Obesity is now the most prevalent nutritional disease, affecting one in five children and adolescents in the United States, and has become a major health problem for all ages. A child is considered overweight if his or her Body Mass Index (BMI) is in the 80th percentile, and obese if the BMI is in the 95th percentile. Recent data have shown that 33 percent of American adults and 20 percent of children/adolescents are overweight, according to the Body Mass Index. (1) And approximately 15 percent of American children are obese, according to the BMI and standard growth charts based on reference data from the 1970s. (1,2) All of these numbers have approximately doubled over the past two decades. Paradoxically, this increase in obesity has occurred during recent years, despite the American obsession with dietary programs, diet products, weight control, health clubs, home exercise equipment, and physical fitness videos.
To avoid obesity in adulthood, it is crucial to employ effective weight-loss treatments early in childhood and adolescence. If weight control has not been achieved by late adolescence, only five percent of obese adolescents will lose weight successfully by adulthood. (3) In fact, the enormity of this epidemic has necessitated a call to action from the American Academy of Pediatrics (AAP), which issued a new policy statement entitled “Prevention of Pediatric Overweight and Obesity” in August of 2003. This statement proposed strategies and recommendations to foster prevention and early identification of overweight and obesity in children. (2)
Obesity can be evaluated by plotting weight for height and age, or by calculating the BMI. The BMI is a height-weight ratio determined by dividing the weight in kilograms by the square of the height in meters (kg/m2). BMI is widely used to define obesity because it correlates well with body fat, is easily calculated, and has been correlated with obesity-related conditions in adults and children. For this reason, one of the recommendations in the AAP policy statement is for all pediatricians to calculate and plot the BMI once a year in all children and adolescents. (2) The BMI is not foolproof, however, as it does not directly measure body composition. Therefore, it cannot differentiate between adiposity and lean body mass. A direct evaluation of adiposity, using skin fold measurements or water submersion techniques, is more accurate and may be more useful in certain situations.
Many factors control the deposit of fat into adipose tissue. Intake of food/energy is a balance between appetite, desire, and satiety. Once food is absorbed, distribution of fat is controlled by an equilibrium between fat deposition and breakdown. Any process that increases appetite, decreases satiety, increases deposition, or decreases breakdown can lead to obesity. These include various social factors, habits, family dynamics, hormones, or genetic factors. Diets high in fat and low in complex carbohydrates are associated with adiposity. Calorie-dense foods, abundant and readily available in the U.S. fast food establishments, are ever-present and the busy lifestyles of many families have made these establishments an easy alternative to more nutritious meals at home. (4)
National survey data have shown that children are currently less active than they have ever been, with increased leisure time. Leisure activity has become more and more sedentary with increased television, computer games, and videos. Recent data reveal that 25 percent of American children watch at least four hours of television per day, and studies have shown that children who watched four or more hours of TV per day had a significantly higher BMI than those watching fewer than two hours a day. (1) Numerous other studies have demonstrated the association between television watching and obesity, and have suggested that healthy lifestyle education to prevent obesity should target the television-watching habits of children. (1,2,5,6) Daily physical activity for children has decreased with less walking to school and reduced household chores, both due to increased urbanization. This declining level of physical activity is at least partially responsible for the rising rates of childhood obesity. (2,5,7,8)
Although many of the complications due to obesity occur in adulthood, numerous health problems, with potentially devastating consequences, begin in obese children. The probability of an obese child becoming an obese adult is very high-approximately 80 percent by adolescence. And along with the persistence of obesity comes a plethora of complications. (2) Complications associated with overweight include insulin resistance and non-insulin-dependent diabetes mellitus, the dyslipidemias including hypercholesterolemia and premature atherosclerosis , hypertension and increased left ventricular mass, menstrual irregularities, depression and low self-esteem, and sleep apnea. (1,2,3,7)
Common complications of obesity in children and adolescents
Increased left ventricular mass
Depression and eating disorders
Slipped capital femoral epiphysis
Polycystic Ovary Disease
Hypertension, dyslipidemia, and NIDDM often cluster together and are referred to as “syndrome X” or the metabolic syndrome. (1,9) Syndrome X is the most prevalent cause of early cardiovascular disease and congestive heart failure. Although usually seen in the adult population, “syndrome X” is now being identified in obese children and adolescents. (9)
Social Issues Related to Obesity
Of great concern as well is the psychological stress of obesity. Discrimination against overweight children begins early in childhood and becomes progressive. (7) The overweight child may be perceived as sloppy, lazy, lacking in self-control, and morally undesirable. Studies have shown that children are more likely to choose as a friend a child who has a visible handicap than someone who is overweight. (1,7) In fact, overweight children are ranked lowest among those with whom other children would like to be friends. (7) The overweight and obese teen is often teased, ridiculed and shunned, leading to social isolation and depression. In addition, chronic obesity often leads to an increase in high-risk behaviors and oppositional-defiant disorders, since the overweight youngster must work harder than others to fit in with the social crowd.
This complication of low self-esteem and depression associated with overweight in adolescence is of great concern, as it tends to persist into adulthood, like the other obesity-associated complications. (7,10,11) Associated with this are other social risks, such as poor social achievement in adulthood, as seen particularly among obese adolescent females. The number of years of advanced education, family income, and rates of marriage are all significantly lower-and the rates of poverty tend to be higher-in obese women, compared to women of the same age who are not obese. (7,10,12) Unfortunately, a sequel to this social discrimination is the preoccupation with thinness and subsequent eating disorders (anorexia, bulimia, and binge-eating) expressed at younger and younger ages. (7,11)
Preventing obesity is extremely important, as treatment is difficult and potentially complex. As the age of the child increases, so does the likelihood that the child will be obese as an adult. It is crucial to be able to identify those individuals at high risk for obesity and to begin intervention early. For example, having at least one obese parent increases the risk of being obese as a child and subsequently as an adult. An obese adolescent with two obese parents is at very high risk for long-term complications, requiring intensive intervention with both nutritional and behavioral support. (1,2,7) Primary prevention should begin in infancy by encouraging mothers to breastfeed, as breastfeeding appears to decrease the risk of adult obesity. (1,2)
As a child grows, anticipatory guidance should include:
Encouraging exposure to healthy foods, particularly fruits and vegetables;
Replacing whole milk with skim after the age of two in families at risk for obesity;
Discouraging the consumption of high-fat snacks and beverages;
Encouraging the replacement of sedentary activities, particularly television viewing, with exercise.
Author: Carla Sottovia, PhD
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