Current controversies in childhood obesity

Health Problems of 14–16-Year-Old Schoolchildren: A Follow-up of Previous Health and Behavioural Assessments

Health and behavioural assessments of 352 children, previously examined at 10–12 years of age, were followed up at 14–16 years of age within the School Health Services. The health problems of the 14–16-year-olds were more serious than those of the younger children, with the onset of chronic illnesses such as terminal ileitis and diabetes. The prevalence of visual disorders increased, mainly with the development of myopia in 15.6% of all children. The functional importance of allergic disorders diminished with age. Twelve percent of the children had pronounced educational and/or adjustment problems and were discussed at the pupil personnel conference. 6.5% were given remedial education and 2.8% were partially exempted from school. There was a predominance of boys and working class children among the ‘pupil act' children. One-third of them were also registered at the Social Welfare Board because of social problems in the families. The behavioural assessments made of the children at 10–12 years of age predicted problems in half the cases, mainly in the teachers' assessments. The school health service is effective in detecting and taking care of physical illnesses and has the important task of supporting children with adjustment difficulties and in acting as counsellor to teachers having children with school problems.

Preschoolers show less trust in physically disabled or obese informants

This research examined whether preschool-aged children show less trust in physically disabled or obese informants. In Study 1, when learning about novel physical activities and facts, 4- and 5-year-olds preferred to endorse the testimony of a physically abled, non-obese informant rather than a physically disabled or obese one. In Study 2, after seeing that the physically disabled or obese informant was previously reliable whereas the physically abled, non-obese one was unreliable, 4- and 5-year-olds did not show a significant preference for either informant. We conclude that in line with the literature on children's negative stereotypes of physically disabled or obese others, preschoolers are biased against these individuals as potential sources of new knowledge. This bias is robust in that past reliability might undermine its effect on children, but cannot reverse it.

Adolescent obesity, overt and relational peer victimization, and romantic relationships

OBJECTIVE

To examine associations between obesity and peer relations in adolescents, specifically testing the hypotheses that obese adolescents are more frequent victims of peer aggression and are less likely to develop romantic relationships.

RESEARCH METHODS AND PROCEDURES

Measures of overt and relational victimization, as well as dating status and satisfaction, were collected for a group of 416 ninth- through twelfth-grade students (51.7% girls). Body mass index was computed for each teen based on self-reported height and weight data.

RESULTS

Results revealed that obese boys reported more overt victimization and obese girls reported more relational victimization compared with their average-weight peers. Obese girls were also less likely to date than their peers. However, both obese boys and girls reported being more dissatisfied with their dating status compared with average-weight peers.

DISCUSSION

The results suggest that obese adolescents are at greater risk for mistreatment by peers and may have fewer opportunities to develop intimate romantic relationships; this may contribute to the psychological and health difficulties frequently associated with obesity.

Physical activity, obesity, and cardiovascular risk factors in children. The Belgian Luxembourg Child Study II

Physical activity was measured in relation to cardiovascular (CV) risk factors in a randomly selected population of 1028 children from Province de Luxembourg in Belgium, a mainly rural area with a high prevalence of such risk factors among adults and children. Physical activity was estimated as participation in sport activities, a major indicator of leisure-time physical activity in schoolchildren, and physical inactivity was estimated as frequency and duration of television (TV) watching. Boys participated more frequently in sport activities than girls did (p = 0.001). A majority of the children watched TV daily. After age adjustment, bodyweight (girls, p < 0.012; boys, p < 0.027) and, in boys, body mass index (BMI) (p < 0.039) were related to days per week of TV watching. No significant relationships with other CV risk factors remained after adjustments for BMI. In analyses of independent contributions of age, TV watching, and sports activity on CV risk factors, age showed highly significant relationships. In boys, TV showed relationships with BMI (p < 0.04) and (borderline) with systolic blood pressure, independent of age and sports activity, whereas the latter was significantly related to subscapular skinfold (p < 0.04) and (borderline) with triceps skinfold and cholesterol. In girls, no significant independent contributions to risk factor associations were found. The father's education was directly associated with sports activities, whereas the mother being a housewife showed negative relationships to physical activity and positive to TV watching in their children, suggesting socioeconomic influence on the activity patterns of children. Furthermore, registrations suggested less physical activity in the most rural part of the area. It is concluded that children in this mainly rural area watch TV frequently. In boys, physical inactivity, measured both as TV watching and as registrations of sports activities, contributes independently to body fat mass. In girls, no contribution or weaker contributions of physical inactivity were found. This suggests that contributory factors leading to obesity might be different in girls and boys.

Cause and effect beliefs and self-esteem of overweight children

In this study, beliefs of the cause and effect of weight were examined in a sample of 9- to 11-year-old clinically overweight children. Lower self-esteem was found in the children who believed they are responsible for their overweight as compared to those who attributed their overweight to an external cause. Lower self-esteem was also found in the children who believed that their overweight hinders their social interaction. Other evidence gathered here lends some support to the view that the overweight child is more vulnerable to low self-esteem. The negative experiences in school and at home that the children reported and the premise that childhood obesity is a stigmatising condition is discussed.

Influence of parental obesity on the physical constitution of preschool children in Japan

The objective of this study was to assess the influence of parental obesity on the physical constitution of preschool children. A total of 3187 children aged between 1-6 years and their parents were studied. A child whose per cent obesity (%OB; per cent overweight for age, height and sex) was greater than 15%, and a parent whose body mass index (BMI; kg/m2) was greater than the 95th percentile were defined to be obese (27.40 and 25.97 for a father and a mother, respectively). We found that the incidence of obesity in children with obese fathers (11.5%) was significantly higher than in those with non-obese fathers (6.2%), and a similar difference was obtained between children with obese mothers (14.5%) and with non-obese mothers (6.2%), respectively. The incidence of obesity in children was 6.0% if both parents were non-obese; this incidence rose to 22.7% if one parent was obese, and to 30.8% if both were obese. The %OB of children was more markedly correlated with the mothers' BMI (r = 0.219) than the fathers' BMI (r = 0.165). The %OB of children correlated significantly with fathers' BMI, but only from the age of 3-6 years, whereas mothers' BMI correlated from the age of 1-6 years. We conclude that parental obesity was of significance in determining the development of juvenile obesity even in the preschool period.

Outpatient evaluation of obesity in adults and children: a review of the performance of internal medicine/pediatrics residents

A chart audit of 115 adults and 113 children seen consecutively in an internal medicine/pediatrics residency was conducted to assess recognition of obesity and appropriateness of suggested therapy. Patients were categorized as obese, overweight, or normal based on body mass index. Forty-four percent of the children and 50% of the adults were classified as overweight or obese. Residents were more likely to document obesity in adults (53%) than in children (18%, p < 0.0001). Higher degree of obesity in adults increased resident documentation of the condition (p = 0.022), but presence of additional cardiovascular risk factors did not. When overweight or obesity was recognized, residents chose appropriate therapy. Enhanced education to improve recognition of obesity appears warranted.

Primary prevention of chronic disease among children: the school-based "Know Your Body" intervention trials

The "Know Your Body" project, initiated in 1975 with funding from the National Heart, Lung, and Blood and the National Cancer Institutes, was developed in response to the empirically-validated suggestion that the primary prevention of chronic disease should begin in childhood. The aim of the program is to favorably modify the population distributions of risk factors for these diseases through changes in their behavioral antecedents. The program is classroom-based and teacher-delivered, and consists of three primary intervention foci: diet, physical activity, and cigarette smoking prevention. The program was subjected to a field trial among two demographically dissimilar populations of schoolchildren in the New York City area. After five years of intervention in one of the populations, the program was associated with significant favorable changes in blood total cholesterol levels and dietary intake of total fat and carbohydrate. In both populations, the program was associated with significant favorable changes in knowledge. After six years of intervention, the program was associated with a significant net reduction in the rate of initiation of cigarette smoking. If these findings can be replicated among diverse populations of schoolchildren, they suggest that such programs may be effective in reducing the population risk for the future development of chronic disease.

Modification of risk factors for coronary heart disease. Five-year results of a school-based intervention trial

We conducted a study of the effectiveness of an educational intervention designed to modify risk factors associated with coronary heart disease among 3388 children in 37 schools in two demographically dissimilar areas (the Bronx and Westchester County) in and around New York City. Schools within each area were randomly assigned to either intervention or nonintervention groups. In schools targeted for intervention, children in the fourth through eighth grades were taught a teacher-delivered curriculum focusing on diet, physical activity, and cigarette smoking. Risk-factor levels were measured in all schools at base line and at four follow-up points. A total of 1769 of the children qualified for analysis of the intervention effect. After five years, the net mean change in plasma levels of total cholesterol was -1.7 mg per deciliter per year (-0.04 mmol per liter) (95 percent confidence interval, -2.7 to -0.7 mg per deciliter [-0.07 to -0.02 mmol per liter]) in the Westchester County schools, or -8.5 mg per deciliter (-0.22 mmol per liter) (5.1 percent) over a period of five years. In the schools in the Bronx, the net mean change was -1.0 mg per deciliter per year (-0.03 mmol per liter) (95 percent confidence interval, -2.3 to +0.3 mg per deciliter [-0.06 to +0.01 mmol per -2.3 to +0.3 mg per deciliter [-0.06 to +0.01 mmol per liter]), or -5.0 mg per deciliter (-0.13 mmol per liter) (2.9 percent) over a period of five years. Favorable trends in dietary intake and health knowledge were also observed, whereas the other targeted risk factors were not significantly altered. If these findings can be replicated, this will suggest that educational programs to modify coronary risk factors are feasible and may have a favorable (albeit small) effect on blood levels of cholesterol in children.

Dietary restraint and obesity: their effects on dietary intake

The current investigation evaluated the effects of levels of restraint, dietary intake, and obesity on both immediate (i.e., in the laboratory) and subsequent (i.e., outside the laboratory) self-reported dietary intake. Subjects were 102 college females, half of whom were given a high-caloric snack of a chocolate milkshake. Subjects were classified according to their level of chronic dieting status and relative weight. Chronic dieting status was measured by utilizing both the Concern for Dieting (CD) and the Weight Fluctuation (WF) factors of the revised restraint scale (Polivy, 1980). When using the WF factor, results indicated that obesity interacted with dieting status on total food consumption (i.e., calories for the entire day). That is, nondieting obese subjects reportedly ate significantly more calories than nondieting normal-weight subjects. Further, nondieting overweight subjects reported eating significantly more than low-restrained normal-weight subjects. On the CD factor, restrained eaters who received a preload reported eating significantly more calories than nondieters at lunch. For those subjects not receiving a milkshake, restrained eaters ate fewer calories at lunch than nondieters. The significance of these results for understanding possible energy imbalances in obese individuals as well as understanding pathological overeating and its consequences is discussed.

A longitudinal view of blood pressure during childhood: the Muscatine Study

Four thousand three hundred and thirteen children beginning at five to fourteen years of age have been examined on three to six occasions in Muscatine, Iowa, on alternate years. To compare blood pressures throughout the period of observation each value was expressed as a percentile rank. For each subject the average percentile rank (level), the trend in rank and the variability over time were calculated. Values for height, weight, relative weight and triceps skinfold thickness measurements were expressed in the same fashion. There is a relationship between average rank of blood pressure and average rank of body size as well as between trend of blood pressure and trend of body size percentiles. These observations indicate the importance of relative rate of growth in the establishment of the rank order of blood pressure during childhood.

Emotional health of families and their members where a child is obese

A controlled study of families with an obese child showed a small but significantly greater impairment in family functioning when this was elicited and rated using clinical methods. However no significant impairment was found when functioning was elicited with standardized objective methods. Mothers of obese children rated their families as more dysfunctional than mothers of control children. Although the emotional health of individual members in obese families was not worse than in control families, significant differences in the family patterning of emotional health were found. The more overweight the obese child, the healthier the mother rated the family, and the better her own mental health as assessed by a self-report method; and in families of obese girls, the greater the degree of overweight, the worse the rated family functioning. The findings are integrated with the literature and a theoretical explanation in which obesity is seen as an identity disturbance is offered.

Tracking of blood pressure during childhood: the Muscatine Study

Four thousand three hundred and thirteen children beginning at five to fourteen years of age have been examined on three to six occasions in Muscatine, Iowa on alternate years. To compare blood pressures throughout the period of observation each value was expressed as a percentile rank. For each subject the average percentile rank (level), the trend in rank and the variability over time were calculated. Values for height, weight, relative weight and triceps skinfold thickness measurements were expressed in the same fashion. The relationship between average rank of blood pressure and average rank of body size as well as between trend of blood pressure and trend of body size percentiles were significant (p less than .05). These observations indicate the importance of relative rate of growth in the establishment of the rank order of blood pressure.

Obesity in childhood and adolescence. Special problems in diagnosis and treatment

Obesity is an emotional, physical, and social problem in search of a definition as well as an explanation for its pathogenesis and an efficacious approach to therapy. The complexities of the problem and the limitations of our knowledge are compounded by the anabolic aspects of growth and the sex-specific differences in fat deposition and energy requirements of children and adolescents. The clinician has a delicately balanced responsibility to moderate weight gain while avoiding dietary regimens that will induce catabolism. Further, the clinician must provide empathetic counseling and support, modify behavior, and encourage physical activity. All this must be undertaken with the knowledge that the objective may be unobtainable and, on those occasions when it is achieved, the recidivism rate will be high. Despite these difficulties, it is critical that the child and the family be provided with a realistic and practical regimen that has the potential to help while doing no harm.

Obesity in lower and middle socio-economic status mothers and their children

To identify potential nursing interventions for obesity in lower socioeconomic status populations, the relationships between maternal and child obesity, socioeconomic status, maternal nutritional knowledge, and locus of control for maternal weight in 144 children and their mothers were studied. Subjects were recruited from two clinic populations; Clinic 1 was of lower socioeconomic status than Clinic 2. As compared with those from Clinic 2, mothers from Clinic 1 were heavier, had less nutritional knowledge, and were more external with respect to locus of weight control. There was a trend for Clinic 1 children to be heavier than those in Clinic 2 but this finding was not statistically significant. The lower socioeconomic status children significantly resembled their mothers' adiposity (possibly foreshadowing adult obesity), however, the middle socioeconomic status children did not resemble their mothers.

Determinants of weight and adiposity in the first year of life

To overcome methodologic defects (failure to control for confounding factors, univariate statistical analyses) in previous studies of etiologic determinants of childhood adiposity, we carried out a prospective cohort study of 462 healthy, full-term infants observed from birth to 12 months. Postpartum, we obtained sociodemographic data and administered two recently validated scales of maternal attitudes toward feeding and infant body habitus. Parental heights and weights and infant feeding variables were determined by interview, and at 6 and 12 months we measured height and weight and triceps, subscapular, and suprailiac skinfolds. Multiple regression analysis was used to determine independently predictive factors for weight, body mass index (BMI = weight/height), and the sum of the three skinfold measurements. Birth weight, sex, age at introduction of solid, and duration of breast-feeding were all significant predictors of weight at 12 months (r2 = 0.296, P less than 0.0001). Significant determinants for BMI included birth weight, duration of breast-feeding, sex, and IBH (r2 = 0.125, P less than 0.0001); those for total skinfold were age at introduction of solid foods and birth weight (r2 = 0.038, P = 0.002). Similar results were obtained at 6 months, although slightly less of the variance was explained. We conclude that the ability to predict which babies will be heavy or obese during the first year is limited. Breast-feeding and delayed introduction of solid foods do offer some protective effect, however, and thus efforts to encourage these practices may be reaping some benefit.

Factors related to tracking of blood pressure in children. U.S. National Center for Health Statistics Health Examination Surveys Cycles II and III

In this paper we examine the relationship of growth, obesity, and the degree of sexual and bone maturation to blood pressure in a U.S. national probability sample of 2165 children examined by the U.S. National Center for Health Statistics on two occasions, approximately 4 years apart. Subjects who maintained, increased, or decreased their peer rank order of blood pressure are described. Children who maintained their blood pressure in the upper quintile were taller, heavier, more obese, had greater bone age, greater numbers of permanent teeth, and were more sexually mature than their peers, while those maintaining their blood pressure in the lowest quintile of blood pressure were shorter, lighter, less obese, had lesser bone age, fewer permanent teeth, and were less sexually mature. Subjects whose blood pressures were initially in the lowest four quintiles and then rose to the top quintile were also taller, heavier, more obese, and had greater bone age, while those with blood pressures falling to the lowest quintile from the upper four quintiles were shorter, lighter, less obese, and had lesser bone age. Thus, the level at which blood pressure tracks during childhood is related to growth, obesity, and to the degree of maturation acquired. In addition, children whose blood pressures are rising or falling in relation to their peers have body growth and maturation characteristics similar to those who maintain their rank order high or low respectively.

Level, trend, and variability of blood pressure during childhood: the Muscatine study

On alternate years from 1970 to 1981 blood pressure has been measured in school children living in Muscatine, Iowa. A total of 4313 children beginning at 5 to 14 years of age have been examined on three to six occasions. To compare blood pressures throughout the period of observation, each value was expressed as a percentile rank. For each subject the average percentile rank (level), the trend in rank, and the variability over time were calculated. Values for height, weight, relative weight, and triceps skinfold thickness were expressed in the same fashion. The relationship between average rank of blood pressure and average rank of body size as well as between trend of blood pressure and trend of body size percentiles were significant (p less than .05). These observations indicate the importance of relative rate of growth in the establishment of the rank order of blood pressure. Using the variables of level, trend, and variability, we identified groups of children who appear to be consistently tracking toward future hypertension: 233 (5.4%) children, whose systolic levels were in the upper quintile with either a flat or rising trend and low variability, and 280 (6.0%) children with systolic levels in the lower four quintiles with high trend and low variability. In addition there were 321 (7.4%) children whose mean systolic levels were in the upper quintile with high variability and who thus resemble adults with labile hypertension. There were similar numbers of children with diastolic pressures showing these features.

Infant adiposity and maternal energy consumption in well-controlled diabetics

This study was designed to determine the relationship of maternal diet and infant adiposity in well-controlled diabetics. The relationship between the fat consumption pattern of the pregnant diabetic and the adiposity of her infant was investigated. Length, weight, and head circumference; triceps, subscapular, and anterior thigh skinfolds; and subcutaneous fat layer were obtained on ten infants of diabetic mothers and ten infants of nondiabetic mothers. Measurements were taken at 48 h, 2 weeks, and 1 month postpartum. Maternal dietary intakes were recorded for 6 days during the third trimester of pregnancy. Infants of diabetic mothers and infants of nondiabetic mothers exhibited differences in birth length, 2-week and 1-month head circumference, 2-week triceps skinfold thickness, and fat layer. However, measurements differing at birth were not consistant with those differing at repeated measurements throughout the first month of life. Only the dietary intake of linoleic acid as a percentage of energy intake differed between the two groups of women. The diabetic women consumed more linoleic acid. The fat consumption pattern in the pregnant diabetic was unrelated to the subsequent anthropometric measurements of her infant. The well-controlled diabetics in this study did not have large-for-gestational-age infants.

Parent--child obesity and cardiovascular risk factors

Blood pressure, cholesterol, high density lipoprotein cholesterol, and triglycerides were studied in obese children and obese parents selected to participate in a weight treatment program. The relationships between parent and child risk levels, as well as the relationship between child and parent weight and risk factors, were established. Results showed that children's cholesterol and triglycerides were related to parental lipid levels, independent of weight. Children's blood pressure readings were strongly related to their weight, but not to parental blood pressure. High density lipoprotein cholesterol levels were negatively related to weight in both child and parent female populations, and weakly positively related to weight for male children. Implications of these risk factor patterns for intervention are discussed.

Effect of a comprehensive nutritional program on the growth and ponderosity of infants

One hundred eighty-two consecutive newborns from a university-based private practice were enrolled in a comprehensive nutritional program in an attempt to lower the incidence of ponderosity in the group. The program emphasized an individualized approach in which the feeding instructions given to parents varied with the growth pattern of their child. Whereas specific modalities of feeding, such as breast vs. bottle and early vs. late addition of baby foods, appeared not to modify growth, the group as a whole exhibited a trend to lower weight-for-length index (WLI) and less ponderosity than in previous published reports. We propose that the individualized nutritional program may have resulted in this improvement, and that such attention to detail will likely be more rewarding than an approach which emphasizes only general nutritional information to the group as a whole.

National study of health and growth: social and family factors and obesity in primary schoolchildren

The association of social and family factors with triceps skinfold and weight for height and age was assessed using multiple regression analyses for 5-11 year-old-children in England and Scotland. Parents' body build was the factor most consistently associated with the two proxy measures of obesity. Number of siblings in the family was inversely related to triceps skinfold thickness. Parents' body-build and number of siblings were more strongly related to our measures of obesity in the older age groups and in girls, whereas child's birth-weight was more associated with weight for height and triceps skinfold in the younger age groups. Father's social class and mother's education made almost no contribution to the variation of triceps skinfold and weight for height in children. The relative risk of obesity associated with any individual independent variables was less than or around two. We conclude that there is little scope for identifying the majority of children at risk of obesity in a characteristic social environment. However, the increase in the association between our measures of obesity in parents and older children provides a possible tool for the early detection of children who may become obese.

Diet, fat accretion, and growth in premature infants

To compare the growth and accumulation of protein, fat, and carbohydrate in the formula-fed premature infant and in the fetus of a similar postconceptional age, we performed 22 metabolic studies in 13 infants of very low birth weight (1155 +/- 39 g [mean +/- S.E.]). Measurements combining nutritional balance and indirect calorimetry demonstrated the deposition rates of protein and fat. We found that the formula-fed, very-low-birth-weight infant who gained weight comparably to the fetus retained the same amount of protein (1.92 +/- 0.1 g per kilogram of body weight per day) but accumulated fat at a rate of 5.4 +/- 0.3 g per kilogram per day - about three times that in the fetus, as confirmed by increased skin-fold thickness. How this change in body composition affects the future growth of formula-fed premature infants, and how body composition is altered by other dietary regimens such as the provision of human milk, remain to be determined.

Excessive carbohydrate intake in pregnancy and neonatal obesity: study in Cap Bon, Tunisia

A high incidence (over 20%) of obesity was found in 250 neonates living in a rural area of Tunisia, by using weight and ponderal index per gestational age as the nutritional index. Maternal diabetes was probably excluded. Two surveys on nutritional habits--one on the general population and the other on pregnant women--showed a tendency to consume a high carbohydrate and low protein diet. The effect of a badly balanced maternal diet on the fetus is discussed.

Obesity in relation to socioeconomic status. A population study of women in Göteborg, Sweden

In a population sample of 1462 middle-aged women socioeconomic data were studied in relation to obesity, assessed by a body weight index. Education, annual income, and social class were negatively correlated with weight index (WI). Husband's social class was a stronger determinant of obesity in the woman than her own class. Age of husband and number of children were significantly correlated with WI. There was also a weak correlation between being single and WI. Sick leave was not correlated to WI. Pension was correlated to WI when adjusted for age, but not when allowance was also made for social class. Age, husband's social class, education, husband's income, and number of children were independent predictors of WI among the married women. In the single women, age and own income were independent predictors of WI but not number of children, education or own social class.

Taste preferences of infants for sweetened or unsweetened foods

This is a report of research on whether or not the addition of sugar to foods consumed by babies early in their feeding significantly alters later preference for sweetened or unsweetened foods. Twenty control babies were fed regular baby food (which already has additional sugar) for the first 3 months of their solid-food feeding experience; 20 experimental babies were fed a diet with no added sugar for a similar time period. The two groups were then studied during a 4-week period in which they were randomly assigned to four different sequences of sweetened and unsweetened food. Their reactions to sweetened and unsweetened food were scored according to parental interpretation of their preferences and according to how much food they consumed. Neither group was found to prefer sweetened or unsweetened food. This finding is in contradiction of other studies and common lay and clinical views that infants prefer sweetened foods. It would seem that if babies do not prefer sweet foods, there is certainly no reason to add sugar to commercial products.

Early nutrition: its long-term role

The widespread belief that problems such as lifelong obesity originate in infancy sometimes leads to overzealous attempts to regulate energy intake too soon and may compromise linear growth. Treatment of obesity should wait unitl after age one.