail to meet these
guidelines.20,25 Low habitual levels of physical activity are associated with higher
obesity incidence in multiple studies.12,16,20 Sedentary behavior, in particular time
spent at the TV or computer screen, is associated with higher BMIs,20 although systematic reviews examining reduced screen time showed no effect on BMI in
children.26
Obesity and sociodemographic influences
Cross-sectional studies have shown that members of certain ethnic groups (eg,
Aboriginal, Hispanic, and South Asian) are more prone to obesity during childhood.
Children from low-income countries with greater food security are more prone to
becoming obese, as are those in urban areas as compared with children in rural areas.
In high-income countries, children in the lowest socioeconomic classes have higher
obesity rates in comparison to children from a more affluent socioeconomic
position.12
Pathologic Causes of Obesity
Endocrine causes
Rare single gene defects, which specifically result in obesity, are those that affect the
leptin-melanocortin regulating pathway.12,13,29 The genes identified thus far include
leptin, the leptin receptor, proopiomelanocortin, prohormone convertase 1, melanocortin receptors (MCR) 3 and 4, and the transcription factor single-minded 1. Of these,
only MCR4 mutations are common, accounting for approximately 4% of early-onset
and childhood cases of severe obesity.29,30 There are also several genetic syndromes
associated with obesity, including Prader-Willi, Bardet-Biedl, Alstrom, and WAGR
(Wilms tumor, aniridia, genitourinary anomaly, mental retardation) syndromes, which
generally exhibit some degree of neurocognitive delay and characteristic dysmorphic
features.12,30
Common genetic variants associated with high adiposity and weight gain, but having weak individual effects, have been identified through genome-wide association
studies, although no single variant contributes in a large way to predict obesity.12
Other causes
Central nervous system tumors such as craniopharyngioma located in the hypothalamic region and the subsequent surgery to debulk these tumors can result in reduced
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satiety, resistance to insulin and leptin, and enhanced insulin secretion due to autonomic dysregulation.31 The net result of these physiologic changes leads to rapid
and unrelenting weight gain.12,16,28 Lastly, medication-induced obesity can occur
from the use of atypical antipsychotics and high-dose glucocorticoids.12,16
COMORBIDITIES/CONSEQUENCES OF CHILDHOOD OBESITY
There are multiple potential comorbidities associated with obesity, many of which
track into adulthood.11 However, not all overweight or obese children exhibit medical
or psychological sequelae; a subset of individuals may exhibit no clinical complications or health risks related to their weight.32
In adults, the metabolic syndrome is defined as a clustering of features including insulin resistance/elevated glucose, hypertension, abdominal obesity and dyslipidemia
that portends risk for T2DM, and cardiovascular disease.33 The metabolic syndrome is
also prevalent in other conditions linked to insulin resistance, such as PCOS and
nonalcoholic fatty liver disease (NAFLD).13,16 In children and adolescents, features
of the metabolic syndrome cluster in a similar fashion, although there is no single
accepted definition.34 A systematic review of studies performed in the pediatric age
range indicates a prevalence of metabolic syndrome in population-based studies of
3.3%, 11.9%, and 29.2% of normal-weight, overweight, and obese children,
respectively.35
There is compelling evidence that the obesity-associated dyslipidemia tracks from
early life into adulthood.36,37 In a report from the Bogalusa Heart Study, pathology
studies of children and young adults aged 2 to 39 years who died primarily from traumatic injuries, fatty streaks in the aorta and coronary arteries were documented early
in life, and these atherosclerotic changes were associated with elevated cholesterol
and higher BMI.38 In the large population-based US study, the National Health and
Nutrition Examination Survey (NHANES) reported that the overall prevalence of dyslipidemia in children and adolescents is 20.3% and increases to 42.9% in obese
youth.39 Recommendations supporting the use of nonhigh-density lipoprotein
(HDL) cholesterol (calculated as total cholesterol HDL cholesterol) have been published, with further evaluation with fasting lipid profile if non-HDL cholesterol is
abnormal.40
Hypertension is defined as elevated systolic or diastolic blood pressure (BP) greater
than or equal to 95th percentile for age, sex, and height-based tables.41 Studies in
American children indicate a prevalence estimate of 10% with prehypertension
(95th percentile > BP 90th percentile) and 3.7% with hypertension, increasing with
increasing BMI and waist circumference.42 Recognition of elevated BP in the office
setting is unrecognized in approximately 25% of cases.43
Rates of T2DM in children have increased in parallel with increases in obesity. In
2009, the total prevalence of T2DM in a representative sample of youth younger
than 20 years in the United States was 0.24 cases per 1000 individuals, with increasing
prevalence with age, whereas the incidence of T2DM in Canada was 11.3 cases per
100,000 children (<18 years) per year, similar to American incidence statistics.4446
Impaired glucose tolerance is particularly common in severely obese adolescents,
with up to 25% exhibiting this finding.47 Of great concern are an increasing number
of reports indicating that youth diagnosed with T2DM go on to develop significant
microvascular and macrovascular complications of diabetes early in adulthood.48
Fat deposition in the liver visualized by ultrasonography or elevated levels of hepatic
alanine aminotransferase are distinctive for NAFLD, which can progress to more
serious liver dysfunction and is a common consequence of obesity in all ages.13,16
Childhood Obesity
Anxiety, depression, stress, low self-esteem and body image, bullying, social withdrawal, and lower quality of life have all been reported to be more common in obese
adolescents.16 Poor school performance, including difficulty with concentration,
homework completion, and missed school days, are 4 times more likely in an adolescent obese population when compared with a healthy control sample.56 Clinical populations of overweight/obese adolescents also show higher lifetime rates of eating
disorders, especially bulimia nervosa, than population-based samples.57 Binge eating
disorder (BED), defined as repetitive loss of control of eating of large quantities of food
over discrete time frames, without compensatory weight-reduction activity, is common. About 20% to 40% of adolescents seeking treatment of overweight/obesity
report symptoms of BED.57
ASSESSMENT/SCREENING
Calculation of BMI and plotting on age- and sex-appropriate growth charts for children
older than 6 years are recommended by the US Obesity Task Force as routine
screening approach for use in clinical practice. There is insufficient evidence to provide a similar recommendation for children younger than 6 years,58 although this
recommendation will likely change over time given increasing obesity incidence in
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this age group. Although BMI is correlated with percent body fat, it is also correlated
with lean tissue mass and height and represents an indirect measure of adiposity.59
Measurement of skinfold thickness, waist to height ratio, waist circumference, and
bioelectrical impedance analysis, which have been shown to predict cardiometabolic
risk, have been used as physical measures of adiposity in pediatric research populations, as BMI may not always be accurate in judging adiposity.13 However, as no reference standards for these measures have been developed for children, from a practical
clinical standpoint, they are not recommended for clinical screening.
Tables 1 and 2 outline specific points to consider when gathering history and conducting a physical examination and list suggested investigations to screen for common obesity-related comorbidities. Additional laboratory tests that could be
performed if history indicates risk factors include thyroid function, abdominal ultrasonography to assess fatty liver, renal function, albumin to creatinine ratio, and clinical
screening for PCOS.13,60
In adults, severity of BMI has historically been described as class IIII and is based
solely on BMI level; however, this classification does not take into account comorbidities. The Edmonton Obesity Staging System incorporates the presence and severity
of comorbidities in adults, divided into 3 major categories, metabolic, mechanical, and
mental health.61 This system has been shown to better predict mortality in NHANES
adult data sets.62 Development of a similar staging system for the pediatric population, to function as part of the clinical care guidelines and risk assessment procedures
for children and adolescents with overweight/obesity, would be beneficial to better
target assessment and intervention strategies.
TREATMENT
The goals of weight management are to prevent and reduce the risk of obesityrelated sequelae, with a focus on healthy behavioral change. For growing children,
weight maintenance may be a goal, and for those who have a more significantly
elevated BMI, a steady, gradual weight loss (ie, not more than 0.5 kg/wk) is
recommended.63
A key message is that improvement of health outcomes, with reduced focus on
weight loss, is the primary goal of treatment. The American Academy of Pediatrics
Expert Committee established a 4-tiered approach to the management of obesity,
outlined in Fig. 1.64 Motivational interviewing approaches to communication are
also recommended.65 The Canadian Obesity Network has developed an office
approach for clinicians to use with children with obesity: the 5As of Obesity ManagementAsk, Assess, Advice, Agree, and Arrange (Box 1).66,67 This 5A approach has
been used previously to address numerous other health interventions, including smoking cessation.67
Nonpharmacologic Approaches
Childhood Obesity
Table 1
Information to consider during assessment of the obese child/adolescent
Checklist
Rationale
History
Past attempts at weight loss; recent weight
gain/loss
Joint pain
Hyperandrogenism, PCOS
Polyuria, nocturia
T2DM
Hypothyroidism
Medications
Drug-induced obesity
Fetal/infant history
Maternal BMI, maternal gestational
diabetes, maternal nutrition
Birth weight
Breast-feeding, introduction of
complementary food
Environmental factors
Access to fresh produce, grocery stores, food
security
Access to parks and recreational community
centers
Access to primary health care providers
Psychosocial factors
Negative affect (depression, anxiety, stress)
Body image, self-esteem
Peer influence (bullying, support, teasing)
Readiness to change, motivation, confidence
School functioning
Family history
Obesity, T2DM, hypertension, dyslipidemia,
coronary artery disease, sleep apnea
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Table 2
Laboratory tests for comorbidity screening
Test
Age Group/Criteria
Outcomes/Thresholds
Prediabetes:
IFG
5.66.9 mmol/L (100
125 mg/dL)
IGT
OGTT 2-h glucose 7.8
11.0 mmol/L (140
199 mg/dL)
A1C 5.7%6.4%
Diabetes:
FPG >7.0 mmol/L
(126 mg/dL) or
OGTT 2-h
glucose >11.0 mmol/L
(200 mg/dL)
Requires second
confirmatory test if
patient is asymptomatic
Detection of hypopneas,
apneas, sleep disruption
and fragmentation, or
cyclic desaturations
Dyslipidemia
FLP
If nonfasting, calculate nonHDL (total cholesterol
HDL), and repeat with
FLP if non-HDL cholesterol
is high or HDL-cholesterol
is low
Repeat every 2 y
NAFLD
ALT/AST
Repeat every 2 y
Sleep-disordered breathing
Sleep study
(polysomnography or
nocturnal pulse oximetry)
Repeat if symptoms arise.
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; FLP, fasting lipid
profile; FPG, fasting plasma glucose; HDL, high-density lipoprotein; IFG, impaired fasting glucose;
IGT, impaired glucose tolerance; IR, insulin resistance; OGTT, oral glucose tolerance test; OSA,
obstructive sleep apnea.
a
Lipid threshold cutoffs may vary depending on number of individual risk factors.
b
Guidelines for diabetes screening are those recommended by the American Diabetes Association, which differ slightly from those suggested by the Canadian Diabetes Association.
c
Recommendations from the American Academy of Pediatrics expert committee on child
obesity. The American Association for the Study of Liver Diseases does not support screening
because of a lack of evidence and specific management guidelines of NAFLD in children.
Data from Refs.64,7783
Childhood Obesity
Fig. 1. Four-tiered approach to managing obesity. Progression through tiers is based on case
severity and lack of improvement in health outcomes. (Data from Barlow SE, Expert C.
Expert committee recommendations regarding the prevention, assessment, and treatment
of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Suppl
4:S16492.)
Pharmacologic Approaches
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Box 1
The 5As of pediatric obesity management
The 5As of Pediatric
Obesity Management
Approach
Ask
Ask for permission to discuss the childs weight and/or BMI
Be nonjudgmental while gauging readiness to change
Assess
Underlying cause and contributing factors
Inquire about enablers and barriers in weight management
Conduct physical and mental health assessment to address any
complications
Advise
Ask for permission to provide information about obesityrelated risks, investigations, and treatment options
Stress the importance of achieving behavioral and healthrelated improvements rather than focusing primarily on weight
loss
Agree
Aim to have child and family choose behavioral goals
themselves, with physician assistance
Assess confidence in achieving the goals, use motivational
interviewing techniques
Agree on a small number of SMART (specific, measurable,
achievable, relevant, timely) goals (12)
Assist
Summarize management plan and address potential solutions
to barriers
Provide additional available resources
Arrange for follow-up within a short time frame
Data from Canadian Obesity Network. CON. 5As for pediatrics. Available at: http://www.
obesitynetwork.ca/5As. Accessed August 1, 2014.
Childhood Obesity
Box 2
Recommendations for nonpharmacologic interventions in obesity management
Intervention
Recommendations
Nutrition therapy
Engage dietician support if possible
Limit sugar-sweetened beverages
Increase fruit and vegetable intake
Decrease snacks and portion sizes
Diets should be lower energy intake to promote weight loss of
w0.5 kg/wk, but maintain nutritional balance for growth and
development
PA and sedentary time
For the young child, increase duration of unstructured free play
Older children should be encouraged to pursue PA that they
enjoy
Limit screen time to <2 h/d
5 y1: 60 min of moderate to vigorous PA daily
04 y: 180 min of any intensity PA daily
Behavioral approach
Increase support around PA and healthy nutrition
Decrease frequency of eating in restaurants
Increase frequency of family meals eaten together at home
Encourage SMART goal setting
Promote self-monitoring
Discourage the use of food as a reward
Use problem solving and motivational interview techniques to
identify priorities and barriers, and create a sense of family
involvement in decision making
Abbreviations: PA, physical activity; SMART, specific, measurable, achievable, relevant, timely.
Data from Refs.64,8486
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Table 3
Bariatric surgery procedures
Roux-en-Y Bypass
Gastric Banding
Sleeve Gastrectomy
Restrictive
Adjustable gastric band
around proximal stomach
Band inflated with saline
from subcutaneous port
Restrictive
Stomach resected along
greater curvature
Gastric ulceration
Gastric remnant dilatation
Reflux
Procedure
Restrictive and
malabsorptive
Proximal pouch of stomach
attached to jejunum
Late complications
Protein-calorie malnutrition and micronutrient
deficiency
Gastric ulceration, stomal
stenosis, gastric dilatation,
internal/incisional hernias
Dumping syndrome, postprandial hypoglycemia
Adolescent outcomes
Average BMI loss at 12 mo of
17.2 kg/m2, with 8
identified studies
Data from Refs.7173,8790
observed heterogeneity.74 Overall, children in the intervention groups had a small but
significant difference in mean BMI compared with the control groups ( 0.15 kg/m2
[95% CI, 0.21 to 0.09]). Intervention seemed to demonstrate larger effects in
younger age groups. Only 8 studies reported on adverse effects, and no evidence
of adverse outcomes, such as unhealthy dieting practices, increased prevalence of
underweight, or body image sensitivities, was found. The researchers concluded
that there was strong evidence to support the beneficial effects of child obesity prevention programs on BMI.74 Although obesity prevention in young children seemed
to demonstrate the largest effect, there have been fewer studies in this age group.
Promising strategies from the Cochrane review, recommendations by the American
Academy of Pediatrics, and the No Time to Wait strategies from the Ministry of
Health Ontario Healthy Kids Panel have been summarized in Box 3 as evidencebased recommendations for practices that can be undertaken at each of the levels
of interaction with the child to promote healthy growth and development and protect
from the early onset of overweight or obesity.13,74,75
FUTURE DIRECTIONS
Childhood Obesity
Fig. 2. Surgical alterations in (1) Roux-en-Y bypass, (2) gastric banding, and (3) sleeve gastrectomy. (Courtesy of Phillip Fournier, BA, Toronto, Canada.)
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Box 3
Obesity prevention recommendations
Structure/Institution
Recommendations
Individual/family
1 h of physical activity (PA), <2 h of screen time per day
Eat breakfast daily
Engage in meals and PA together as a family
Reduced portion sizes, lower frequency of snacks, low consumption
of sugar-sweetened drinks
Optimize weight gain during pregnancy, exclusive breast-feeding
during first 6 mo of life
Primary care
Monitoring BMI at regular intervalsfacilitate early intervention
and prevent comorbidities
Counsel pregnant mothers regarding adequate maternal nutrition,
recommended weight gain in pregnancy, and benefits of breastfeeding
Advocate for community and policy action supporting healthy
growth of children
Support social marketing to promote healthy foods to growing
children
School/community
Ensure adequate PA, development of fundamental movement skills,
and recess periods at school
Mandate nutritional standards for food provided at schools and in
vending machines, including in Aboriginal communities
Provide nutritional education curriculum to stress importance of
healthy eating and positive body image
Expand accessibility of play spaces, recreational parks, and safe
walking and biking routes in residential areas
Implement health promotion strategies (eg, professional
development, capacity building activities)
Improve mental health services and access
Establish comprehensive community programs to promote healthy
child development and support those from lower socioeconomic
status
Public policy
Ensure adequate funding for treatment of obesity and obesityrelated comorbidities
Encourage social marketing of healthy food options and legislate
bans/restrictions of marketing unhealthy foods to young children
Provide incentives to ensure retailers to provide quality, affordable
fruits and vegetables
Childhood Obesity
Fig. 3. A socioecological framework depicting various levels of organization involved in promoting and implementing healthy lifestyles. (From Caprio S, Daniels SR, Drewnowski A,
et al. Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment. Obesity 2008;16(12):2572; with permission.)
the most effective use of limited clinical resources. Prevention will remain the most
effective method of reducing the societal burden of obesity and will necessitate attention to the social determinants of health, a focus on the developing child from in utero
through to adulthood, and collaboration between multiple organizations at the micro
and macro level (Fig. 3).
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