In 2016, Browne and Haynes published in this journal “An Elevator Speech for a Teachable Moment,” a collection of brief educational components of pediatric obesity education (Browne & Haynes, 2016). In that document, pediatric obesity was outlined as a complex, poorly understood problem related to an incomplete understanding of the body's energy regulatory system (ERS; physiology) and why this system can go awry resulting in obesity (pathophysiology). At the same time, the authors presented optimism that an understanding of the physiology would bring advances rapidly to the evolving field of pediatric obesity management. As observed, factors are emerging that affect the ERS; although a complete understanding of how this occurs is still being determined, using our early understanding allows further education to families during teachable moments. We present here two additional emerging areas that are amenable to intervention; doing so may modify the body's response to stressors and allow for improvement in the risk for and management of obesity. These areas include food insecurity and sleep disturbances.
Food insecurity is defined as the state of being without reliable access to a sufficient quantity of affordable, nutritious food. According to the U.S. Department of Agriculture in 2016, an estimated one in eight Americans were food insecure, equating to 41 million Americans including 13 million children (one in every six children; Coleman-Jensen, Rabbitt, Gregory, & Singh, 2017). The prevalence of obesity in U.S. children similarly involves large numbers with approximately 33% of children experiencing overweight and obesity (Skinner, Ravanbakht, Skelton, Perrin, & Armstrong, 2018). In a 2011 report, Eisenmann, Gundersen, Lohman, Garasky, and Stewart summarized the literature studying associations between food insecurity and overweight/obesity in children. They concluded that food insecurity and overweight coexist, with a high prevalence of obesity in food-insecure children (Eisenmann et al., 2011).
As attention grew on the importance of addressing food insecurity in youth, tools became available to screen for food insecurity in pediatric primary care and specialty offices, where children and families feel safe and are open to an honest conversation on this difficult subject. Food insecurity tool questions were designed to identify struggling families, with the goal of appropriate referrals where support and healthy foods are available. In 2010, Hager et al. developed two questions for clinical use, which are endorsed by the American Academy of Pediatrics. Families answer yes or no to (a) “Within the past 12 months, we worried whether our food would run out before we got money to buy more” and (b) “Within the past 12 months, the food we bought just did not last and we did not have money to get more” (Hager et al., 2010). A positive response then necessitates a further conversation involving safety, social issues, and resources. A modification of a yes/no response includes “sometimes,” which allows for episodic food-insecure situations.
Children with obesity who are also food insecure face similar obstacles often including economic challenges, sedentary lifestyle, and inexpensive processed foods. Other concerns include the following:
- Limited resources: area dependent, low access to full grocery stores and farmers' markets, and high access to fast foods and corner stores. Families with better access to supermarkets and limited access to convenience stores tend to have healthier diets and a reduced risk for obesity (Bell, Mora, Hagan, Rubin, & Karpyn, 2013 ; Larson, Story, & Nelson, 2009).
- Cycles of food deprivation and overeating: Eating less when foods deplete and overeating to compensate for hunger may lead to metabolic changes that promote weight gain. Overconsumption is tempting given the availability of inexpensive, energy-dense foods in low-income communities (Hilmers, Hilmers, & Dave, 2012).
- High levels of stress, anxiety, and depression: Research indicates that a concurrent association of maternal stress and food insecurity may negatively impact children's weight status (Lohman, Stewart, Gundersen, Garasky, & Eisenmann, 2009). Stress and poor mental health may lead to maternal weight gain through stress-induced hormonal and metabolic changes (Gordon-Larsen, Nelson, Page, & Popkin, 2006 ; Sallis & Glanz, 2009).
- Fewer opportunities for physical activity: In lower income neighborhoods, there are typically less parks, green space, and recreation areas, making physical activity difficult. Limited access to recreation is a risk factor for obesity, and food insecurity is associated with less physical activity (Singh, Siahpush, & Kogan, 2010 ; To, Frongillo, Gallegos, & Moore, 2014).
Although food insecurity is often linked to poverty, families of any economic circumstances may experience periodic or chronic food challenges. All families benefit from screening at every encounter as episodic situations can occur; food insecurity is not always obvious. Explaining why the food insecurity questions are asked can transform a difficult conversation into a productive encounter. Families appreciate a private and sensitive discussion with an emphasis on support and resources.
An association has emerged between poor cardiometabolic health and sleep disturbances in children during the past two decades (Cappuccio et al., 2008 ; Chen, Beydoun, & Wang, 2008). Sleep disturbances are linked to insulin resistance, cardiovascular disease, and Type 2 diabetes, conditions that are increasingly seen in children with obesity (Hakim, Kheirandish-Gozal, & Gozal, 2015). In 2008, Cappuccio et al. performed a meta-analysis studying a potential relationship between short sleep duration and obesity in children and adults. Using a cross-sectional design, an association between insufficient sleep and increased risk of obesity in children was found (Cappuccio et al., 2008).
The relationship between pediatric obesity and sleep disturbances seems to be bidirectional (Capdevila, Kheirandish-Gozal, Dayyat, & Gozal, 2008 ; Hakim et al., 2015 ; Koren & Taveras, 2018 ; Narang & Mathew, 2012), with several studies, including two meta-analyses (Dutil & Chaput, 2017 ; Miller, Kruisbrink, Wallace, Ji, & Cappuccio, 2018), suggesting an association between sleep duration and elevated body mass index percentiles in children (including severe obesity). Obesity increases the risk of some sleep-related breathing disturbances including obstructive sleep apnea in children (Hakim et al., 2015). Both obesity and sleep disturbances are associated with metabolic disease (Iglayreger et al., 2014 ; Isacco et al., 2017 ; Koren, Dumin, & Gozal, 2016 ; Koren & Taveras, 2018 ; Narang & Mathew, 2012).
Using this knowledge, screening for sleep disturbances becomes a part of a general pediatric screen during any encounter, particularly if the child is over the 85th percentile for weight and height. Sleep difficulties are common with infants and children and typically are of short duration. Chronic, insufficient sleep, however, suggests a clinical sleep disturbance. The American Academy of Sleep Medicine's “International Classification of Sleep Disorders (3rd Edition)” describes seven categories of sleep disturbances (Sateia, 2014; Table 1). A functional way to classify sleep disturbances to facilitate screening includes (a) insufficient sleep quantity, (b) poor sleep quality, (c) inappropriate timing of the sleep period, and (d) primary disorders of excessive daytime sleepiness.
Assessment for sleep disorders uses general screening questions followed by a focused history and physical examination; sleep pattern, duration, quality, daytime sleepiness, and timing of sleep are key areas to ascertain. Disturbances of circadian rhythm are highlighted by starting sleep late (2–3 a.m.) and awakening 7–8 hours later if there is not a social need to awaken earlier (school). Emerging studies suggest that altered circadian rhythm may affect individual organs and cells, which influence metabolic efficiency (Voigt, Forsyth, Green, Engen, & Keshavarzian, 2016). Assisting the patients to improve their circadian cycle to a normal one may be beneficial for metabolic health.
Several screening tools for disordered sleep exist with a select few that are age appropriate for pediatrics. If a general history reveals potential for sleep disturbances, then screening tools may be beneficial to guide the next treatment course (Combs, Goodwin, Quan, Morgan, & Parthasarathy, 2015 ; Janssen, Phillipson, O'Connor, & Johns, 2017 ; Mindell & Owens, 2015 ; Shahid, Shen, & Shapiro, 2010 ; Shahid, Wilkinson, Marcu, & Shapiro, 2011).
Recognizing sleep disturbances as potential modulators of metabolic syndrome and obesity in children allows for an early opportunity to intervene, opening the way for potential treatment of these conditions while simultaneously improving sleep hygiene and overall health.
Researchers, scientists, clinicians, and others continue to unravel the complex question “Why is one person affected by obesity and not another?” Whereas some families present with several affected children, often in other families, there are siblings who are not affected. There is always an opportunity to improve the level of health in the family dynamics, but how to affect unwanted changes in the body's ERS is another pursuit. As our understanding of the complex components creating ERS derangement improves, clinicians will improve in practicing precision medicine to help the individual child being treated. Until this understanding matures, clinicians need to be aware of all the known factors that might potentiate ERS pathophysiology. With this global knowledge, clinicians can address these factors with scheduled encounters or at teachable moments when connecting with children and their families.
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