Childhood Obesity

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By Nancy Evans, BS

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Describe the incidence and prevalence of overweight and obesity among children from birth through adolescence.
• Discuss the short-term and long-term consequences of childhood obesity.
• Identify major factors contributing to overweight and obesity.
• Explain approaches to treatment of overweight and obese children and adolescents.
• Discuss individual approaches to prevention of overweight and obesity.
• Describe public health approaches to prevention of overweight and obesity.

DEFINING THE ISSUE

Americans are the fattest people in the industrialized world. Two-thirds of adults in the United States are either overweight or obese. While adult obesity rates have doubled since 1980, childhood obesity rates have nearly tripled during that time.

Incidence and Prevalence

One out of five children in America is overweight or obese—a total of 9 million children (CDC, 2006). The prevalence of overweight and obesity has nearly tripled among adolescents (12 to 19 years old) and quadrupled among younger children (6 to 11 years old). Prevalence is highest among African American and Latino adolescents. Life-threatening health problems once diagnosed in adulthood—type 2 diabetes, high blood pressure, and high cholesterol—are increasing among children and adolescents. These conditions threaten to decrease the life expectancy of today’s teenagers and to bankrupt the nation’s healthcare system.

Causes and Solutions

Today’s obesity epidemic defies simple explanation. It is not just a matter of overeating and under-exercising, although that’s part of the problem. A convergence of factors—genetic, behavioral, nutritional, socioeconomic, political, and environmental—have created a public health catastrophe for adults and children. Over the past 30 years, what, how, when, and where we eat and where and how families live, work, and play have undergone enormous change. Aggressive marketing of cheap high-fat, high-sugar foods, particularly to children; the fast-food invasion of school cafeterias; too much television and video gaming; too little exercise; and manipulation of nutritional messages by the food industry have together widened the waistlines of children and narrowed their chances for a healthy future.

Halting this multifaceted epidemic will not be simple; there is no one quick fix. Solutions must involve changes by individuals, communities, and society. Nurses and other health professionals, parents, teachers, and policy makers all need to be informed and involved in making change. Motivating change begins with understanding the causes and consequences of obesity and implementing programs and policies that will reverse the epidemic.

This case example shows the complex nature of obesity:

Dario has type 2 diabetes and high cholesterol. He weighs 310 pounds. He is 14 years old. Without professional help and major changes in diet and physical activity, he is destined for a shorter-than-normal life expectancy burdened by increasing health problems and limited career opportunities.

Like many Latino and African American adolescents, Dario is trapped in a complex web of circumstances—social, economic, and cultural—that have created an epidemic of obesity in America. The mean streets of his low-income inner-city neighborhood aren’t safe for walking or sports, and the nearest full-service supermarket is miles away. With both parents working, Dario is on his own for lunches, after-school snacks, and sometimes dinner, so convenience foods rule at his house. Sadly, Dario’s situation is not unusual.

Defining Overweight and Obesity

Overweight and obesity are measured according to body-mass index (BMI), which is calculated from a child’s weight and height. BMI is considered a reliable indicator of body fatness for most children and teens. Although BMI does not directly measure body fat, it is an inexpensive, easy-to-use screening tool to identify those whose weight may have a negative impact on lifetime health.

A person is considered overweight when his or her BMI exceeds the 85th percentile but is less than the 95th percentile. A person is considered obese when his or her BMI exceeds the 95th percentile. Severe obesity is defined as BMI at or exceeding the 99th percentile. Morbid obesity is defined as BMI ≥40 kg/m².

According to the CDC, for children and teens, BMI is age- and sex-specific and is often referred to as BMI-for-age.

After BMI is calculated for children and teens, the BMI number is plotted on the CDC BMI-for-age growth charts (for either girls or boys) to obtain a percentile ranking. Percentiles are the most commonly used indicator to assess the size and growth patterns of individual children in the United States. The percentile indicates the relative position of the child’s BMI number among children of the same sex and age. The growth charts show the weight-status categories used with children and teens (underweight, healthy weight, overweight, and obese).

BODY-MASS INDEX FOR AGE

Weight Status Category	Percentile Range
Underweight	Less than the 5th percentile
Healthy weight	5th percentile to less than the 85th percentile
Overweight	85th to less than the 95th percentile
Obese	Equal to or greater than the 95th percentile
Severely obese	Equal to or greater than the 99th percentile
Morbidly obese	BMI equal to or greater than 40 kg/m2

CDC Growth Charts: United States (CDC/National Center for Health Statistics).

CDC growth charts are often used as visual aids to educate parents about their children’s growth. However, a recent online survey found that “many parents cannot comprehend the data” (Ben-Joseph et al., 2009). When explaining BMI levels to parents, particularly those with limited English skills or limited health literacy/numeracy, color-coded charts can increase understanding. Researchers at the University of North Carolina developed BMI charts color-coded like a traffic light: green means the healthiest zone, yellow indicates more risk, and red indicates unhealthy BMI zones. When assessing parents’ understanding of BMI, researchers found that parents using the color-coded charts were four times more likely to answer questions correctly than those using the standard charts (Oettinger et al., 2009).

Consequences of Childhood Obesity

Being overweight or obese has serious short- and long-term consequences for individuals and for society. In the short term, overweight or obese children are at higher risk for type 2 diabetes, asthma, liver disease, sleep problems, and impaired cognitive function than other children (Li et al., 2008). They may also face teasing, bullying, and discrimination in school and social settings, leading to low self-esteem and depression.

In the long term, overweight children are more likely to become obese adults with serious, even life-threatening, chronic conditions such as type 2 diabetes, cardiovascular disease, stroke, and increased risk of Alzheimer’s disease (see box below). Overweight and obesity increase the risk of breast cancer in women and prostate cancer in men. Recent studies also suggest that cancer of the esophagus and upper stomach also may be linked with obesity. The incidence of both of these cancers is increasing in industrialized countries. One study that tracked more than 40,000 people for an average of 11 years found that obese individuals had 4 times the risk of esophageal cancer or upper stomach cancer than individuals of normal weight (MacInnis et al., 2006). Other studies show similar findings (Layke & Lopez, 2006; Corley et al., 2008; Chak et al., 2009; Falk, 2009).

Harvard scientists reported that obesity at age 18 was associated with a greater than two-fold increased risk of multiple sclerosis (MS) (Munger et al., 2009). This was a large prospective study using data from the Nurses’ Health Study. The researchers wrote, “Although the mechanisms of this association remain uncertain, this result suggests that prevention of adolescent obesity may contribute to reduced MS risk.”

Obesity may also increase the risk of serious complications from H1N1 influenza. A study in California showed that about 25% of the people hospitalized for H1N1 complications were morbidly obese, even though morbidly obese individuals account for less than 5% of the U.S. population. Of the 156 obese people hospitalized for H1N1, 46 died. Two-thirds of obese patients had underlying health problems, the most common of which were chronic lung disease, heart disease, and diabetes (Louie et al., 2009).

Although fat is fast becoming the new normal, overweight and obese people still face tremendous discrimination in education, employment, and other areas of life. Dealing with discrimination can be a major stressor, leading to depression and social isolation.

As a society, America faces escalating healthcare costs from obesity. The public health consequences of this epidemic carry a hefty price tag, exceeding $147 billion in 2008 in weight-related medical bills (Finkelstein et al., 2009). Experts estimate that the cost of treating diabetes alone may bankrupt our already crippled healthcare system within the next 20 years. The impact of so much diabetes and other chronic disease could affect our productivity as a nation and our ability to keep pace with other countries in the world.

MAJOR CONTRIBUTORS TO OVERWEIGHT AND OBESITY

Fast food is now served at restaurants and drive-throughs, at stadiums, airports, zoos, high schools, elementary schools, and universities, on cruise ships, trains, and airplanes, at K-Marts, Wal-Marts, gas stations, and even at hospital cafeterias.
—ERIC SCHLOSSER, in Fast Food Nation

Overfed and Undernourished: Food Industry Influences

Before America became a “fast-food nation,” obesity rates held steady at about 15% of the population. Today 2 out of 3 adults in the United States are overweight or obese, and children are on their way to matching that statistic.

FAST FOOD

Although the fast-food industry is not the sole perpetrator of America’s obesity epidemic, it wields a powerful influence on how and what America eats. For example, researchers found that students in schools near fast-food restaurants “consumed fewer servings of fruits and vegetables, consumed more servings of soda, and were more likely to be overweight or obese than were youths whose schools were not near fast-food restaurants” (Davis & Carpenter, 2009).

As more women entered the workforce during the 1970s and 1980s, the food industry responded with highly processed “convenience foods”—snacks and frozen dinners that could be microwaved in minutes. Eating on the run and/or in front of the TV—dad on one schedule, kids on another, and mom on a third—replaced home-cooked family meals around the table. The food industry rushed to oblige with single-portion packaging of microwavable foods. Increased sugar, fat, and salt not only boosted the appeal of these foods but also the desire for more sugar, fat, and salt—and Americans continued packing on the pounds. As David Kessler (2009) writes, “Eating foods high in sugar, fat, and salt makes us eat more of foods high in sugar, fat, and salt…. When offered a varied selection and large portions of high-sugar, high-fat, high-salt foods, many of us will eat them in excessive amounts.”

SUPERSIZED, SUPERSWEET

With the explosion of fast-food restaurants and their super-sized portions, the switch from sugar to high fructose corn syrup as the sweetener of choice in sodas, juice drinks, cereals, and a host of other foods, obesity rates skyrocketed.

High Fructose Corn Syrup

Many scientists see the 1980s sweetener switch by Coca-Cola and Pepsi from refined cane sugar to high fructose corn syrup (HFCS) as jump-starting the obesity epidemic. Corn is a federally subsidized commodity, which makes HFCS a cheaper sweetener than sugar. Other snack and beverage manufacturers swiftly followed suit, lured by higher profits and the ability to offer consumers larger-size portions without raising prices. Consumption of sweetened beverages and snacks soared. Today’s movie patrons enjoy 20-ounce sodas (equal to 17 teaspoons of sugar) with their jumbo buckets of butter-flavored popcorn. Some chain stores now offer 32- and 64-ounce soft drinks, which contain 416 to 832 calories, respectively—a significant portion of the recommended total calories for a single day. In addition to sweetening soft drinks, HFCS is now a stealth ingredient in bread and other baked goods, syrups, and jelly.

How Sweet Is It? Calories and Teaspoons of Sugar in 12-ounce Beverages
(Reprinted by permission from The Nutrition Source, Dept. of Nutrition, Harvard School of Public Health, “How Sweet Is It?,” http://www.hsph.harvard.edu/nutritionsource/healthy-drinks/how-sweet-is-it/index.html. © 2010 Harvard University.)

HFCS is a highly processed sweetener derived from cornstarch, usually a combination of 55% fructose and 45% sucrose. Some studies show that the body metabolizes HFCS differently than sucrose—which is either cane sugar or beet sugar, generally called “table sugar” or just “sugar”—and may increase cholesterol and triglyceride levels as well as the risk of developing metabolic syndrome (Stanhope et al., 2009; Cummings et al., 2010). Metabolic syndrome (also called insulin resistance syndrome) is a constellation of health problems, including hypertension, dyslipidemia, hyperinsulinemia, impaired glucose tolerance, and an increased risk for ischemic cardiovascular disease and type 2 diabetes mellitus.

Increased Soda, Decreased Milk

Sweetened soft drinks have replaced milk in the diets of many children and adolescents, as indicated by school purchases. For example, between 1985 and 1997, school districts decreased the amount of milk purchased by nearly 30% and increased their purchases of carbonated sodas by 1,100% (Daft et al., 1998). When sodas replace milk in a child’s diet, the risk of fractures increases. Studies show that adolescents who consume soft drinks have 3 to 4 times the risk of bone fractures than children who do not. The rate of fractures among those in late childhood and early adolescence is second only to fractures among the elderly (Kalkwarf, 2006). Nearly half of children have a fracture by age 18, and the incidence seems to be rising (Jones et al., 2002).

Sweetened soft drinks that contain caffeine (for instance, Coke, Pepsi, Mountain Dew, and Dr. Pepper) are doubly addictive. These beverages not only reinforce our innate preference for sweetness but also hook children on caffeine, known to be habit-forming. Caffeine interferes with the absorption of calcium from foods, a major concern because childhood and adolescence are the most important times for establishing strong, healthy bones.

New research in California shows a direct link between soda consumption and obesity in children and adults (Babey et al., 2009). Scientists found that 41% of young children (2 to 11 years of age) consume at least one soda or sweetened beverage every day. Adolescents (12 to 17 years) consume even more: 62% (more than 2 million teens) drink one or more sodas every day, which is the equivalent of consuming 39 pounds of sugar each year in soda or other sweetened beverages. Those who consume one or more sodas daily are 27% more likely to be overweight or obese than those who do not consume any soda. No wonder the Center for Science in the Public Interest refers to sweetened soft drinks as “liquid candy” (Jacobson, 2005).

Drinking sweetened beverages also contributes to tooth decay, a serious threat to general health, particularly in underserved populations who may not have access to dental care.

California banned the sale of soft drinks in elementary and middle schools effective July 2007. However, most students outside California have access to soft drinks in vending machines and in the school cafeteria at lunch. Many secondary schools have “pouring rights contracts” with soft drink companies. These contracts provide large lump-sum payments to school districts and additional revenue over 5 to 10 years in return for exclusive sales of a particular company’s products in vending machines and at all school events. Most students (83% in high school and 67% in middle schools) are in schools that have a pouring rights contract with a bottler (Johnston et al., 2007).

FOLLOW THE MONEY: MARKETING TO CHILDREN

The food industry exerts enormous influence on food policy and nutritional messages. Every day children’s television releases an avalanche of commercials for sugary, salty, high-fat, low-nutrient food—an onslaught of “empty” calories. The commercials are echoed by in-store advertising, the Internet, and sweepstakes. According to the Federal Trade Commission (2008), the food and beverage industries spent more than $1.6 billion to hype their products to children, some as young as 2 years old. One study (Lewin et al., 2006) reported the industry’s annual investment in promoting junk food to kids as $10 billion. This strategy aims to create brand awareness and preferences that carry into adulthood. Advertising aimed at the preschool market (ages 2 to 5 years) associates food products with fun and happiness and/or with excitement and energy (Connor, 2005).

The age of digital media has opened a vast array of marketing channels to reach children at younger and younger ages. As Yale researchers explain in a new report, “What was once a simple marketing landscape—television advertising during cartoons—has morphed into a complex web of persuasive messages even adults may not perceive as marketing. Internet games and marketing through social media such as Facebook are just the beginning and do not capture digital advances that will occur in the future” (Harris et al., 2009). This report shows that the cereals most highly advertised to children are the least nutritious, containing 85% more sugar, 60% more sodium, and 65% less fiber than those advertised only to adults. Eleven of the 13 most-advertised cereals do not qualify for inclusion in the Women, Infants, and Children (WIC) program. None would be allowed to be advertised to children on television in the United Kingdom. Yet all qualify for the industry-funded “Smart Choices” designation.

Parents and other children’s advocates are pushing to curb food marketing to children, as more than 50 other countries do. As Marion Nestle (2006) writes, “Australia, for example, bans food advertisements aimed at children younger than 14 years of age; the Netherlands bans advertisements for sweets to those younger than 12; and Sweden bans the use of cartoon characters to promote foods to children younger than 12.”

Marketing directly to children and adolescents is not the only weapon in the food industry arsenal. Food industry–sponsored research often tends to minimize health concerns related to their products. As pediatrician David Ludwig told U.S. News & World Report, “If a study is funded by the industry, it may be closer to advertising than science” (Voiland, 2009). The industry also donates to major nutrition organizations such as the American Dietetic Association and “partners with” medical organizations such as the American Academy of Family Practice (AAFP). A number of AAFP members have resigned in protest of the organization’s partnering with Coca-Cola on a new initiative to reduce consumption of sweetened beverages among children and adults. Harvard nutrition expert Walter Willett responded to AAFP’s deal with Coca-Cola in an e-mail to the Associated Press: “Coca-Cola, like other sodas, causes enormous suffering and premature death by increasing the risks of obesity, diabetes, heart attacks, gout, and cavities” (Tanner, 2009).

Industry also supports “astro-turf” groups that masquerade as grassroots groups to misinform/discredit campaigns that might affect industry sales and profits. For instance, the Center for Consumer Freedom, which is funded by corporate food interests such as Coca-Cola, Cargill, Tyson Foods, and Wendy’s, actively opposes obesity-related public health campaigns such as the one aimed at getting junk food out of schools (Center for Media and Democracy). Similarly, Americans Against Food Taxes lobbies against taxing sodas and other sweetened soft drinks.

Socioeconomic/Cultural Influences

Socioeconomic and cultural factors help shape our lives and our bodies. A family’s income is a powerful predictor of where and how they live, where and what they eat, where they go to school, and where they play.

INCOME AND ACCESS

Research shows that children and parents in more affluent families are less likely to be overweight or obese than those in lower-income families They are more likely to eat a healthier diet at home and at school than their lower-income cohort: more fresh fruits and vegetables, less junk food, and fewer soft drinks. They are more likely to live near parks, playgrounds, and other green spaces where it is safe to walk, run, and play (Sallis & Glanz, 2009). They are also more likely to have private health insurance with access to doctors than families in low-income groups, who are more likely to have only emergency care and hospitalizations. These are the realities that healthcare providers need to consider when caring for children who are overweight or obese.

Food insecurity (lack of access to enough nutritious food for an active, healthy life) affects more than 1 in 10 households in the U.S., and prevalence rates are higher in households with children younger than 6 years old and those in black and Hispanic households. Paradoxically, food insecurity in a family contributes to overweight, in part because the cheapest food is likely to be low-nutrient, high-fat, high-sugar, and/or salty processed food. A recent study of more than 8,000 low-income children ages 1 month to 5 years found that nearly one-third were from food-insecure households (more than 8% with hunger) and nearly one-fifth of those children were overweight. The prevalence of overweight was highest in girls ages 2 to 5 years old from food insecure households with hunger (Metallinos-Katsaras et al., 2009).

PARENTAL PERCEPTIONS AND BEHAVIOR

Parents serve as role models for children in many ways, including behaviors and attitudes related to food and nutrition. Researchers in the United Kingdom reported that the relationship between children and their same-gender parent might help explain why some children become obese and others do not. New research from the EarlyBird Diabetes Study showed that girls whose mothers are classified as clinically obese are significantly more likely to have weight problems in childhood than daughters of healthy-weight mothers. A similar association occurs between boys and their obese fathers. However, the same relationship does not exist between obese mothers and their sons or between obese fathers and their daughters. This indicates that the association is based on behaviors rather than genetics and that behavior change should begin with the parent (Perez-Pastor et al., 2009).

If parents are overweight or obese themselves, they may not perceive their children as too heavy, and they may be inactive themselves. In addition, they may not understand the current and future health risks involved in obesity for themselves or their children.

Children of Immigrants

Parental beliefs about weight may also influence the development of overweight and obesity in their children. For example, children of immigrants are at high risk of becoming obese. Parents who come to the United States from countries where food insecurity and hunger are the major problems for children may consider extra weight a sign of prosperity rather than a serious health problem.

A report from the Migration Policy Institute reported that nearly 34% of kindergarten-age sons of new immigrants to the United States have high levels of obesity compared to 25% of the sons of native-born Americans. By eighth grade, the rate among sons of immigrants rises to 49%, compared with 33% among the sons of natives. Researchers suggest that newly arrived immigrant parents may find it difficult to protect their children from obesity, possibly because economic challenges make it difficult to provide children with adequate supervision, healthy food, and opportunities for physical activity. This study used data collected by the Early Childhood Longitudinal Study, a project of the U.S. Department of Education (Van Hook et al., 2009).

Even though many immigrant families are poor, economic factors do not fully explain the higher prevalence of obesity in their children. Researchers found that for all children, those in the highest socioeconomic group tend to have lower rates of obesity than those in the medium or low socioeconomic group. However, within each of those groups, the differentiating factor was the age at which the parents had emigrated to the United States. Children of parents who had emigrated as adolescents or adults had higher rates of obesity than those whose parents had emigrated before age 12 and significantly higher than the sons of natives.

Children, particularly sons, of non-English-speaking parents are at higher risk of becoming obese than those whose parents have high levels of English proficiency. This may be because non-English-speaking parents do not understand the health risks of American junk food and may not be aware of the need for and availability of opportunities for sports and physical activities.

ADOLESCENT VULNERABILITIES

Adolescents who are overweight or obese account for one-third of the U.S. population ages 12 to 19. These young people present a special challenge to parents and healthcare professionals. In addition to socioeconomic and cultural influences and their own immaturity, adolescents are subject to peer pressure and to aggressive food marketing via digital media that parents are unaware of.

Research on alcohol and tobacco advertising shows that adolescents are more vulnerable to influence than adults, and that vulnerability extends to food advertising. Unlike most adults, adolescents are less capable of inhibiting impulsive behaviors and forgoing immediate gratification for longer-term rewards. They are more easily swayed by peer pressure and image advertising and have an elevated risk of addiction (Brownell et al., 2009b).

Peers are a powerful influence on many aspects of adolescent behavior, including eating. A study by Salvy and colleagues (2009) found that how much tweens and teens eat can affect how much their friends weigh. Researchers allowed 130 kids to snack as much as they wanted while hanging out with a friend or with a peer they did not know. All ate more when they were with a friend than with a stranger, but those who were overweight ate an average of 300 more calories when eating with overweight friends than when eating with leaner friends. So, in a sense, obesity can be contagious, and other studies have shown similar results among adults. However, parents should not encourage overweight kids to avoid their overweight buddies—that could lead to social isolation, which could make things worse. Other research has shown that eating alone causes teens to ingest an average of 400 more calories than when they’re with friends.

REGIONAL DIFFERENCES

Perceptions of what constitutes a healthy weight may differ in various regions of the United States, depending on socioeconomic status. For example, youth in low-income rural Appalachia showed greater acceptance of a higher average body weight than in other parts of the United States even though they are at a disproportionately higher risk of obesity due to inadequate physical activity and poor dietary habits. Girls were more concerned about weight than boys, but both groups noted the social stigma associated with overweight and discussed issues of guilt and lowered self-esteem (Williams et al., 2008).

THE BUILT ENVIRONMENT

We now realize that how we design the built environment may hold tremendous potential for addressing many of the nation’s greatest current public health concerns, including obesity, cardiovascular disease, diabetes, asthma, injury, depression, violence, and social inequities.
—RICHARD J. JACKSON (2003)

The built environment includes our homes, schools, workplaces, parks/recreation areas, business areas, and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains, and across the country in the form of highways. The built environment encompasses all buildings, spaces, and products that are created or modified by people. It impacts indoor and outdoor physical environments (e.g., climatic conditions and indoor/outdoor air quality) as well as social environments (e.g., civic participation, community capacity, and investment) and subsequently our health and quality of life (Srinivasan et al., 2003).

The built environment—where we live, work, play, and go to school—has a major influence on many aspects of public health, including obesity. Many aspects of today’s built environment do not encourage walking, biking, or other physical activities. Low-income urban neighborhoods often lack safe playgrounds, green spaces, and readily available healthy foods. The only open spaces available may be trash-strewn vacant lots or abandoned industrial sites. Schools in low-income neighborhoods are often poorly funded, with limited space for physical activity. Many are surrounded by fast-food outlets and corner stores that sell high-calorie, low-nutrient snacks and other foods. A study in Philadelphia found that the most frequently purchased items by middle-school children were low-nutrient foods and beverages such as chips, candy, and sweetened beverages, averaging 360 calories per purchase (Borradaile et al., 2009).

Studies suggest that residents with limited access to fast-food restaurants tend to have healthier diets and lower levels of obesity compared to residents of low-income neighborhoods. However, many suburban neighborhoods have no sidewalks, bike lanes, or walking trails, so children are driven everywhere. Only 25% to 50% of children walk to school.

Prenatal and Early Childhood Factors

Growing evidence indicates that obesity (and many other health problems) may begin in the womb. Exposures during critical windows of intrauterine development and early childhood can alter normal programming. For example, prenatal and early childhood exposures have been associated with adult obesity and cardiovascular disease (Barker et al., 2005).

GENETICS

According to the CDC (2009d), genetics has a role in the current obesity epidemic, but genes are not destiny. The child with a family history of obesity may be predisposed to gain weight, making early prevention of obesity especially important. One proposed genetic explanation for soaring obesity rates is the imbalance between today’s abundant food environment and “energy-thrifty genes” that developed in leaner times—when food supplies were uncertain and actual famines occurred. These ancient genes favored the storage of body fat to enable survival. Those who survived these famines passed these energy-thrifty genes on to their offspring. Genes may also influence the tendency to overeat (poor regulation of appetite and satiety), the tendency to be sedentary, and the diminished ability to use dietary fats as fuel.

Much of what is known about genetics and obesity comes from studies of resemblance and differences among family members, twins, and adoptees. Researchers continue to seek specific genetic factors related to obesity and have been most successful in studies of extreme obesity related to mutations of single genes (monogenic cases). However, those cases explain only a very small fraction of cases worldwide. Recently, mutations in a single gene (Melanocortin 4-receptor gene, related to the control of feeding behavior) have been found to be strongly associated with a minority (perhaps 5%) of obesity cases in several populations.

Several independent population-based studies report that a gene of unknown function, FTO (fat mass and obesity-associated gene), might be responsible for up to 22% of all cases of common obesity in the general population. This gene also shows a strong association with diabetes. Intense scientific investigation is underway to identify how this gene operates (CDC, 2009d).

A very small percentage of childhood obesity cases are related to genetic abnormalities or endocrine disorders: Prader Willi syndrome, Cushing’s syndrome, hypothyroidism, and adrenal hypercorticoidism (Krebs et al., 2007).

Asian Americans of Indian descent have an increased risk of diabetes (compared with other Asian Americans) even when their weight is in the normal range, according to a new study (Oza-Frank et al., 2009). Researchers used data from the National Health Interview Survey for 1997–2005 and found that diabetes prevalence among Asian Indians ranged from 6% to 7% among adults of normal weight to 19% to 33% among the obese. Although only adults were included in the study, the results could have implications for children, particularly given the typical high-fat American diet.

EPIGENETICS AND OBESOGENS

Epigenetics is the study of gene expression, the switching on and off of gene action without causing a mutation (a change in the genetic code [DNA]). Gene expression signals the cells in the body on how and when to differentiate. When gene expression is altered—for example, by exposure to chemicals, radiation, or nutrition—abnormal development of cells, organs, and systems can occur. Environmental epigenetics looks at how chemicals or other environmental exposures can interfere with gene expression and thereby disrupt development. These epigenetic changes can increase susceptibility to obesity and other serious health problems, and the changes can be inherited by successive generations.

Maternal exposure to environmental chemicals that disrupt hormone function can increase the risk of obesity in her offspring (Oken & Gillman, 2003). These chemicals invade and persist in women’s bodies (called “body burden”), cross the placenta, and result in epigenetic changes that can persist across generations. According to Linda Birnbaum, Director of the National Institute of Environmental Health Sciences (2009), “You may be affected by what your mother and grandmother were exposed to during pregnancy.”

Animal studies show that prenatal exposure to some environmental chemicals increases the risk of obesity, hypertension, and insulin resistance in offspring. These chemical compounds are called obesogens. Epidemiological evidence suggests that these effects may also be happening in humans. For example, Harvard scientists reported that the prevalence of overweight in 6-month-old infants increased 73% between 1980 and 2001 (Kim et al., 2006). These very young infants don’t fit the overeating, under-exercising profile of older children and adolescents, suggesting that prenatal exposure to obesogens puts children on the pathway to obesity very early in life.

Obesogens include chemicals such as bisphenol A (BPA), a synthetic estrogen used in the manufacture of polycarbonate plastic, or phthalates, which is a family of chemicals found in soft plastics, cosmetics, fragrances, household cleaning products, and pesticides such as atrazine (Lim et al., 2009) and hexachlorobenzene (Smink et al., 2008). Even chemicals that have been banned for decades, such as DDE (a metabolite of the pesticide DDT) and PCBs (polychlorinated biphenyls, used in electrical insulation and other industrial products), persist in women’s bodies and result in increased BMI in their offspring during the first 3 years of life (Verhulst et al., 2009). Lead may also be an obesogen (as well as a neurotoxin), at least among males, according to a study by Leasure and colleagues (2008).

Bisphenol A (BPA) is a lipophilic (fat-seeking) chemical ubiquitous in the environment and in people. Scientists from the CDC found BPA present in more than 93% of Americans tested (Calafat et al., 2005). Human exposure is primarily through food. The vast majority of food and beverage cans are lined with BPA, which can leach into the food contained. Consumer Reports Magazine (2009) tested 19 brand-name foods packed in canned and packaged foods and found that almost all contained BPA, even those packed in cans labeled “BPA-free.” Once in food, BPA moves quickly into humans. Microwavable cookware also contains BPA, which when heated, more readily migrates into food, particularly fatty foods. Some baby bottles and sippy cups also contain BPA, exposing young children to this estrogenic chemical. Animal studies show that prenatal exposure to low levels of BPA increases the number and size of adipocytes (fat cells), resulting in obesity in young animals (Somm et al., 2009).

MATERNAL HEALTH, WEIGHT, AND BEHAVIORS

Women who are overweight are more likely to have premature/low birth-weight newborns than are women of healthy weight. Low birth weight followed by rapid weight gain is a risk factor for central (visceral) obesity, which is associated with a group of health problems, including hypertension, dyslipidemia, hyperinsulinemia, impaired glucose tolerance, and an increased risk for ischemic cardiovascular disease. This constellation of disorders is called the “insulin resistance syndrome,” or metabolic syndrome. Higher birth weight is also associated with higher BMI in later life.

Pre-pregnancy overweight (BMI ≥25.0 kg/m²) increases the risk of congenital heart defects such as tetralogy of Fallot and pulmonary valve stenosis (Gilboa et al., 2009). A meta-analysis of studies on maternal weight and congenital abnormalities (Stothard et al., 2009) found that women with a BMI ≥29 before pregnancy were more than twice as likely to have an infant with spina bifida or other neural tube defects and more likely to have an infant with cleft palate or cleft lip, abnormal rectum or anus development, and hydrocephaly. The researchers hypothesized that three factors may influence the link between maternal obesity and congenital anomalies in their infants: (1) many of the women may have had undiagnosed diabetes, which can interfere with normal fetal development; (2) the mothers’ diets may have been deficient in key nutrients such as folic acid; (3) ultrasound monitoring may have failed to detect the abnormalities because adequate visibility of the fetus is much more difficult in obese women.

Daughters of overweight mothers are more likely to experience early puberty than daughters of healthy-weight mothers. Early puberty involves other health risks, including increased risk of:

• Breast cancer
• Polycystic ovary syndrome
• Early drug and alcohol abuse
• Unprotected sex
• Violent victimization
• Depression and anxiety
• Conduct disorders and delinquency
• Lower academic education (Steingraber, 2008).

Maternal diabetes is also a risk factor for overweight or obesity in offspring (Huang et al., 2007). Women who smoke during pregnancy also increase the risk of nicotine-related obesity and hypertension in their offspring (Gao et al., 2005).

EARLY CHILDHOOD FEEDING

Most excess weight before puberty is gained before 5 years of age.
—GARDNER ET AL., 2009

Nutrition during infancy and early childhood can affect an individual’s health throughout life. This is the time when parents have the greatest opportunity to make healthy food choices for their family and to establish healthful eating habits in their children.

Rapid weight gain in the first 6 months of life can predict obesity and elevated blood pressure later in childhood and in adult life. Harvard researchers recently reported that the rapidity of weight gain may have more impact on the risk of obesity than birth weight (Taveras et al., 2009). They found that more rapid increases in weight for length were associated with increased risk of obesity at 3 years of age.

As discussed earlier, infants at both ends of the birth weight spectrum are at increased risk of obesity, possibly due to prenatal exposures. There is a parental tendency to overfeed low birth-weight infants because they don’t fit the “healthy“ image of the chubby-cheeked baby. Overfeeding is more likely to occur with formula feeding than with breastfeeding. Early introduction of commercially prepared baby foods may also contribute to rapid weight gain, depending on the fat and sugar content of the foods.

The increasing number of women in the workforce has changed infant feeding practices. Beginning in the 1980s, breastfeeding rates declined, replaced by formula feeding. Few breastfeeding mothers persist beyond 6 months, rather than the 1-year minimum recommended by the American Academy of Pediatrics. Breastfeeding confers many long-term benefits on both mother and infant, not the least of which is the reduced lifetime risk of obesity in the offspring (AAP, 2005). On the other hand, the genistein found in soy-based formula is a potential risk factor for overweight later in life (Stettler et al., 2005). Animal studies show that genistein also alters the development of the mammary gland, even in male rodents (Latendresse et al., 2009).

Actual feeding practices vary widely from the AAP recommendations, particularly with regard to breastfeeding and the introduction of solid foods. In one large study, researchers found that only 8% of subjects followed the 6-month exclusive breastfeeding recommendation. Although 70% of infants were breastfed for the first 6 months, 78% were also fed formula, generally starting around 2 months of age. A similar percentage was also fed solid food (baby food) beginning at 4 months and finger food beginning around 7 months. Researchers reported that the children who were fed formula and solid food in the first 6 months of life had significantly higher BMI at 2 years than those who were fed breast milk exclusively for 6 months. Those who were given a combination of breast milk, formula, and solid food in the first 6 months also had significantly higher BMI at 2 years than those fed breast milk exclusively for 6 months (Philipsen et al., 2009).

There may be several reasons for non-adherence to the AAP infant feeding recommendations, including parental lack of knowledge, feasibility of breastfeeding, and ethnic/cultural customs. Those with the greatest need for the information may have the least access to it due to socioeconomic factors. However, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (see “Resources” below) has a wealth of information available for parents and health professionals as well as a recently updated offering of more nutritious foods. For the first time in more than 35 years, this federal voucher program now includes fresh produce, whole grains, and low-fat sources of protein, while reducing juices and dairy products.

ASSESSMENT FOR OBESITY

Assessment of the overweight or obese child has three major goals:

• Identify modifiable dietary and physical activity practices
• Assess current and future risks for comorbidities
• Assess patient and/or family readiness to make behavioral changes

In addition to measuring vital signs, assessment should include:

• Measurement of height and weight
• Calculation of body-mass index (BMI)
• Skin inspection for skin tags and acanthosis nigricans (a disorder associated with obesity and elevated insulin levels, characterized by velvety, light brown-to-black skin tones usually on the neck, under the arms, or in the groin)
• Measurement of waist circumference and the fat distribution pattern (waist-to-hip ratio; “apple” shape vs. “pear” shape)
• History of height and weight of the child, parents, and siblings
• Eating habits and patterns, including appetite
• Physical activities of the child
• Medications the child is taking (some second-generation anti-psychotic medications [aripiprazole, olanzapine, quetiapine, risperidone] are reported to cause significant weight gain in young patients, which could exacerbate obesity [Correll et al., 2009])

Obesity generally occurs as 1 of 2 types of fat distribution: central obesity and peripheral obesity. The fat distribution pattern is important in assessing risk of comorbidities. Adipose tissue is not inert fat; instead, it is metabolically active tissue that can affect the physiology of other tissue.

Central obesity (also known as intra-abdominal, visceral, android, or masculine obesity) is characterized by fat localized around the abdomen and upper body, resulting in an “apple” shape. Visceral or android adipose tissue is more metabolically active than other adipose tissue and increases the risk of metabolic syndrome. Peripheral obesity (also known as gluteal-femoral or feminine obesity) is characterized by fat distribution around the thighs and buttocks, resulting in a “pear” shape (Huether, 2008).

Assessing Dietary and Physical Activity Practices

Brown University scientists have developed two convenient assessment tools to use in working with children and adults. The first tool, called “WAVE,” is a guide for assessing weight, activity, variety [of foods], and excess [nutrient groups/portion size] in patients (see box). The second is called “REAP,” or Rapid Eating Assessment for Patients, to be completed by parents of younger children or by adolescents (see “Resources”).

A simple method to measure current physical activity in children and adolescents is by using a pedometer. Taking about 4,000 steps in 30 minutes and 8,000 steps in 60 minutes (fast walking) meets the current CDC physical activity recommendations. Use of a pedometer along with an activity diary for 1 week can determine a baseline average of number of daily steps.

Assessing Current and Future Risk for Comorbidities

Metabolic syndrome, also called insulin resistance syndrome, is associated with increased risk of type 2 diabetes and cardiovascular disease. Increasingly common in overweight and obese adults, metabolic syndrome has evaded a consistent definition in children and adolescents. However, the International Diabetes Federation (IDF) proposed some defining criteria for adolescents. An adolescent has metabolic syndrome if he or she has abdominal obesity (waist circumference ≥90th percentile) and two of the following: triglycerides ≥1.7 mmol/l; HDL cholesterol <1.03 mmol/l; blood pressure ≥130 mmHg systolic or ≥86 mmHg diastolic; or glucose ≥5.6 mmol/l (10).

According to IDF criteria, analysis of National Health and Nutrition Examination Survey (NHANES) showed that 4.5% of U.S. 12- to 19-year-old adolescents have metabolic syndrome (Ford et al., 2008). However, a study of 1,400 racially/ethnically diverse eighth-grade students in three states (Texas, North Carolina, and California) showed that prevalence of metabolic syndrome was 9.5%, more than double that of the NHANES analysis. More than 92% of students with the syndrome had low HDL cholesterol, and 80% had high fasting glucose levels (STOPP-T2D, 2008). Males were more likely to have low HDL cholesterol, high blood pressure, and high fasting glucose than females.

Male adolescents with metabolic syndrome also face an additional risk: non-alcoholic fatty liver disease (NAFLD), which may progress to irreversible liver damage. The liver enzyme alanine aminotransferase (ALT) is a marker for NAFLD. Researchers reported that males ages 12 to 19 with metabolic syndrome had elevated levels of ALT, but females did not (Graham et al., 2009). The only known treatment for NAFLD is weight loss.

Hypertension and hypercholesterolemia are increasingly common in obese children and adolescents. The currently established guidelines for diagnosing these conditions are summarized below.

CONSENSUS GUIDELINES FOR DIAGNOSIS OF HYPERTENSION AND DYSLIPIDEMIA IN CHILDREN

Source: American Heart Association Scientific Statement: Dietary Recommendations for Children and Adolescents—A Guide for Practitioners, 2005.
Prehypertension	Systolic or diastolic blood pressure >90th percentile for age and gender or 120/80 mm Hg, whichever is less
Stage 1 hypertension	Systolic or diastolic blood pressure >95th percentile for age and gender on 3 consecutive visits or 140/90 mm Hg, whichever is less
Stage 2 hypertension	Systolic or diastolic blood pressure >99th percentile + 5 mm Hg for age and gender or 160/110 mm hg, whichever is less
Total cholesterol: Borderline Abnormal	≥170 mm/dL ≥200 mg/dL
LDL cholesterol: Borderline Abnormal	≥100 mg/dL ≥130 mg/dL
HDL cholesterol: Abnormal	<40 mg/dL
Triglycerides: Abnormal	≥200 mg/dL

Assessing Patient and Family Readiness to Change

Successful treatment of obesity ultimately depends on changing parent and/or patient behavior related to dietary intake and physical activity. To communicate effectively with parents of overweight or obese children and with the patients themselves, the healthcare provider needs to determine (1) how important it is to the parent/patient to make changes and (2) how confident the parent/patient is in the ability to make the changes. If either the parent or the patient fails to see the importance of making changes in diet and physical activity, the healthcare provider needs to focus on the serious health risks, both short-term and long-term. If either the parent or the patient lacks confidence in their ability to make changes, the healthcare provider needs to determine what the perceived/actual barriers are. Once barriers are identified, the provider and the patient/parent can explore together ways to overcome or minimize those barriers (Krebs et al., 2007).

TREATMENT OPTIONS

Residential Treatment Programs

Successful treatment of severely obese adolescents may involve more than just changes in diet and exercise patterns. Teens in more affluent families may enter residential treatment, either a program such as those at Duke University or one of several other private facilities. Summer camps with weight loss as a primary goal are also available. These programs use a comprehensive approach that includes behavioral intervention and counseling, healthy eating, exercise, and nutritional education. The goal is not just weight loss but changing lifetime eating behaviors to achieve and maintain a healthy weight. However, these programs are inaccessible to the vast majority of adolescents because they are very expensive ($1,500 per week and up) and unlikely to be covered by health insurance.

Pharmacologic Interventions

The Food & Drug Administration (FDA) has approved two prescription weight-loss drugs for adolescents: sibutramine (Meridia) and orlistat (Xenical). Sibutramine is approved for adolescents older than 16. It changes brain chemistry to speed the feeling of fullness. Orlistat is approved for adolescents older than 12 and prevents the absorption of fat in the intestines. The FDA has also approved a reduced-strength over-the-counter version of orlistat called Alli; however, it is not approved for children or adolescents under the age of 18.

According to the Mayo Clinic (2008), prescription medication isn’t often advisable for adolescents. Both FDA-approved drugs have significant side effects and achieve only modest improvement in weight loss compared with behavioral interventions alone. Sibutramine (Meridia) is associated with cardiovascular effects such as tachycardia and increase in systolic and diastolic blood pressure. Orlistat (Xenical) is associated with adverse gastrointestinal effects, which include oily spotting, oily evacuation, abdominal pain, fecal urgency, flatulence with discharge, and fecal incontinence (Whitlock et al., 2010).

A study in the United Kingdom found that “most prescribed antiobesity drugs in children and adolescents are rapidly discontinued before patients can see clinical benefit, suggesting that they are poorly tolerated or poorly efficacious” (Viner et al., 2009). The American Academy of Pediatrics considers weight loss medications for adolescents an “intensive” intervention that should be offered only to some severely obese youths for whom more conservative measures have failed (Barlow et al., 2007).

Whether these drugs are effective in weight loss and weight maintenance remains controversial. No drug is without side effects, and the risks of long-term use are unknown. Finally, drugs don’t replace the need to establish a healthy lifetime diet and exercise program.

Bariatric Surgery

Bariatric (weight-loss) surgery is becoming one of the most commonly used operative procedures in U.S. adults. Given the prevalence of obesity, this is not surprising. Teens account for less than 1% of bariatric surgery patients, but the number of adolescents undergoing bariatric surgery continues to grow, tripling between 2000 and 2003 (Tsai, 2007). A survey of bariatric surgeons in the United States found that 70% of them were planning to perform adolescent bariatric surgery within the following year (Allen et al., 2007).

The use of bariatric surgery to treat morbidly obese adolescents remains highly controversial, not only because of the lifelong physiological implications and uncertainty about potential complications, but also because of the ethical implications. As one pediatric surgeon wrote,

Performance of bariatric surgery in pediatric patients carries profound ethical burdens for all stakeholders: morbidly obese children and adolescents, their parents and families, pediatric physicians and surgeons, pediatric healthcare institutions, and society. The decision to proceed with a bariatric intervention should be made only after it is established that the patient’s comorbidities could not be treated with less invasive means, the patient has a favorable risk/benefit profile, the patient and his/her family have received extensive preoperative counseling and given informed consent, and the pediatric bariatric team has a comprehensive system of short- and long-term care. (Caniano, 2009)

Most adolescents undergoing bariatric surgery have private insurance, are more likely to be male, and have fewer comorbid conditions than adults undergoing this type of surgery. The cost of bariatric surgery ranges from $17,000 to $35,000, which generally includes the pre-operative laboratory and imaging fees, anesthesia, hospital charges, and surgeon’s fee. Additional post-surgical expenses may include additional body contouring surgery to remove excess skin, lift sagging body areas, tighten loose muscles, or treat fat deposits (Consumer Guide to Bariatric Surgery, 2009). Residential weight-loss programs, such as summer camps or boarding schools, may be less expensive, depending on the length of stay needed to achieve goal weight.

PATIENT SELECTION

A consensus conference of pediatricians and pediatric surgeons (Inge et al., 2004) concluded that adolescent bariatric surgical patients should be cared for in multidisciplinary programs by professionals with special expertise in dealing with adolescents. These programs would include “pediatric endocrinologists, nephrologists, psychiatrists and psychologists, as well as dietitians and exercise therapists. Pediatric surgeons who wish to participate in the surgical management of these individuals will have to take the time to learn to perform these procedures safely and care for these patients postoperatively.” In addition, they suggested criteria for patient selection, including:

• Participation in at least 6 consecutive months of aggressive dietary and exercise therapy with appropriate compliance
• Achievement of skeletal maturity, normally 13 years of age for females and 15 years of age for males (because of concerns about calcium absorption)
• BMI of ≥40 with serious comorbidities or ≥50 with somewhat less serious comorbidities

Candidates for bariatric surgery should also demonstrate commitment to comprehensive medical and psychological evaluation before and after surgery, willingness and ability to follow post-operative nutritional guidelines and exercise programs, and informed consent to surgery.

RISKS AND BENEFITS

There is limited research on the long-term benefits and risk of complications. In 2007 the National Institutes of Health launched an observational study to evaluate the benefits and risks of bariatric surgery in adolescents. However, the study will only recruit 200 subjects over five years, so the results will not be available until perhaps 2013.

Researchers from Cincinnati Children’s Hospital Medical Center reported that there is a narrow window of opportunity for surgical reversal of obesity in adolescents. Their study of 61 teens found that one year after surgery their BMI had dropped by 37% and cardiovascular risk factors had improved. However, because of the teens’ high preoperative weight, they were still morbidly obese. These results suggest the need for earlier intervention when teens begin to rapidly gain weight (Inge et al., 2009). “Late” referral at the highest BMI values may preclude reversal of obesity.

Other research evidence suggests that adolescent bariatric surgery achieves significant weight loss and may be “as well tolerated as in adults when performed in centers with appropriate experience and adequate surgical volume. The pathophysiologic implications of bariatric surgery are profound” (Levitsky et al., 2009). One small study (11 patients) showed a reversal of type 2 diabetes and improvements in cardiovascular risk factors following bariatric surgery (Inge et al., 2009). However, as one pediatric surgeon pointed out, “I suggest that it is the weight loss that reverses diabetes and not the surgery. Unfortunately, this is not a randomized trial nor does it compare results to a cohort of obese patients with similar non-surgical weight loss. One has to ask the question: success at what price?” This surgeon raises the issue that adolescents are developmentally incapable of recognizing the serious long-term consequences of this surgery, which can include mortality, cancer, adhesive bowel obstructions, iron deficiency anemia, internal hernias, and flatulence. She explains that “the cognitive ability to understand mortality does not occur until approximately age 25” (Farmer, 2009).

Female adolescents considering surgery need to be aware of the possible effects of bariatric surgery on future pregnancies. These effects are not completely understood, although there have been a number of studies. An analysis of the existing literature (Maggard et al., 2008) reported that the most common maternal complication during pregnancy was bowel obstruction related to internal hernias. However, the analysis also suggested that the risks for maternal complications such as gestational diabetes and preeclampsia may be lower after surgically induced weight loss than the risks in obese women. The risk of neonatal complications such as prematurity or low birth-weight may also be lower after bariatric surgery. The typical recommended post-surgical waiting period prior to conception is one year, but some programs recommend 18 to 24 months.

One study reported follow-up results of the laparoscopic adjustable gastric banding (LAGB) procedure in more than 40 morbidly obese adolescents. At 1-year follow-up, patients had lost 46% of their excess body weight. They also had a significant decrease in total and android (visceral) fat mass. More than half of the identified comorbidities were completely resolved and 1/4 of them were improved, compared with baseline. At 2 years, the initial weight loss had been sustained and improvements in metabolic status were seen, based on liver function tests, lipid levels, and measures of glucose homeostasis. It is important to note that 4 of the 7 authors of the article had affiliations with Allergan, the manufacturer of the restrictive device used in the study (Nadler et al., 2009).

It is too soon to tell whether the weight loss achieved by bariatric surgery in adolescence will prove durable. One of the largest studies done on teens showed that 15% of patients regained some or all of their body weight within 5 to 10 years after surgery (Sugerman &; Sugerman, 2003).

Morbidly obese adolescents may also have psychological problems such as depression and aberrant eating behaviors. Depression is common among overweight and obese individuals of any age, and adolescents are no exception. Aberrant eating behaviors may include binge eating, eating too fast, having guilt associated with eating, eating until uncomfortably full, eating when not hungry, and eating alone. Counseling and behavioral therapy to deal with these behaviors before surgery may increase the likelihood of a more successful long-term outcome (Kim et al., 2008).

TYPES OF BARIATRIC SURGERY

There are a number of different types of bariatric surgical procedures. Some are restrictive, causing weight loss by limiting the amount of food that can be consumed in one meal. Other types are malabsorptive, causing weight loss by reducing the amount of food absorbed by the body. The two most common bariatric surgical procedures used are laparoscopic adjustable gastric banding (LAGB), which is purely restrictive, and Roux-en-Y gastric bypass (RYGB), which is both restrictive and malabsorptive. RYGB can be performed using laparoscopic techniques, depending on the patient’s individual circumstances.

RYGB is the most frequently used bariatric surgical procedure in adolescents. It not only reduces the size of the stomach but also narrows the connection between the stomach and small intestine and decreases the amount of food the patient can eat. The procedure takes 2 to 4 hours and requires a 3- to 5-day hospital stay plus an intense schedule of follow-up visits for the first year. In addition, the patient needs to make long-term lifestyle changes after the surgery, including:

• Taking daily vitamin and mineral supplements
• Eating a very low-calorie, low-carbohydrate diet
• Exercising on a regular basis
• Taking prescribed medications for six months
• Avoiding pregnancy until at least one and possibly two years after surgery

Gallstones (cholelithiasis) are a common result of obesity. About one-third of bariatric surgery patients have gallstones and another one-third develop gallstones after surgery. Therefore, the gallbladder is often removed during RYGB.

PATIENT AND FAMILY EDUCATION

Both the patient and the family need to understand that bariatric surgery is not a “quick fix” for adolescent obesity. It is a life-altering procedure with potential benefit to health and quality of life but also with known and unknown risks and complications. The surgical team needs to discuss with the patient and the family:

• The expected benefits of the surgery
• Realistic goals for weight loss and maintenance of that loss
• Long-term consequences of the surgery
• Possible risks and complications of the surgery

Once the surgery is completed and the patient has gone home, he or she and the family are responsible for the day-to-day management of diet and exercise. Most centers performing these procedures have group support available to answer questions and concerns. The patient and family are also responsible for adhering to the recommended schedule of follow-up visits.

At Lucile Packard Children’s Hospital at Stanford (2009), pre- and post-bariatric surgery patients and families are required to attend at least 4 support groups per year and are encouraged to attend monthly. At these meetings, attendees can get their questions answered, voice their concerns, and receive guidance and support from other patients and families.

PREVENTION OF CHILDHOOD OBESITY

Prevention of obesity starting in childhood is critical and can have lifelong, perhaps multigenerational impact.
—EMILY OKEN and MATTHEW W. GILLMAN, 2003

Childhood obesity is far easier to prevent than to treat, and many points in the healthcare system offer opportunities for prevention. Newborn nursery nurses, other pediatric nurses, and school nurses are obvious examples, but those in community health, family nursing, women’s health, and occupational health can also make a difference.

For example, teaching parents, especially women, the importance of healthy food and physical activity to the lifetime health of their children is essential. Healthcare professionals can help young women understand the need to achieve and maintain a healthy weight before and during pregnancy to reduce the risk of birth defects and obesity in their infants. Teaching pregnant women about the many benefits of breastfeeding for themselves and their infants is another way to reduce obesity risk. Healthcare providers can also connect patients and families with community programs on physical activities and food access, such as WIC, food banks, urban gardens, and farmers’ markets.

Improving Diets

What, where, and how much a family eats influences the dietary quality and food-related behaviors of all family members, especially younger children who have little control over what foods are available. Families who eat out frequently may consume more calories than those families who eat at home and are more aware of the nutritional content of meals. Snacking is common in many families—especially after school—and can be an opportunity for introducing healthy foods such as fruits or vegetables (carrot sticks, for example). Unfortunately, the most popular, highly advertised snack foods are salty chips and sweetened soft drinks—precisely the ones children need to avoid.

According to the Health Eating Index—2005, U.S. children between the ages of 2 and 17 years need an improvement to the quality of their diets. Children of all ages need to increase their consumption of whole fruit, whole grains, dark green and orange vegetables, and legumes. They need to decrease consumption of saturated fat, sodium, and extra calories from solid fats and added sugars (USDA, 2009). These findings are based on the 2005 Dietary Guidelines for Americans, which will be revised in 2010 and every five years thereafter.

Any dietary changes recommended for overweight or obese children should provide for:

• Slow, steady weight loss
• Lack of metabolic complications
• Lack of hunger
• Absence of psychiatric reactions
• Normal activity
• Growth

The dietary regimen should involve ordinary food in controlled-size portions, not special “diet” food. Widely advertised fad or crash diets should be avoided.

Food-related behaviors that should be targeted for change in combating obesity include: skipping breakfast or eating a low-nutrient breakfast, frequent eating outside the home in restaurants or fast-food outlets, excessive consumption of sweetened beverages and/or 100% fruit juice, consumption of excessive portion sizes for age, excessive consumption of energy-dense foods, meal frequency and snacking behaviors, and low consumption of fruits and vegetables.

Children who start the day with a nutritious breakfast perform better in school and are less likely to need snacks to get them through to lunch. “Eating out” should be a very occasional treat, not a regular habit, and children should be helped to make healthy choices when ordering. Substituting water or milk for sweetened soft drinks or 100% juice can cut calories dramatically. Snacking on fruits or vegetables is one way to boost consumption of these healthful foods without adding excess calories.

Sitting down together for family meals can also have a positive effect. However, plates should be served in the kitchen and taken to the table. Serving “family style” encourages refills and overeating. A reasonable portion or serving of food is about the size of a deck of cards. Healthcare providers and parents should discourage eating in front of a screen, whether TV, computer, or video game. Children who eat during “screen time” eat too fast and too much; one researcher calls this “mindless eating.” Don’t make snacking too convenient—keep snacks, even healthy ones, at least six feet away (Wansink, 2007).

Parents and children ages 6 to 11 years old who have Internet access can visit MyPyramid.gov to get interactive, personalized nutrition information and assess their own food intake and physical activity level. This site provides in-depth information about each food group, oils, discretionary calories, and physical activity. For parents and patients without Internet access, nurses and other health professionals can provide handouts from MyPyramid.gov or other websites listed in “Resources“ at the end of this course.

Encouraging Physical Activity

Physical activity is an essential part of good health. It burns calories and helps build strong bones and muscles. The bodies of healthy children were meant to move. Left to their own devices, young children want to be active—to move rather than sit and watch TV or videos. Physical activity helps children stay alert during the day and sleep well at night.

The CDC (2008) recommends that children and adolescents should have at least 60 minutes or more of physical activity every day. Most of that activity should be either moderate-intensity aerobic activity such as brisk walking or vigorous-intensity activity such as running. Muscle strengthening activities such as gymnastics or push-ups should be part of the 60 minutes at least 3 days a week. Bone strengthening activities such as jumping rope or running should be included in the 60 minutes at least 3 days a week. Younger children generally do not need structured muscle-strengthening activities because their normal play activities, such as climbing trees or playing on a jungle gym, strengthen muscles. However, adolescents may need more structured weight-lifting programs.

Parents can encourage and supervise age-appropriate activities that allow movement in safe areas, both inside the home and outside. Overweight youngsters are less likely than children of healthy weight to be active unless prompted by older children, parents, or other adults. Whether the extra weight leads to inactivity or vice versa, the inactivity will contribute to overweight. Parents also need to lead by example and find activities that the family can do together, such as swimming, hiking, bowling, or just taking a walk.

Walking to school is excellent exercise, and forty years ago almost all students who lived close to school walked or biked to get there. Today, less than half of students do that. Most students are driven to school either by parents or on school buses because of parental concerns about safety—crime-infested neighborhoods, traffic, sexual predators. However, a collaboration of state and federal government agencies has created Safe Routes to School, a program that enables community leaders, schools, and parents “to improve safety and encourage more children to safely walk and bicycle to school.” For example, some parents have formed “walking school buses,” in which two or more parents escort children to and from school. Others have worked to improve sidewalk conditions in the neighborhood or to get bike trails that connect homes and school. (See “Resources” for more information.)

Minimizing “Screen Time”

Time spent watching TV or playing video or computer games increases the risk of obesity. Children who are overweight or obese tend to spend more time in these types of sedentary activities and less time in physical activity, setting up an unhealthy feedback loop—the fatter they become, the more sedentary activity they engage in, which in turn makes them fatter.

The American Academy of Pediatrics recommends that children younger than 2 years not watch television. This not only avoids sedentary time but also protects young children from relentless marketing messages that link junk food with fun and games. After age 2, screen time should be limited to less than 2 hours a day. No television should be permitted in children’s bedrooms.

PUBLIC HEALTH APPROACHES TO PREVENTION

Overcoming or minimizing the barriers to dietary and physical activity changes will be most successful if the larger community supports individual efforts. Even the most committed patients and parents will find it difficult to sustain their efforts unless healthy foods are readily available and affordable and safe places to walk and play are close by. Prohibiting the sale of commercial low-nutrient, energy-dense foods and snacks in school cafeterias can further support campaigns to end obesity. Healthcare professionals can join parents in advocating for public health policies and programs that will support individual efforts to combat obesity.

Framing the Issue

To end the epidemic of obesity in children and adolescents will require an integrated public health approach based on prevention. Brownell and colleagues (2009b) offer a framework for mobilizing the social and political change essential to that approach. The framework is based on the concept of optimal defaults, using five issues as examples:

1. Framing the obesity issue. Shifting from causative models centered on personal responsibility to public-health models based on concepts of population, risk, and environmental determinants of diet and activity (see table).
2. Treatment versus prevention. Emphasizing that treating individuals has limited public health impact because of the expense, while preventing obesity can have broad impact at much less expense.
3. Schools as an important starting point. Making schools a support for parental efforts to raise healthy children, with exemplary nutrition and opportunities for physical activity.
4. Food marketing to youth. Restricting marketing of unhealthy food to children and adolescents, especially the “stealth” avenues such as product placement in movies, television, “viral marketing” (using online social networks such as email lists, Facebook, and others), and event sponsorship.
5. Weight stigma. Shifting the focus of prevention strategies to emphasize lifestyle factors that can be modified rather than on individuals and their appearance; increasing education and awareness of weight bias in school settings; replacing negative depictions of overweight characters in children’s media with more positive portrayals of people of diverse body weights.

FRAMING AND CONCEPTUALIZING OBESITY: MEDICAL MODEL VS. PUBLIC HEALTH MODEL

	Medical Model	Public Health Model
Source: Brownell et al., 2009b.
Basic Frame	Personal responsibility	Public, government, and corporate responsibility
Assessment	Individual severity Who is affected	Population severity How many are affected
Etiology	Individual causes Biology or personal choice drives weight	Population causes Environment as a major driver
Response	Treatment Individualism Right to medical care Medical system intervenes	Prevention Collectivism Right to safe/healthy conditions Government and the private sector intervene

Nurses and other health professionals can contribute to reframing the issue of obesity as a public health crisis rather than a failure of personal responsibility. They can “urge with their persuasive and credible voices that social, political, and economic conditions must change to prevent obesity. Thus, bold and decisive actions become more possible” (Brownell et al., 2009b).

Changes at Schools

Although some school cafeterias get a failing grade in nutrition, others are working hard to serve healthy meals for breakfast and lunch and to banish junk food from the premises. According to a new survey (Alliance for a Healthier Generation, 2009), most parents want schools to limit students’ access to high-calorie, low-nutrient chips, sodas, and candy and to provide more opportunities for physical activity throughout the day. More than 90% of parents surveyed agreed that physical activity and healthy eating have a positive effect on learning.

New recommendations from the Institute of Medicine (IOM, 2009b) for federal programs that provide breakfast and lunch in primary and secondary schools include calorie limits. Breakfasts should total between 500 and 800 calories depending on the grade; and lunches should not exceed 650 calories in grades K through five, 700 calories in middle school, and 850 for grades 9 through 12.

The IOM also recommends that schools increase the amount and variety of fruits and vegetables offered. Juice should account for no more than half of the fruit provided. Those who buy food a la carte should be required to take at least 1 serving of fruit or vegetables per meal. The IOM also advises schools to provide whole-grain products rather than the refined type and switch from whole or 2% milk to 1% or nonfat milk.

Implementing the IOM recommendations will be more expensive in the short term but could save a lot in the long term by making children healthier. Experts estimate that the cost of breakfast will increase about 20% and lunch about 4%, requiring additional federal funding. Considering the annual expense of caring for people with obesity-related chronic diseases and disorders, the investment seems more than worthwhile.

Public Health Programs That Work

All across the United States, parents and health professionals are working together to prevent childhood obesity and help those affected achieve and maintain a healthy weight. Programs at the local, state, and federal levels help support the efforts of individual families to eat healthier and exercise more. These efforts are gaining momentum. Some are focused on nutrition—teaching children where food comes from through school gardens and farm visits or offering healthier choices in school cafeterias. Others are focused on physical activity—bringing back recess to elementary schools, advocating for physical education programs, or encouraging walking or biking to school. Following are four examples of programs that work and could be replicated elsewhere.

SCHOOL LUNCH INITIATIVE, BERKELEY, CALIFORNIA

Founded by renowned chef Alice Waters and funded by the Chez Panisse Foundation, the School Lunch Initiative has worked with the Berkeley Unified School District to reform the school lunch program and “transform the way children are educated about food, health, and the environment.” Cafeterias are now 100% trans-fat and HFCS-free. The central kitchen at Martin Luther King Jr. Middle School services all 16 district schools with meals that use all fresh whole produce, organic milk, and healthy snacks. All 16 schools have a salad bar featuring seasonal fruits and vegetables and offer Universal Breakfast at no cost to all students regardless of household income. This program is supported by federal and state reimbursement plus private donations.

MEATLESS MONDAYS (AND BEYOND), BALTIMORE, MARYLAND

We need to bring America’s kids back to the table, to put them back in touch with honest-to-goodness, un-messed-around-with food, in touch with the earth and the resources that make real food possible.
—ANTHONY GERACI, Director, Food & Nutrition Services, Baltimore City Public Schools

Across the continent from Berkeley, California, Baltimore schools have instituted a program called “Meatless Mondays” to teach students about the importance of a plant-based diet. The meatless meals are made with fresh, locally raised fruits, vegetables, and milk from nearby farms and distributors. Buying produce and milk from local farmers has saved money and made it possible to serve healthy food even within severe budget constraints. Students learn that the fiber in a plant-based meal makes you feel full with fewer calories and gives you more of the protein, vitamins, and minerals essential to good health with less intake of fat. Why Mondays? Because practices starting on Monday are more likely to be continued later on. Led by school chef Anthony Geraci, Baltimore City Public Schools have also opened Great Kids Farm, “a working organic farm and education center that trains future urban farmers…. Today at Great Kids Farm, children are raising bees, goats, and chicken; using organic farming techniques to grow tomatoes, lettuce, greens, and mushrooms” (Geraci, 2009).

HEALTHY SCHOOLS CAMPAIGN, CHICAGO, ILLINOIS

This nonprofit organization advocates for policies and practices that allow students, teachers, and staff to learn and work in a healthy school environment. Their annual benefit, Cooking for Change, features teams of high school chefs in a healthy cooking contest—creating nutritious school lunches on a skinny budget ($1 per meal) and with limited ingredients and prep work. Chicago schools still serve french fries, but they’re baked, not fried. Fresh fruits and vegetables are featured. As one student/chef told the Chicago Tribune, “We’re changing the idea that healthy food is nasty” (McNamara, 2009).

THE SWITCH

“Switch what you do, view, and chew.” Researchers at Iowa State University called it a “multiple ecological level” program (involving community, family, school, and individual) aimed at changing behaviors that contribute to obesity: children’s screen time, inadequate fruit and vegetable consumption, and sedentary activity (Gentile et al., 2009). The program was reinforced in the community with editorials, billboards, and other pro bono media about the importance of healthy lifestyles. The school reinforced the effort by providing teachers with materials and methods to integrate health messages into the school day.

Participating families received monthly packets containing behavioral tips to help them change their health behaviors. More than 1,300 students (third, fourth, and fifth graders) in 2 cities participated in the 8-month study. The key behaviors were evaluated at baseline, at the end of the study, and 6 months post-study. Children in the experimental group reported less screen time, more physical activity, and increased consumption of fruits and vegetables. The most encouraging finding: targeted behaviors were not only sustained 6 months after the study ended, they were improved. In other words, it takes a village—a public health approach—to make a difference in childhood obesity.

An Idea for Funding Public Health Programs

Funding for local, state, and federal programs will need to come from many sources. One major source of funding could be a tax on sweetened soft drinks, with the revenues earmarked for programs related to good nutrition and physical activity (see box). More than 30 states have sales taxes on soft drinks, but the taxes are too small to reduce consumption, and the revenues are not dedicated to programs related to health.

Brownell and colleagues (2009a) propose an excise tax of $0.01 per ounce for beverages that have any added caloric sweetener. The tax would be levied on producers and wholesalers, not retailers. This could close two loopholes in the current taxing system: (1) the currently untaxed syrups used in fountain drinks, which are often served with multiple refills, would be taxed, and (2) the currently untaxed sugar-sweetened beverages that are now exempt from taxation in states that do not tax food would be taxed. Food is a necessity; sugar-sweetened beverages are not. The researchers estimate that an excise tax of $0.01 per ounce would lead to a minimum reduction of 10% in calories consumed from sweetened beverages, which is sufficient for weight loss. “A national tax of 1 cent per ounce on sugar-sweetened beverages would raise $14.9 billion in the first year alone.”

Although taxing sugar-sweetened soft drinks will not solve the obesity epidemic, the researchers believe it makes financial sense and public health sense. They point out that “seat-belt legislation and tobacco taxation do not eliminate traffic accidents and heart disease but are nevertheless sound policies” (Brownell et al., 2009a). A survey of New York State residents showed that 72% support such a tax if the revenue is used to support programs for the prevention of obesity in children and adults (Powell & Chaloupka, 2009).

The beverage industry is opposing any taxes on their products and has already created an “astro-turf” organization called Americans Against Food Taxes to support their position.

CONCLUSION

Childhood obesity is a global health challenge with no single cause and no single solution. Meeting this challenge demands more than individual efforts. It demands changes in public health policies and in the built environment at the local, state, and federal levels to prevent obesity beginning in early childhood and to make treatment available to overweight and obese children and adolescents. Without a concerted, cohesive effort to reverse the obesity epidemic, today’s children will have shortened lives filled with chronic illness.

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