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Pediatric Obesity Column

Impact of Childhood Obesity in America

Larery, Trina DNP, FNP-C

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Journal of Pediatric Surgical Nursing: 10/12 2021 - Volume 10 - Issue 4 - p 150-152
doi: 10.1097/JPS.0000000000000307
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“I am a fat kid. I have a fat mom and dad. But I will die first.”

(Hopkins et al., 2011).

Childhood obesity is considered a major health threat. The World Health Organization has labeled the epidemic of childhood obesity as “globesity” (Hopkins et al., 2011). Obesity is a chronic disease that is not fully understood but is believed to be multifactorial. Disproportionate food intake along with low energy expenditure typically result in an excessive accumulation of adipose tissue, resulting in obesity (Sanyaolu et al., 2019). Current data from the National Health and Nutrition Examination Survey show an increasing prevalence of obesity among U.S. children and adolescents (Sanyaolu et al., 2019). Studies document that 32%–33% of children are considered overweight and 18% are considered obese (Centers for Disease Control and Prevention [CDC], 2017; Savinon et al., 2012; Thompson, 2018). Children who are overweight at the age of 5 years were 4 times more likely to be obese between the ages of 5 and 14 years than children who were of normal weight at that age. The same study found that approximately 70% of obese adolescents will become obese adults (Cunningham et al., 2014). Obesity in the 17- to 24-year age group is currently at 25%, which puts them above the weight threshold to join the U.S. military (Rankin, 2018). The Bogalusa Heart Study was even more impressive and found that 84% of children with a body mass index (BMI) between the 95th and 98th percentiles became obese adults, whereas those with a BMI over the 98th percentile became obese 100% of the time (Savinon et al., 2012). It is estimated that this generation of children will be the first in history to have a shorter lifespan than previous generations (Cuda & Censani, 2019).

The fight against obesity and for lifelong health and wellness begins in childhood. As noted in a study by Cunningham et al. (2014), the course for childhood obesity leading into adult obesity may already be established by the age of 5 years. Children who are overweight in kindergarten are responsible for over half of children who are overweight/obese between the ages of 5 and 14 years (Cunningham et al., 2014). Multiple interventions will be needed to resolve this complex and ever-evolving disease.

The recommendation from the Expert Committee and the Institute for Clinical Systems Improvement (ICSI) is to evaluate children with a BMI in at least the 85th percentile (overweight) for associated comorbidities and complications such as diabetes, dyslipidemia, and hypertension. It has also been recommended that all children be screened for sleep disorders. Sleep deprivation occurs in approximately 27% of school-aged children and 45% of adolescents (Thompson, 2018). Studies have suggested that sleep deprivation is inversely associated with elevated BMI percentiles (Thompson, 2018). Children and adolescents who are sleep deprived are 2 times as likely to be overweight/obese compared with their peers (Thompson, 2018). A necessary component to successful weight management is addressing comorbid conditions (Cuda & Censani, 2019).

Providers should obtain a family history focused on obesity, Type 2 Diabetes Mellitus, and cardiovascular disease in first- and second-degree relatives to assess the risk of current and future comorbidities associated with the patient's weight status (ICSI, 2013). By the age of 10 years, 60% of overweight children will have at least one biochemical or clinical cardiovascular risk factor, with 25% having more than two (Walpole et al., 2011). If BMI is over the 95th percentile for weight (obese), almost 40% of adolescents will have two or more risk factors for cardiovascular disease and almost 20% will have three or more (Shreve, 2015).

Approximately one third of children born in 2000 will develop Type 2 diabetes (Walpole et al., 2011). A strong association exists between childhood obesity and early-onset dyslipidemia, hypertension, and insulin resistance (CDC, 2020; Raghuveer, 2010). Dyslipidemia manifests in children as high triglycerides and usually a combination of high total and low-density lipoprotein (Cuda & Censani, 2019). Vascular abnormalities can be observed in children during the first year of life (Barton, 2012). Studies have shown that high total cholesterol, high BMI, and high low-density lipoprotein are associated with an increased carotid artery intima-media thickness, which is a marker of atherosclerosis and heart disease (Raghuveer, 2010). That same study also found these children had adverse vascular effects into adulthood (CDC, 2020; Raghuveer, 2010). Barton (2012) found that inflammation plays a role in insulin resistance and metabolic changes with obesity. Obesity increases the carotid artery intima-media thickness and tissue levels of endothelin-1 (Barton, 2012). The study concluded, based on the inflammatory process, obesity can be considered a process that accelerates aging and in turn explains the accelerated atherosclerosis in children (Barton, 2012). Children with premature acceleration of atherosclerosis need to have diet modification and possible intensive statin therapy to lower cardiovascular-related burdens (Raghuveer, 2010).

The most impressive study on comorbidities associated with childhood obesity was performed by Franks et al. (2010). The study addressed the extent in which obesity, glucose intolerance, hypertension, and hypercholesterolemia without diabetes predicted premature death in children. Premature death was defined by the study as death before 55 years old. Deaths from endogenous causes among children in the highest quartile of BMI were more than double of those among children in the lowest BMI quartile (Franks et al., 2010). Children with glucose intolerance were 73% more likely to die from endogenous causes than children in the lowest quartile for weight (Franks et al., 2010). Childhood hypertension, along with placement in the highest BMI quartile, was found to be associated with premature death by endogenous causes 57% of the time (Franks et al., 2010). Children with hypertension along with placement below the highest BMI quartile found no increased rates of premature death because of endogenous causes (Franks et al., 2010). To summarize, this study found that children without a diagnosis of diabetes or hypertension, but diagnosed with obesity, will have an increased rate of premature death from endogenous causes (Franks et al., 2010).

Another health complication that has become common in children is nonalcoholic fatty liver disease (NAFLD). Once known as a problem that occurs in adults and the aging population, it is quickly becoming a health concern for children with obesity. There has been a direct association between obesity and NAFLD in children and obesity and metabolic syndrome. Approximately 35% of children with obesity have NAFLD. Metabolic syndrome is found in more than 50% of children with NAFLD. The complications that can arise include end-stage liver disease in early adolescence. NAFLD has become one the most common forms of liver disease in children and adolescents (CDC, 2020).

Multiple interventions will be needed to resolve this complex and ever-evolving disease. A collaborative approach by healthcare providers, use of current guidelines, parental support, and education is necessary to combat childhood obesity. An assessment of diet, physical activity, and sedentary behaviors should be done annually (ICSI, 2013; Sample et al., 2013). This assessment should be used to target the necessary needs of each family (ICSI, 2013). Prevention begins with children who have a BMI between the 5th and 85th percentiles; those children are a healthy weight and should have an assessment and screening done annually (Sample et al., 2013). According to a pediatric obesity algorithm by the American Academy of Pediatrics, the goal of childhood obesity management is to minimize the disease state and decrease development of further complications rather than to focus on decreasing BMI. If weight gain is slowed down, it could delay the onset of future cardiovascular and endocrine diseases (Cuda & Censani, 2019).

The 5210 program is a nationally recognized weight management strategy aimed specifically at childhood obesity. It is widely endorsed by the American Academy of Pediatrics and can be used by primary care providers for weight-based management goal setting. The International Clinical Systems Improvement guidelines include the 5210 program as a preventative strategy. The 5210 program has been shown to be an effective foundation in sustainable behavior change (ICSI, 2013). Literature supports a comprehensive approach to influencing dietary habits of young children and prevention interventions that start early in childhood (CDC, 2017, Cuda & Censani, 2019). Once poor dietary habits are established, it is difficult to break the cycle. The 5210 program for daily healthy habit goals include 5 = five or more fruits and vegetables, 2 = 2 hours or fewer recreational screen time, 1 = 1 hour or more of physical activity, and 0 = zero sugary drinks, more water, and only low-fat milk (ICSI, 2013).

Sedentary behavior and low levels of activity have been found to contribute to childhood obesity (Barton, 2012; CDC, 2020). Sixty minutes of physical activity is recommended by multiple organizations and in current evidence-based practice guidelines (CDC, 2017; Cuda & Censani, 2019). It has been shown that children who engage in over 4 hours of screen time can still be very physically active and not considered overweight or obese (Steele et al., 2010). A study by Steele et al. (2010) found that encouraging high levels of weekend activity may hold the most possibilities in trying to combat childhood obesity and the recommendations should be made to all children regardless of weight status. Jiménez-Pavón et al. (2010) performed a systematic review over 4 years that included 48 cross-sectional studies. They found consistent evidence of negative associations with minimal physical activity and high BMI. Seventy-nine percent of the studies reported a negative association between obesity and decreased physical activity. On the basis of this study, increased physical activity on a regular basis appeared to be protective against childhood obesity and adiposity (Jiménez-Pavón et al., 2010).

Childhood obesity is an ever-growing health concern, and more work is needed to care for these children effectively and prevent a lifetime of medical problems. The comorbidities associated with childhood obesity have the potential to evolve into chronic health conditions at a younger age and can contribute to premature death. Families and healthcare providers must be ready with evidence-based knowledge and be prepared to use it with the children of the community to put a stop to this ever-growing health concern. Prevention programs and utilization of them has become increasingly common. The programs offer a way for healthcare providers to assess comorbidities and implement changes using an evidence-based, consistent method. In return, the potential for positive outcomes in children with obesity will be increased.


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