OBESITY AFFECTS MORE THAN 18% of all children and adolescents in the US, contributing to a number of debilitating health consequences including an increased risk for cardiovascular disease and Type 2 diabetes (T2D).1 Children age 2 years and older may be characterized as obese according to their body mass index (BMI), which is an accepted measure of obesity that compares an individual's height and weight to others of the same age and gender.2 A BMI in the 95th percentile or higher is considered obese (see BMI characterizations).3,4
Various risk factors can contribute to obesity. To remember these, the authors created the SALAD acronym to foster reflection among healthcare professionals regarding the contributing factors. It offers a simple way to aid providers in formulating appropriate, individualized family plans to ameliorate these factors. The acronym is broken down as follows:
Socioeconomic factors. Some US communities have limited resources and subsequently limited choices for healthy dietary options. Busy working parents often buy foods and snacks that do not quickly spoil, such as frozen meals, crackers, and cookies, but these tend to be low in nutrition. Additionally, foods that are high in sugar are easily obtainable in vending machines at hospitals, gyms, malls, and supermarkets.5 These foods can be addictive and contribute to the obesity epidemic.5
Anxiety. Personal, family, and parental stress can increase a child's risk for developing obesity. Children and adolescents may overeat to fight anxiety, or sometimes boredom, which can lead to psychological issues and low self-esteem in the future.4
Lack of exercise. Children who exercise less due to time spent watching TV or playing video games are more likely to gain weight, as sedentary lifestyles contribute to obesity. The link between TV and childhood obesity was detected more than 30 years ago.4,6
Ancestry. Children and adolescents with obese parents have an 80% chance of being overweight and developing obesity.7
Diet. High-calorie foods from vending machines and fast-food options contribute significantly to increasing obesity rates. The key to a healthy diet is to consume whole foods, such as fruits and vegetables, whole grains, lean meats, and low-fat dairy products, rather than processed foods.8
Healthcare disparities among different races and ethnicities represent a persistent problem in the US.9 Moreover, childhood obesity rates are expected to grow, and people from minority communities are at an increased risk due to various genetic, physiologic, cultural, socioeconomic, and environmental factors.10,11 For example, the current obesity rate is 22.5% among Black children, 20.6% among Hispanic children, and 12.5% among White children.9
Regardless of the social determinants, however, childhood and adolescent obesity can have lifelong clinical and psychosocial consequences, including hypertension, hypercholesterolemia, metabolic syndrome, T2D, orthopedic disorders, obstructive sleep apnea (OSA), asthma, fatty liver disease, and an increased risk for cardiovascular disease.12 Additionally, obesity can lead to low self-esteem, body image shame, social isolation, discrimination, and depression among young patients.4
Children who are overweight, such as those with a BMI between the 85th and 95th percentiles, are more prone to becoming obese as they enter adulthood.2,13 Prevention efforts, including lifestyle and environmental interventions, can reduce the incidence of childhood obesity and lead to a healthier future for children and adolescents in the US. This article offers an overview of childhood obesity, which is characterized by a BMI greater than or equal to the 95th percentile, as well as the associated physical and psychosocial consequences and the appropriate interventions to combat this epidemic.2
Obesity among children and adolescents can have the following long-term physiologic consequences:1
Cardiovascular system. Obesity is associated with increased adipose tissue, and adiposity is associated with hypertension. Dysfunctional adipocyte and neurohormonal activation of the sympathetic nervous system are key factors in obesity. Additionally, unbalanced diets can lead to hypercholesteremia and cause plaque buildup in the arteries, increasing the risk of myocardial infarction or stroke later in life.14 Similarly, children and adolescents with diabetes, hypothyroidism, and renal and liver disease are at an increased risk of hypercholesteremia.15
Endocrine system. Obesity and sedentary lifestyles increase an individual's risk for T2D, which affects the way the body uses glucose. The prevalence of children and adolescents with T2D is on the rise. T2D has long-term life-threatening consequences, so children must be monitored and treated for this disorder.4 Additionally, children and adolescents who are obese may experience other comorbidities, including impaired glucose tolerance; abnormalities related to growth and puberty such as accelerated bone age and linear growth; and, in females, hyperandrogenism and early-onset polycystic ovary syndrome.16
Metabolic syndrome. Metabolic syndrome describes groupings of the following risk factors for T2D and atherosclerotic cardiovascular disease: abdominal obesity, hyperglycemia, dyslipidemia, and hypertension.16 Children experiencing obesity are at an increased risk of developing metabolic syndrome, which has also been linked to insulin resistance characterized by “the accumulation of proinflammatory macrophages and inflammation” and associated with obesity and T2D.16-18
Dermatologic effects. Obesity is associated with multiple skin conditions. This includes acanthosis nigricans, which is characterized by dark, velvety discolorations in the folds and creases of the body and thickened skin. It may affect patient armpits, groin, and neck. Children who develop acanthosis nigricans are at increased risk of T2D.16,19 Additionally, obesity may be associated with other dermatologic conditions, including distensae (stretch marks), intertrigo (inflamed skin folds), furunculosis (boils), and inflammation of the hair follicles.16,19
Renal system. Children and adolescents who are experiencing obesity may have larger kidneys than their normal-weight counterparts.16,20 Similarly, hypertension and T2D may impair renal function in this population.16,20
Neurologic effects. Children and adolescents with obesity have an increased risk for idiopathic intracranial hypertension, which refers to high pressure in the epidural spaces around the brain and spinal cord. These spaces are filled with cerebral spinal fluid to cushion against injury, provide nourishment, and carry away waste.21
Pulmonary system. Globally, obesity and asthma are common pediatric health problems, and recently a correlation between the two has been found.22 Higher body weights affect and modify asthma characteristics, such as increased airflow obstructions and a slightly reduced response to corticosteroids, but it does not appear to exacerbate symptoms or affect stability.22,23 Although these are not mutually exclusive, an increased incidence of asthma in obese children and adolescents is significant.22
OSA is a serious disorder in which an individual's breathing stops and starts repeatedly while sleeping. Snoring is also common in these patients. OSA can lead to a complete obstruction of the airway, oxygen desaturation, fragmented sleep patterns, and sleep disruptions. In obese patients, it can magnify underlying cardiovascular or metabolic issues, and early identification can reduce these issues.24 Similarly, obesity hypoventilation syndrome is a rare, life-threatening disorder characterized by severe obesity and alveolar hypoventilation while a patient is awake.16
Musculoskeletal system. Obesity puts increased stress on bones, potentially causing fractures. For example, pelvic fractures are more prevalent among children or adolescents who are obese than in those who are not. Given the rising rates of obesity, safety devices such as car seats must provide effective sizing to prevent fractures in obese individuals.25 Additionally, in comparison with children and adolescents with lower BMIs, those who are characterized as obese may also be at an increased risk for genu valgum; mobility impairments; malalignment of the lower extremities; and musculoskeletal pain in the back, legs, knees, ankles, and feet.16 These individuals may also experience orthopedic comorbidities such as slipped capital femoral epiphysis or Blount disease.16
Gastrointestinal system. Combined with a sedentary lifestyle, eating high amounts of refined carbohydrates can increase an individual's risk for nonalcoholic fatty liver disease (NAFLD), in which fatty deposits build up in the liver and cause scarring. Obesity is the leading cause of NAFLD, and it affects 10% of people globally regardless of ethnic background. Family lifestyles and habits are contributors to its increased prevalence.26 However, research related to poor outcomes from NAFLD and the development of future health conditions in pediatric patients is limited.27 Additionally, in male and female children and adolescents with no preexisting conditions, obesity increases the risk of cholelithiasis.16
Besides the physiologic consequences, obesity in children and adolescents can also have negative effects on self-esteem and cognitive development. For example, one study demonstrated significant impairments in attention, retention, intelligence, and cognitive flexibility among obese adolescents.28 Another study concluded that the link between adolescent obesity and cognitive deficit was “alarming” and may reduce an adolescent's academic and professional potential.”29
In 2012, researchers at the University of Calgary conducted a comprehensive review of the literature on the mental health consequences of childhood obesity.30 They found that, despite greater concern from healthcare professionals about its biological impacts, little research has been conducted on the relationship between mental health and childhood obesity.30
While the number of studies examining the mental health aspects of obesity has since grown, research in this area remains sparse. According to a 2016 review of the literature, it remains unclear whether mental health is a causative factor or a consequence of childhood obesity.31 More recent studies have also demonstrated a knowledge gap in this area.30,32 Further study on issues of causation and prevention are necessary given the expected increase in childhood obesity rates combined with the rising incidence of long-term mental health disorders associated with obesity.
Nurses working in provider offices, hospitals, outpatient clinics, and schools have the unique opportunity to assess mental health in children and adolescents who are experiencing obesity. They are also well positioned to educate young patients, parents, and caregivers on the emotional impact and consequences of obesity, including:
- social shaming. Obese children are more likely to experience shame, ridicule, and bullying. It remains unclear whether childhood obesity is a cause or a consequence of the psychological complications associated with those experiences.31 Nevertheless, bullying and the stigma surrounding obesity have become pervasive.31 Peers, teachers, coaches, parents, and even healthcare professionals can perpetrate this type of emotional abuse.
Children who experience psychological distress from bullying may have difficulties in adulthood, placing them at an increased risk for diminished flourishing markers such as finishing tasks, remaining calm, and caring about academics.33 Children experiencing obesity are also at an increased risk for anxiety, addiction, and suicide.1 One 2016 study demonstrated that those who experience weight-related teasing, social stigmatization, and peer rejection are at a significantly higher risk for psychosocial problems, including eating disorders and other unhealthy weight-control behaviors.31 Parents may be unaware that their children are victims of social shaming or bullying. Healthcare professionals must educate and advise them to be vigilant for the warning signs, such as social isolation and low self-esteem, and establish open communication.34
- depression. Negative childhood events can be long-lasting and may be linked to childhood obesity and depression, potentially affecting health later in life.1 Among children ages 3 to 17, 3.2% (approximately 1.9 million) have been diagnosed with depression.1 The association between depression and childhood obesity is well documented.31,35 Despite this association, direct statistical causation has not been established. For example, one study reported no statistically significant difference in the rates of most common psychiatric disorders, including depression, among those who were experiencing or had experienced obesity.31 However, recent research suggests that psychosocial issues such as depression and suicide may result from shaming and social isolation related to obesity.3,30,32
Children or adolescents who are experiencing obesity and are subsequently diagnosed with depression face additional concerns. For example, many psychiatric medications can cause weight gain.2 As such, some treatments for the psychological sequelae related to obesity may exacerbate the underlying disorder.36
- anxiety. Anxiety disorders are the most common mental health disorders in children.1,35 Among children ages 3 to 17, 7.1% (approximately 4.4 million) have been diagnosed with anxiety.1 The association between childhood obesity and anxiety is still under debate, however, with some researchers reporting a strong connection and others reporting a relatively weak link between the two.31,35,37
- low self-esteem: Limited or low self-esteem increases the risk of depression. Children and adolescents often struggle with low self-esteem, which adversely affects their day-to-day quality of life.1 Children and adolescents who experience obesity are more likely to have a reduced sense of self-worth and self-confidence than their peers.31,37 They may experience feelings of shame about their body, leading to overwhelming feelings of hopelessness and depression.38 Low self-confidence may also lead to poor academic performance.12
- attention-deficit hyperactivity disorder (ADHD) and behavioral problems. Although a statistically significant causation has not been established, an association has been demonstrated between anxiety, limited social skills, and childhood obesity.39 Coupled with a lack of proper sleep, these children and adolescents may act out in the classroom or withdraw socially.40 Researchers have also demonstrated an association between ADHD and childhood obesity, as well as a lower incidence of obesity in children being treated for ADHD. Children and adolescents who are subject to bullying or teasing for being overweight or obese may exhibit poor conduct and involvement in academic and social situations compared with other children.31 Regardless of whether behavioral problems and poor academic performance are consequences of body image shaming, they present warning signs to parents and teachers.12
- eating disorders. Obese children and adolescents, particularly those who identify as female, are at an increased risk of developing eating disorders. Approximately 25% of female adolescents who experience obesity engage in these extreme behaviors, with one study finding an association between the prevalence of mood disorders and the lifetime prevalence of bulimia nervosa in patients with childhood obesity who are seeking to lose weight.31 Caregivers must distinguish eating disorders such as bulimia nervosa, which may be related to obesity, from restrictive eating disorders, which are associated with other risk factors. For example, avoidant restrictive food intake disorder is associated with autism, but it has not been shown to be related to fears about obesity.41
- suicide. Suicide is the second leading cause of death among children and young adults between ages 10 and 34.4 A 2019 study demonstrated a statistically significant association between obesity in adolescence and suicidal ideation.30
Public health initiatives
The World Health Organization's Global Strategy on Diet, Physical Activity and Health calls for local, regional, and global efforts to improve the well-being of children around the world through education, exercise, and healthy food choices.42 The World Health Assembly has established six global targets to improve maternal, infant, and childhood nutrition by 2025.42 These include:43
- a 40% reduction in the number of developmentally delayed children under age 5
- a 50% reduction in anemia among women of reproductive age
- a 30% reduction in low-birth-weight infants
- no increase in the rate of overweight children
- a minimum 50% increase in the rate of exclusive breastfeeding in the first 6 months
- a reduction in the rate of childhood wasting to less than 5% and continued maintenance of this figure.
Support enables children to cope with daily restrictions in their environment. The World Health Organization suggests “making healthy choices easy choices” by collaborating with school and community programs to provide healthy options for school lunches.42
The CDC encourages incentives to retailers to sell healthy food and beverage options in underserved areas.7,44,45 Recognizing goals and strategies for children and adolescents who are experiencing obesity encourages positive behaviors and promotes healthy choices and practices.39 Additionally, exploring different ways to cope with environmental restrictions can help children with the choices they do have and ultimately guide them to a healthier lifestyle.46
Recognizing the associated contributing factors is the first step in combating childhood obesity. Once the causes have been identified, families can be taught how to change their lifestyle habits. For example, healthcare professionals should encourage families to eat together at regular times and avoid skipping breakfast. It is also recommended that families engage in 60 minutes of daily physical activity and limit TV and screen time to 2 hours a day.13 Additionally, consumption of fast-food meals should be limited, and sugar-sweetened beverages should be avoided entirely.47,48
Issues such as inconsistent family mealtimes, decreased communication, and a sense of abandonment may contribute to a lack of support.46 Through their own cultural beliefs, parents may contribute to their child's self-image and influence behaviors.46
Childhood obesity is associated with an increasing rate of cohabitation and divorce among parents. Pediatric providers can recognize family dynamics during patient assessments and create individualized interventions for all types of families.49 Supportive interventions, including family exercise, healthy family meals, monitoring weight on a home scale, and providing behavioral modification techniques such as stickers and new clothing for weight loss, are vital for children and adolescents at increased risk for psychosocial issues during sensitive stages of development.1
Experts in mental health and in childhood obesity can contribute to plans of care and offer guidance. Similarly, an assessment of the family atmosphere, dynamics, values, and beliefs is crucial.46
Although underutilized, family-based behavioral interventions are an evidence-based approach to help prevent excess weight gain and obesity in children and adolescents. Effective interventions for pediatric obesity may be hampered by family dysfunction, divorce, single parenthood, nonadherence to interventions, and limited motivation and low participation rates. Emphasis on adherence must be recognized by multidisciplinary teams, and continuous patient follow-up can combat some of the issues that deter adherence to healthcare provider recommendations.46
Combating childhood obesity requires a multifaceted approach. One strategy to reduce childhood obesity rates involves improving the eating and exercise habits of the entire family. Treating and preventing obesity helps protect health throughout a child's lifetime.
Access to fresh, nutritious foods in low-income urban and rural areas can promote healthy lifestyles. Communities can also create task forces to reduce the rate of childhood obesity. These include parent and teacher associations; local health, parks and recreation, and public transportation departments; and groups working on issues of zoning, bike lanes, and sidewalks for pedestrian safety.8 Reducing the risk of chronic health conditions associated with childhood obesity should be a high priority for parents, caregivers, teachers, and community members.7
For example, communities and schools can implement support groups for children who are overweight or experiencing obesity. School boards are also encouraged to make physical education not only mandatory, but also to integrate programs that are fun and exciting for children. Community and government officials are encouraged to create safe venues for children to exercise in unsafe neighborhoods. Similarly, professionals with different areas of expertise can effect change with a range of ideas.7
Early interventions directed at obesity can limit the long-term consequences of childhood obesity.7 Starting at age 6, school children should be weighed and measured annually as part of regular school health exams.50 Using BMI to determine obesity and performing a patient history to assess physical activity, nurses and primary care providers are uniquely positioned to evaluate children and adolescents in healthcare settings and educate their parents.51 Other interventions include talking with parents about time the child spends on social media or watching TV. Similarly, pedometers represent an inexpensive, simple, and appealing way to measure a child's activity level. Refer families to www.choosemyplate.gov for help improving their eating habits.52 (See Nutritional recommendations for parents.)
Cognitive behavioral therapy (CBT) is another effective tool for changing and replacing negative behaviors with positive actions, such as healthy food options and increased daily activity.42,46 CBT is a common psychotherapy in which patients work with a mental health counselor to address inaccurate or negative thinking patterns and respond to challenging situations more effectively.53 Animal-assisted therapy is a type of CBT that enhances childhood well-being through play and activities such as dog walking.46 It can be used to increase activity levels, diminish physical restrictions, and assist with any negative feelings such as social isolation and rejection.46
Focus on healthy choices
Nurses serve as advocates and educators, and their assessments and interventions can help families manage childhood obesity. They can teach parents to understand the impact of obesity and the role of healthy eating patterns and physical activity in reducing this growing epidemic. Focusing on healthy choices at home can teach children and adolescents to make similar choices in school. As children represent the future, nurses are in a unique position to help reduce obesity in the US over time.
Based on the age and gender of children between ages 2 and 20 years, BMI ranges can be characterized as follows.
- Underweight: BMI under the 5th percentile.
- Normal weight: BMI greater than or equal to the 5th percentile and less than the 85th percentile.
- Overweight: BMI greater than or equal to the 85th percentile and less than the 95th percentile.
- Obesity: BMI greater than or equal to the 95th percentile.
- Severe obesity: BMI that is either greater than or equal to 120% of the 95th percentile, or BMI greater than or equal to 35 kg/m2 (whichever is lower).
Nutritional recommendations for parents7,50-52,55
The food children consume can have a lasting effect on their health as adults.
- Make healthy foods accessible; for example, fruits, vegetables, and water pitchers can be left out in plain sight.
- Enjoy foods in various colors, and use smaller plates and bowls to decrease portion size.
- Stock up on healthy on-the-run breakfast items such as fruits, nuts, trail mix, whole grain muffins, or low-fat yogurt to discourage skipping meals.
- Avoid sugar-sweetened beverages and consume low-fat or non-fat dairy products.
- Have fun preparing food as a family and include the children in the process.
- Choose lean meats such as poultry or fish for protein. Other sources may include plant-based protein such as beans, raisins, oatmeal, almonds, and tofu.
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