Childhood Obesity: An Expanding Epidemic

CHILDHOOD OBESITY RATES in the United States have consistently escalated over the past five decades. These higher childhood obesity rates continue to adversely affect the overall physical and mental health of the nation’s children and continue to burden our healthcare system. And, until this trend slows and reverses, more children will become obese, and many will become obese adults.

According to the Centers for Disease Control and Prevention (CDC), obesity is defined as a body mass index (BMI) at or above the 95th percentile of the CDC sex-specific BMI-for-age growth charts (Figures 1 and 2).¹ However, a new classification system recognizes BMI above the 95th percentile as class I obesity, BMI greater than 120 percent of the 95th percentile as class II obesity, and BMI greater than 140 percent of the 95th percentile as class III obesity.² And, while not all children who carry extra pounds are obese (some children have larger-than-average body frames, and children normally carry different amounts of body fat at various stages of development³), BMI is still the accepted measure to diagnose obesity.

The percentage of children and adolescents affected by obesity has more than tripled since the 1970s. Data shows nearly one in five school-age children and young people (6 years to 19 years) is obese,⁴ affecting about 13.7 million children and adolescents.¹ Data from the National Health and Nutrition Examination Survey (NHANES) found in 2015-2016 the prevalence of obesity was 18.5 percent in youth. The survey also found the prevalence of obesity was higher among youth aged 6 years to 11 years (18.4 percent) and adolescents aged 12 years to 19 years (20.6 percent) compared with children aged 2 years to 5 years (13.9 percent). And, from 1999-2000 through 2015-2016, a significantly increasing trend in obesity was observed in youth.⁵

The reason for the dramatic increase in childhood obesity in the U.S. can be directly correlated to the period of time when women started to enter the workforce in large numbers in the 1970s. At that time, homemade meals became less prevalent in families’ homes, and there was a definitive uptick in the consumption of processed food, fast food and restaurant food, resulting in many children eating unhealthfully.

Other attributable causes include electronic games such as Atari, Gameboy, Nintendo and Sega Genesis, which became popular in the 1980s, and Xbox, PlayStation and Wii in later years. Today, computers, smartphones and tablets have become ubiquitous among children and adolescents, with electronic games and devices resulting in increased indoor activity time for children and adolescents and, hence, decreased outdoor activity time, leading to an untold number of children who lack regular exercise or physical activity.

Yet, while there are myriad causes, symptoms and consequences of childhood obesity, it is preventable and treatable. And, pediatricians can play an active role.

Causes of Childhood Obesity

The causes of childhood obesity can include physical, psychological and socioeconomic factors or a combination of these factors. However, the most common causes of childhood obesity are excessive and/or unhealthy food consumption and a lack of exercise or physical activity, which can sometimes be caused by a lack of available heathy food and opportunities for exercise or physical activity. In rare cases, childhood obesity can be caused by medical or genetic factors, both of which can be ruled out with a physical exam and blood tests.

Set-point (the weight range in which the body is programmed to function optimally) theory suggests a person’s weight is determined by complex interactions of genetic, hormonal and metabolic factors. However, this theory would account only for children who are slightly to moderately overweight, not for children who are obese or morbidly obese.

Symptoms of Obesity

According to Boston Children’s Hospital, each obese child may experience different symptoms, but some of the most common include stretch marks on the hips and abdomen; dark, velvety skin (known as acanthosis nigricans) around the neck and in other areas; fatty tissue deposition in breast area (an especially troublesome issue for boys); poor self-esteem and eating disorders; shortness of breath when physically active and sleep apnea; constipation and gastroesophageal reflux disease; early puberty and irregular menstrual cycles in girls and delayed puberty in boys, as well as disproportionately small genitals in males; and flat feet, knock knees or dislocated hips.⁶

Consequences of Childhood Obesity

Obese children are at a much greater risk for myriad health conditions, which can include high cholesterol, high blood pressure, early heart disease, stroke, type 2 diabetes, nonalcoholic fatty liver disease, asthma, chronic obstructive pulmonary disease, gall bladder issues, osteoarthritis, bone fractures, and pain in the knees and lower back. In addition to suffering from adverse health conditions, obese children also suffer from emotional and social conditions.

Obesity can also lead to low self-esteem and a higher risk of being bullied. “Children often tease or bully their overweight peers, who suffer a loss of self-esteem and an increased risk of depression as a result,” reports the Mayo Clinic. Obese children also suffer from behavior and learning problems: “Overweight children tend to have more anxiety and poorer social skills than normal-weight children do. These problems might lead children who are overweight either to act out and disrupt their classrooms or to withdraw socially.” Lastly, obese children also suffer from depression: “Low self-esteem can create overwhelming feelings of hopelessness, which can lead to depression in some children who are overweight.”¹

Perhaps the greatest consequence of childhood obesity is the propensity for becoming obese adults who suffer exacerbated symptoms. According to the World Health Organization, “Childhood obesity is associated with a higher chance of premature death and disability in adulthood. Overweight and obese children are more likely to stay obese into adulthood and to develop noncommunicable diseases (NCDs) like diabetes and cardiovascular diseases at a younger age. For most NCDs resulting from obesity, the risks depend partly on the age of onset and on the duration of obesity. Obese children and adolescents suffer from both short-term and long-term health consequences.”⁷

The Role of Pediatricians

As a second line of defense behind parents, pediatricians are the most qualified to assist patients with preventing and treating obesity. Depending on the age and maturity level of the child, pediatricians can disseminate guidelines either to their child patients or parents of the child about how to plan a healthy diet and exercise program to prevent children from becoming overweight or obese or who are currently overweight or obese.

The U.S. Department of Health and Human Services (HHS) published the “2015-2020 Dietary Guidelines for Americans,” which includes sections for children and adolescents and shows types of healthy foods; how to build a healthy meal; how to limit calories by eliminating added sugars, saturated fats and sodium; how to make healthier food and beverage choices; and how to include everyone in choosing and preparing healthy meals from home to school to work to communities.⁸

Pediatricians can also encourage parents to keep a daily food log of what their children eat and the associated calories to gauge food and caloric intake over time. This can help parents adjust their children’s diet if they continue to gain weight or do not lose the recommended weight as prescribed by their pediatrician.

HHS has also published the “Physical Activity Guidelines for Americans,” which can help children improve their body composition Perhaps the greatest consequence of childhood obesity is the propensity for becoming obese adults who suffer exacerbated symptoms by reducing overall levels of body fat, as well as abdominal fat, through regular exercise. The guidelines outline types of activities (aerobic, muscle strengthening and bone strengthening) for age groups (preschool-aged children ages 3 years through 5 years and school-aged youth and adolescents ages 6 years through 17), and recommends each age group perform 60 minutes of moderate-to-vigorous physical activity three times per week.⁹ Based on these recommendations, parents can plan weekly exercise programs for their children and adjust them, if required, to meet their weight goals as prescribed by their pediatrician.

In 2013, the American Academy of Pediatrics launched the Institute for Healthy Childhood Weight (IHCW) to address the complex problem of childhood obesity from prevention through treatment. IHCW’s focus is on translating policy, research and best practices into action within healthcare, communities and families, and emphasizing strategic and methodological innovation and evaluation.

One of IHCW’s goals is to improve healthy weight assessments during health supervision visits. To accomplish this, it has partnered with the Bright Futures Guidelines, which is currently in progress, by supporting training and implementation tools on best practices for effective weight assessment and counseling for nutrition and physical activity for children from birth to 21 years of age.¹⁰

IHCW also supports healthcare providers in the delivery of anticipatory guidance around early feeding and nutrition by being part of the Building a Foundation for Healthy Active Living (BFHAL) project. BFHAL includes a portfolio of resources, including a series of online continuous medical education and maintenance of certification modules to help healthcare providers improve delivery of key content during the first 11 well visits, and a suite of family engagement resources (videos, infographics and social media graphics) to create awareness and engage families in the importance of sound nutrition and healthy behaviors.¹⁰

Through its Healthy Active Living for Families (HALF) project, IHCW also supports healthcare providers in delivering anticipatory guidance about early obesity prevention. Resources in the HALF project were designed to support the implementation of early obesity prevention (infancy through age 5 years) at the point of primary care by leveraging parent focus groups and the latest evidence. Resources include an implementation guide, an app and web-based patient engagement tools for providers’ websites.¹⁰

Lastly, the Childhood Obesity Foundation recommends obese children LIVE 5-2-1-0!: Eat five or more veggies and fruits per day; get no more than two hours of screen time per day; get at least one hour of physical activity or more per day; and drink zero sugary drinks per day.¹¹

Moving Forward

In the article “Prevalence of Obesity and Severe Obesity in U.S. Children, 1999-2016” by Ashley Cockrell Skinner, PhD, whose mandate was to provide updated prevalence data on obesity trends among U.S. children and adolescents aged 2 years to 19 years from a nationally representative sample, Dr. Skinner concluded: “Despite previous reports that obesity in children and adolescents has remained stable or decreased in recent years, we found no evidence of a decline in obesity prevalence at any age. In contrast, we report a significant increase in severe obesity among children aged 2 to 5 years since the 2013-2014 cycle, a trend that continued upward for many subgroups.”

Dr. Skinner also reported: “Nationally representative data provided by the NHANES demonstrates clearly that childhood obesity continues to be a significant concern for the United States. The past 18 years have seen increases in the levels of severe obesity in all ages and populations despite increased attention and efforts across numerous domains of public health and individual care. Present efforts must continue, as must innovation, research [and] … collaboration among clinicians, public health leaders, hospitals and all levels of government.”²

To quote the African proverb, “It takes a village to raise a child,” which means an entire community of people must interact with children for them to experience and grow in a safe and healthy environment. To address the United States’ high childhood obesity rates, not only are parents responsible for the health and well-being of their children, but the entire community — healthcare practitioners (pediatricians), teachers (school cafeterias) and government officials (state lawmakers) — is responsible for the health of the nation’s children. All need to work together to ensure all children are provided with the healthy food and regular exercise they require to grow to become healthy adults.