Pediatric Obesity. Not only a Weight Concern

Model and insist on good meal habits— eating less breakfast and more dinner or skipping breakfast increase the risk for obesity. Don't mistake healthy eating for dieting. Eating large amounts of high calorie foods "Want to super-size that? Bad eating habits become accepted as normal eating habits. Eating healthful foods in a healthy manner is not the same as dieting. The food pyramid is a thing of the past. Use MyPlate to help guide your food choices for your family. The emphasis should be on a variety of vegetables, with half your plate being vegetables and fruits.

Grains should be whole grains. Keep only healthy foods in your home. The American Dietetic Association offers information on eating healthy—check out their daily tips and nutrition fact sheets. Children under 2 may need a little more fat in their diet for proper brain development. Between ages you can gradually transition your child to the lower-fat diet that is healthiest for the rest of the family.

Pay attention to snacks. Lots of snacking leads to a higher calorie intake, and many typical snack foods are not very nutritious. Keep healthy snacks on hand, like fruit and cut up veggies. Allow your child easy access to them. As kids move into adolescence, their levels of activity tend to drop too low. Do active things together as a family, like bike riding, hiking, walking and swimming. Here are some great ideas in print, audio and Spanish for helping to get your child and your family more active.

Build activity into your family's daily life with household chores, walking to school, parking farther from buildings and taking the stairs. Decreasing inactivity works better for long-term weight loss than focusing on vigorous aerobic exercise. It's also an easier lifestyle change for your family to make! Make sure your kid gets outside during daylight hours.

You could make it a policy in your family that unless the weather is bad, your children play outdoors after school. This encourages physical activity, and rules out the inactive pursuits of TV and other media. For more information and tips: For more practical tips, see what our own Dr. Gahagan has to say about how parents can fight obesity in their kids. It includes many useful tips and resources. A weight-control program should: Have the overriding goal of helping the whole family make and maintain healthy changes in their eating and activity habits.

Have dieticians, exercise physiologists, doctors, and either psychiatrists or psychologists on staff. Perform a medical evaluation of your child—including weight, growth, and health—before starting the program, and at regular intervals throughout the program. Be developmentally appropriate for the age and capabilities of your child. Focus on behavior changes. Teach your child how to choose a healthy variety of foods and the right size portion.

Encourage daily physical activity. Include a maintenance program and other support and referrals. Focus on your whole family—not just your overweight child. What books do you recommend? This is a book all parents should read, whether their children are overweight or not.

It applies to kids from birth through the teen years. The advice in this book can help your child develop a healthy relationship with food that will last a lifetime. Ending the Food Fight: A nine-week program with all the tools you need to help your kids develop healthy eating habits. The Stoplight Diet for Children: This book is out of print, but should be available in your public library.

INTRODUCTION

A 7-day meal plan is included for , , and calorie plans. Shapedown books and workbooks for parents and kids ages —find out more about this program at the bottom of this page. They can help you and your child with pamphlets, fact sheets and referrals. The Nutrition and Fitness Center at Kidshealth has information and the latest news on food and exercise. The Weight-control Information Network provides information about weight control, obesity, and related topics to health professionals and the public.

Develops, identifies, and distributes educational materials. Information for kids and teens: The Nutrition Information Service is part of the University of Alabama-Birmingham, and provides up-to-date, accurate, and useful nutrition, health, and food information to the community and health care professionals. They will answer nutrition questions from health professionals and the public. The National Association to Advance Fat Acceptance provides support and attempts to eliminate discrimination against overweight people.

Provides information to health professionals on how to treat very large patients e. The President's Challenge works to promote the development of physical fitness facilities and programs. This study has several limitations and strengths that should be considered when interpreting our findings.

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Study limitations include the restricted range of child weight in our sample. The sample was comprised of children toward the upper end of the BMI spectrum, but who were not yet obese th BMI percentile , so we were not able to assess the relationship between parental concern about child weight and weight-related behaviors of interest among parents of children who were obese.

In addition, we did not examine the relationship between parental perceptions of child weight status and parent and child weight-related behaviors because of statistical and conceptual concerns; there was limited variability in parent perceived child weight i. This is a limitation, as parental perceptions of child weight status are likely to be related to parental concern about child weight, further influencing parent behaviors supporting child diet, PA, and media usage.

Parents were asked whether their child ate a typical amount on the day of the recall, and dietary data were included in analyses if parents reported their child ate a typical amount of food on the recalled day. Another limitation is that constructs measuring parenting practices related to family restaurant use and media use are comprised of one item, which may not fully capture these parenting dimensions. Lastly, our analyses were cross-sectional, and as such we cannot make causal inferences about the relationships between parental concern about child weight and the variables of interest.

Limitations aside, our consideration of weight-related variables across three domains is an important strength; baseline HHHK data allowed us to examine the relationship between parental concern about child weight and child-, parent-, and household-level factors related to child diet, PA, and media use, all of which may influence child weight. Second, child and parent height and weight were measured by trained study staff, and child minutes of MVPA were measured using the gold standard method of assessing PA, accelerometer.

Future analyses using HHHK follow-up data will provide an opportunity to investigate these relationships prospectively in an obesity prevention intervention targeting young children at-risk for overweight and obesity. Without providing parents support and strategies to effectively manage child weight, parental concern about child weight may contribute to unproductive parenting practices. Human Subjects Approval Statement.

Concern about Child Weight among Parents of Children At-Risk for Obesity

Parent informed consent and child assent were obtained from all parent-child dyads, and study protocol and procedures were approved by the HealthPartners Institute for Education and Research Institutional Review Board A National Center for Biotechnology Information , U. Health Behav Policy Rev. Author manuscript; available in PMC May 1. Author information Copyright and License information Disclaimer. See other articles in PMC that cite the published article. Measures Demographic characteristics Parents reported child, their own, and sociodemographic characteristics, such as ethnicity, race, and free or reduced price school lunch eligibility.

Parent classification of child weight and concern regarding child weight One item from the perceived child weight subscale of the Child Feeding Questionnaire CFQ 26 was used to determine the accuracy of parent perceived child weight. Media-related variables Four items separately assessed child computer and video game use and child TV use on an average weekday and weekend day. Open in a separate window.

Totals may not add to due to missing data. Concern about Child Weight: Relationship with Diet-, PA-, and Media-Related Variables The role of parental concern in diet-, PA-, and media-related child behaviors, household characteristics, and parenting practices is presented in Table 3. Footnotes Human Subjects Approval Statement Parent informed consent and child assent were obtained from all parent-child dyads, and study protocol and procedures were approved by the HealthPartners Institute for Education and Research Institutional Review Board A Prevalence of obesity and trends in body mass index among US children and adolescents, Health consequences of obesity in youth: Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents.

J Clin Endocrinol Metab. The relation of overweight to cardiovascular risk factors among children and adolescents: Stigma, obesity, and the health of the nation's children. Reilly JJ, Kelly J. Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: Int J Obes Lond ; 35 7: The importance of parental beliefs and support for physical activity and body weights of children: Can J Public Health. Association of family environment with children's television viewing and with low level of physical activity. Fruit and vegetable consumption, nutritional knowledge and beliefs in mothers and children.

Influences on the Development of Children's Eating Behaviours: From Infancy to Adolescence. Can J Diet Pract Res. Maternal perceptions of overweight preschool children.

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Maternal perceptions of weight status of children. A systematic review of parental perception of overweight status in children. J Ambul Care Manage. Parental disconnect between perceived and actual weight status of children: J Am Acad Nurse Pract. Parents' perceptions of their child's weight and health.

Parental concerns about childhood obesity and the strategies employed to prevent unhealthy weight gain in children. Int J Pediatr Obes. Social foundations of thought and action. Health promotion from the perspective of social cognitive theory. Exploring the relationship between parental concern and the management of childhood obesity. Matern Child Health J. J Am Diet Assoc. Associations between child weight and maternal feeding styles are mediated by maternal perceptions and concerns. Eur J Clin Nutr. Hyperandrogenism is central to the presentation in adolescents.

Evaluation of adolescents with PCOS should exclude alternate androgen-excess disorders. Obesity causes changes in other hormonal systems. Age of onset of puberty continues to decrease, particularly in African Americans. This has been attributed, in part, to overnutrition and increased BMI values in this population Excessive aromatization of androgens to estrogens by peripheral adipose tissue may promote gynecomastia in males.

Obstructive sleep apnea is among the pulmonary complications of obesity and the hypercapnia associated with this can suppress hypothalamic gonadotropin-releasing hormone function and lead to delayed puberty Obesity accelerates statural growth and causes advancement of the bone age. It is also important to keep in mind that most of the weight gain in hypothyroid individuals is due to accumulation of salt and water, so hypothyroidism rarely causes substantial weight gain. Cardiovascular comorbidities include hypertension, dyslipidemia and risks for adult coronary heart disease as discussed above.

Cardiovascular disease is the leading cause of adult mortality and morbidity. Longitudinal epidemiologic studies have demonstrated that risk factors in childhood, such as obesity and dyslipidemia, are predictors of adult cardiovascular disease. The prevalence of clinically recognized hypertension and dyslipidemia were found to increase 8. Excess weight in adolescence persists into young adulthood and has a strong adverse impact on multiple cardiovascular risk factors, indicating the importance of primary prevention early in life NAFLD has become the most common cause of chronic liver disease in children in the US, parallel to the increasing frequency of obesity 9 , NAFLD represents the fatty infiltration of the liver in the absence of alcohol consumption.

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NAFLD encompasses a range of severity from bland steatosis to NASH that may ultimately result in advanced fibrosis, cirrhosis and hepatocellular carcinoma. The clinician must be cognizant of the fact that these diagnostic methods are suboptimal in sensitivity and specificity for NAFLD and other causes of liver disease must be ruled out. Pulmonary comorbidities include obstructive sleep apnea and obesity hypoventilation syndrome 2 , 9 , 61 , Obese children are up to six times more likely than lean children to have obstructive sleep apnea.

Symptoms include habitual nightly snoring often with intermittent pauses, snorts, or gasps , disturbed sleep and daytime neurobehavioral problems. Daytime sleepiness may occur Obstructive sleep apnea is independently related to the development of hypertension, cardiovascular disease, behavioral disorders and poor school performance in children The prevalence of asthma is also increased in obese children.

Orthopedic complications encompass slipped capital femoral epiphysis SCFE , genu valga, tibia vara Blount disease and fractures. Blount disease presents with pain at the medial aspect of the knee. The clinician should have a low threshold for suspicion of SCFE in the obese child with knee, thigh, or hip pain with or without antecedent trauma. Overweight children have a higher incidence of fractures Neurologic complications include idiopathic intracranial hypertension, a disorder which typically presents with headache and blurred vision and is diagnosed by presence of papilledema and elevated intracranial pressure in the absence of infectious, vascular, or structural causes.

The prevalence of pseudotumor cerebri also increases fold with increasing BMI. As to dermatologic complications, obesity alters the skin barrier, can induce skin manifestations and worsens existing skin diseases like psoriasis. Cutaneous manifestations of obesity include acanthosis nigricans formerly named pseudo-acanthosis nigricans , fibroma pendulans skin tags, fibroepithelial polyps and striae distensae Acanthosis nigricans is a dermatologic condition which is associated with obesity, T2DM and insulin resistance 40 , 68 Figure 2.

Acanthosis nigricans is a velvety thickening of the epidermis that primarily affects the axillae, posterior neck fold, flexor skin surfaces and umbilicus. Clinically, the lesions appear as dark-brown thickened plaques. Histologically, it is characterized by the proliferation of epidermal keratinocytes and fibroblasts. Acanthosis nigricans is an important cutaneous marker of insulin resistance that is more commonly being diagnosed in obese children and adolescents worldwide.

Treatment involves management of the underlying disorder Obesity is also associated with hyperandrogenism in women and girls, promoting acne vulgaris, hirsutism and androgenic alopecia.

In addition, there is a pathogenic association between obesity and psoriasis: Obesity promotes skin infections like erysipelas and intertrigo Psychosocial complications include body dissatisfaction, symptoms of depression, loss-of-control in eating, unhealthy and extreme weight control behaviors, impaired social relationships and decreased health-related quality of life. These are conditions which show small to moderate associations with child and adolescent obesity. Additional complications manifested in later life include decreased educational and financial attainment.

As the medical setting is often the first point of contact for families, pediatricians are instrumental in the identification and referral of children with psychological complications 69 , 70 , 71 , Motivational interviewing, patient talking points, brief screening measures and referral resources are important tools in this process. Calculation of BMI is a clinically practical tool for the assessment of overweight and obesity in children. All children older than two years should have their BMI calculated at least annually from measured height and weight.

The results should be plotted on an appropriate growth curve. Laboratory and radiologic studies also may be obtained as indicated by the history and examination. The evaluation should also identify treatable causes and comorbidities 5 , It is recommended to consider certain screening tests for a general metabolic assessment in all patients and pursue a more in-depth evaluation if and when indicated by the case-specific characteristics of the child being evaluated.

It is also noteworthy that the assessment of BMI must not be confined to the evaluation of dietary patterns and physical activity. Environmental and social supports and barriers, opinions on cause and effect of the problems and self-efficacy and readiness to change should be evaluated. It is the responsibility of the clinician to recognize the interactions between pediatric obesity and psychological complications and to engage patients and their caregivers accordingly.

Age of onset is helpful in distinguishing overfeeding from genetic causes of overweight since syndromic obesity often has its onset before two years of age. It is also important to keep in mind the single gene defects associated with obesity which present with early-onset obesity Table 2. Information obtained from the dietary and physical activity history may identify potential areas for intervention. A history of inability to control consumption of large amounts of food may be indicative of an eating disorder. However, this is not a causal relationship 5 , The medical history should include a review of all medications, particularly those that are known to be weight-promoting antipsychotics such as thioridazine, risperidone and lithium carbonate; tricyclic antidepressants such as amitriptyline, antiepileptic drugs such as valproate, carbamezapine, gabapentin and hormones, especially corticosteroids and insulinotropic agents, insulin 1 , 2 , 5 , The review of systems should search for evidence of comorbidities or underlying etiologies.

For example, an abrupt onset of obesity with rapid weight gain should prompt investigation of medication-induced weight gain, a major psychosocial trigger such as depression , endocrine causes of obesity e. The family history should include information about obesity in first-degree relatives parents and siblings.

It also should include information about common comorbidities of obesity, such as cardiovascular disease, hypertension, diabetes, liver or gallbladder disease and respiratory insufficiency in first and second-degree relatives grandparents, uncles, aunts, half-siblings, nephews and nieces 76 , 77 , 78 , The psychosocial history should include information related to depression, to school and social environment and to tobacco use cigarette smoking increases the long-term cardiovascular risk.

The topics of weight and mental health issues must be approached with care and consideration Evidence suggests that even health care professionals hold biased attitudes toward adult patients, biases that may be extended to younger patients The physical examination should evaluate the presence of comorbidities and underlying etiologies.

Overweight and Obesity in Children and Adolescents

Assessment of general appearance may help to distinguish the etiology of obesity. This assessment should include inspection for dysmorphic features which may suggest a genetic syndrome, assessment of affect and assessment of fat distribution. The excess fat in obesity resulting from overeating, i.

In contrast, the centripetal distribution of body fat concentrated in the interscapular area, face, neck and trunk is suggestive of Cushing syndrome. Abdominal obesity also called central, visceral, android or male-type obesity is associated with certain comorbidities, including the MetS, PCOS and insulin resistance. Measurement of the waist circumference, in conjunction with calculation of the BMI, may help to identify patients at risk for these comorbidities.

Waist circumference standards for American children of various ethnic groups are available There are numerous publications on waist circumference measurements in children from various geographic regions which may be utilized in individual clinics. Blood pressure should be measured carefully using a proper-sized cuff. The bladder of the cuff should cover at least 80 percent of the arm circumference the width of the bladder will be about 40 percent of the arm circumference.

Hypertension increases the long-term cardiovascular risk in overweight or obese children. In addition, hypertension may be a sign of Cushing syndrome 5 , Hypertension is defined as a blood pressure greater than the 95th percentile for gender, age and height obtained on three separate occasions. Age- and height-specific blood pressure percentile references should be used Assessment of stature and height velocity is useful in distinguishing exogenous obesity from obesity that is secondary to genetic or endocrine abnormalities, including hypothalamic or pituitary lesions.

Exogenous obesity drives linear height, so most obese children are tall for their age. In contrast, most endocrine and genetic causes of obesity are associated with short stature 5 , For example, microcephaly is a feature of Cohen syndrome. Blurred disc margins may indicate pseudotumor cerebri, an unexplained but not uncommon association with obesity 65 , Nystagmus or visual complaints raise the possibility of a hypothalamic-pituitary lesion Other findings that support this possibility are rapid onset of obesity or hyperphagia, decrease in growth velocity, precocious puberty or neurologic symptoms.

Clumps of pigment in the peripheral retina may indicate retinitis pigmentosa, which occurs in Bardet-Biedl syndrome 5 , Enlarged tonsils may indicate obstructive sleep apnea. Erosion of the tooth enamel may indicate self-induced vomiting in patients with an eating disorder. Dry, coarse or brittle hair may be present in hypothyroidism. Striae and ecchymoses may be manifestations of Cushing syndrome; however, striae are much more likely to be the result of rapid accumulation of subcutaneous fat. Acanthosis nigricans may signify T2DM or insulin resistance.

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Abdominal tenderness may be a sign of gallbladder disease. The musculoskeletal examination may provide evidence of underlying etiology or comorbidity of childhood overweight. Nonpitting edema may indicate hypothyroidism. Postaxial polydactyly an extra digit next to the fifth digit may be present in Bardet-Biedl syndrome and small hands and feet may be present in Prader-Willi syndrome 5 , The musculoskeletal examination may provide evidence of SCFE limited range of motion at the hip, gait abnormality or Blount disease bowing of the lower legs.

Dorsal finger callousness may be a clue to self-induced vomiting in patients with an eating disorder The genitourinary examination and evaluation of pubertal stage may provide evidence for genetic or endocrine causes of obesity Undescended testicles, small penis and scrotal hypoplasia may indicate Prader-Willi syndrome. Small testes may suggest Prader-Willi or Bardet-Biedl syndrome 5 , Delayed or absent puberty may occur in the presence of hypothalamic-pituitary tumors, Prader-Willi syndrome, Bardet-Biedl syndrome, leptin deficiency or leptin receptor deficiency 5 , 10 , Precocious puberty occasionally is a presenting symptom of a hypothalamic-pituitary lesion Most of the syndromic causes of overweight in children listed in Table 2 are associated with cognitive or developmental delay.

Prader-Willi syndrome is also associated with marked hypotonia during infancy and delayed development of gross motor skills. The laboratory evaluation for overweight and obesity in children is not fully standardized. The child is likely to be non-fasting at the time of initial clinical evaluation. The metabolic panel provides a random glucose, serum alanine aminotransferase ALT and aspartate aminotransferase. HbA1c is a useful marker of the average blood glucose concentration over the preceding 8 to 12 weeks. Because of improved assay standardization and validation against other diagnostic methods, HbA1c has recently gained more emphasis as a screening tool for diabetes mellitus.

In year , the American Diabetes Association ADA authorized the use of HbA1c as a diagnostic criterion for diabetes and other glucose abnormalities provided that an assay that is certified by the National Glycohemoglobin Standardization Program is used The primary potential benefit of using HbA1c is practicality, i. Furthermore, HbA1c has less variability in repeat studies compared with fasting glucose values. However, there are also some disadvantages of use of HbA1c for the screening of diabetes in the pediatric population. For example, diseases such as iron-deficiency anemia, cystic fibrosis, sickle-cell disease, thalassemia and other hemoglobinopathies alter HbA1c results.

Ethnic variation in HbA1c levels has also been reported. The high cost of the test is also a handicap. Therefore, clinical judgment should be used Recent studies have shown that health care providers started to include HbA1c in their screening practices and are more willing to include this test in the context of the recent ADA guidelines The fasting laboratory tests include a lipid panel total cholesterol, triglycerides, LDL cholesterol and HDL cholesterol , fasting glucose and insulin. A fasting insulin level may be included for purposes of counseling rather than screening, as also recommended by an international consensus report on pediatric insulin resistance in Based on the ADA Consensus Panel Guidelines from year , screening for diabetes should be performed in children over 10 years of age or at the onset of puberty if it occurs at a younger age who are overweight or obese and have two or more additional risk factors.

The additional risk factors include a family history of T2DM in a first- or second-degree relative, high-risk ethnicity, acanthosis nigricans or PCOS The ADA recommends measurement of fasting plasma glucose level in these patients. In the context of the new screening guidelines advocating the use of HbA1c, clinical approaches are likely to incorporate this test. The risk markers consist of strong family history of T2DM or intrauterine exposure to diabetes maternal gestational DM , clinical indications for insulin resistance acanthosis nigricans, PCOS and a HbA1c level in the suspicious zone for prediabetes 5.

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Clinical judgment is also a key in making these decisions. Children with an elevated fasting glucose should have a confirmatory OGTT. Patients with intermediate or conflicting results for any of these tests should undergo repeat testing and be monitored for future development of diabetes. Definitive diagnosis of diabetes mellitus requires meeting diagnostic criteria on at least two separate occasions The panel recommended universal lipid screening with a non-fasting non-HDL cholesterol subtracting the HDL from the total cholesterol measurement for children of ages years and years.

Stepwise approach includes lifestyle modification and medical therapy if indicated 92 , 93 , In broad terms, two forms of approach are recommended for the management of hyperlipidemia. The first is a population-based approach to improve lifestyle and lipid levels in all children. The second is a high-risk strategy to identify children with genetic and environmental dyslipidemias by screening and treating as indicated 92 , 93 , Obese children with an elevation of ALT greater than two times the norm that persists for greater than three months should be evaluated for the presence of NAFLD and other chronic liver diseases e.

Assessment for other comorbidities including sleep apnea and PCOS depends on the presence of risk factors or symptoms and should be pursued on a case-by-case basis if indicated. Studies from various geographical regions reported that vitamin D deficiency was present in about half of children and adults with severe obesity and was associated with higher BMI and features of the MetS 95 , 96 , 97 , There are no guidelines recommending routine screening of overweight children for vitamin D status, therefore, clinical judgment is recommended.

If screening for vitamin D deficiency is undertaken, levels are measured as serum 25 hydroxyvitamin D. In populations of children with obesity, vitamin D deficiency was not generally associated with overt clinical symptoms 95 , 96 , 97 , However, if deficiency is found, vitamin D supplementation should be initiated to avoid long-term consequences. Additional testing should be performed as needed if there are findings consistent with hypothyroidism, PCOS, Cushing syndrome and sleep apnea 5 , 39 , 66 , Syndromic obesity should be evaluated in children with developmental delay or dysmorphic features.

As previously discussed, endocrine causes of obesity are unlikely if the growth velocity is normal during childhood or early adolescence Radiographic evaluation of overweight or obese children may be pursued if indicated by findings in the history and physical examination. For example, plain radiographs of the lower extremities should be obtained if there are clinical findings consistent with SCFE hip or knee pain, limited range of motion, abnormal gait or Blount disease bowed tibia.

Abdominal ultrasonography may be indicated in children with findings consistent with gallstones e. Abdominal ultrasonography may be used to confirm the presence of fatty liver. Pharmacotherapy options for the treatment of pediatric obesity are very limited. Therefore, it is crucial to establish a comprehensive management program that emphasizes appropriate nutrition, exercise and behavior modification. Lifestyle modification involving nutrition and physical activity i.

Behavioral change is needed to improve the energy balance, i. Treatment should encompass the concepts of primary and secondary prevention. In either case, a family-based approach will help extend these concepts of prevention to the other family members. Providing simple tips for maintaining a healthy weight by nutrition modification and increased physical activity and parenting strategies to support these goals will be a good start.

The clinician should provide counseling to optimize lifestyle habits with a goal of slowing the rate of weight gain. These families should be provided with information about a healthy lifestyle and direct counseling from a dietitian to address their specific challenges should be considered.