Management of childhood obesity in pediatric practice

Addressing Pediatric Obesity in Clinic

There is an epidemic of pediatric obesity in the United States. In most cases, there is an excess in the amount of calories consumed, compared with the amount of calories expended. Numerous body systems are affected by pediatric obesity, with complications varying between boys and girls. Behavioral, genetic, and environmental factors affect the ability of children to avoid becoming obese. Primary care physicians should screen for obesity in children as much as possible. Associated risk factors for obesity should be uncovered. Methods of preventing obesity should be discussed routinely with children and their families. Healthy dietary habits are key, and so are family-oriented interventions, such as eating together at dinnertime. One hour of moderate to vigorous activity daily is recommended for children and adolescents. While pediatric bariatric surgery is an option, there are also numerous nonpharmacological and pharmacological measures available as management for pediatric obesity. Family-based approaches, such as reducing screen time, have been very successful. Non-weight-bearing exercises also help children and adolescents expend calories without causing injury to themselves. Family availability, activity preference, and developmental levels should all be considerations when managing pediatric obesity. Motivational interviewing may also be helpful, especially when customized for each specific patient and family. Clinicians will play an increasing role in terms of identifying, treating, and preventing pediatric obesity; measures that can be done in the clinic should be considered more and more.

Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators

BACKGROUND/AIMS

To examine the effects of a 3-month multidisciplinary intervention on anthropometric measures, physical activity patterns and fitness, inflammatory cytokines, adipocytokines, and growth mediators in obese children.

METHODS

21 obese subjects completed the 3-month intervention and were compared with 20 age-, gender- and maturity-matched controls. Subjects underwent anthropometric measurements (weight, height, BMI percentile and waist circumference), blood tests (IL-6, CRP, leptin, adiponectin, insulin, IGF-I and glucose), a progressive treadmill exercise test to evaluate fitness, and habitual activity assessment before and after the intervention.

RESULTS

The intervention led to a significant change of differences in body weight (-1.3 ± 4.1 vs. 2.5 ± 3.3 kg), BMI percentile (-0.96 ± 1.29 vs. 0.19 ± 0.8), waist circumference (-2.1 ± 2.7 vs. 2.9 ± 3.0 cm) and running time (149.9 ± 86.3 vs. -8.2 ± 88.0 s) in the intervention compared to control. There was a significant increase in leisure-time physical activity (Godin questionnaire, 29.04 ± 6.8 vs. -1.3 ± 9.2) and a decrease in sedentary activity (-1.4 ± 0.73 vs. 0.02 ± 0.62 h/day) in the intervention compared to control. Significant change differences in adiponectin (2,308 ± 1,640 vs. -801 ± 465 ng/ml), IGF-I (33.8 ± 37.8 vs. -1.0 ± 36.2 ng/ml), CRP (-0.06 ± 0.29 vs. 0.5 ± 0.86 mg/dl) and HOMA-IR (-0.15 ± 0.57 vs. 0.55 ± 0.84) were found in the intervention group compared to control.

CONCLUSIONS

Our results highlight the short-term beneficial effects of a childhood obesity multidisciplinary intervention on anthropometrics, habitual activity, fitness, inflammatory and metabolic measures. The longer-term effects of these changes on obesity-associated metabolic risks are yet to be determined.

Health-related knowledge and preferences in low socio-economic kindergarteners

OBJECTIVE

The aim of the present study was to determine physical activity (PA) and nutrition knowledge and preferences in low socio-economic status kindergarten children.

METHODS

Following height and weight measurement, 795 low socio-economic status kindergarten children (age 3.8-6.8 y.o) completed a photo-pair knowledge and preferences food and exercise questionnaire.

RESULTS

No difference was found between nutrition and PA knowledge scores (52.3 ± 0.9 versus 52.6 ± 0.8%, respectively). There was no difference between the nutrition knowledge and preference score (52.3 ± 0.9 versus 50.9 ± 0.9%, respectively). PA preference was significantly higher than knowledge (56.9 ± 1.5 versus 52.6 ± 0.8%, respectively; p < 0.0001). Significant correlations were found between nutrition knowledge and preferences (r = 0.55, p < 0.0001), physical activity knowledge and preferences (r = 0.46, p < 0.0001), and nutrition and PA preferences (r = 0.46, p < 0.001). Nutrition preference scores were significantly lower in overweight compared to normal weight kindergartners 48.1 ± 1.7 versus 52.0 ± 1.0%; p < 0.05). PA knowledge and preference scores were significantly higher among male compared to the female kindergartners (p < 0.001 for both).

CONCLUSION

Our data demonstrate diversities in physical activity and nutrition knowledge and preferences among low socio-economic status kindergarten children. These findings may be important for the development of health promotion programs in low socioeconomic kindergarten children.

Diet intervention on obese children with hypertension in China

BACKGROUND

Obesity has made obesity-related diseases a worldwide problem. This study was undertaken to evaluate the effects of diet-oriented intervention on obese children with hypertension in China and to determine the relationship between anthropometric indexes and hypertension.

METHODS

A total of 469 obese children, aged 6 to 18 years, were evaluated between January 2001 and December 2005; 184 of them were diagnosed with hypertension. Hypertensive children were provided with individual diet-oriented intervention for more than 6 months. Physical exercises were recommended for obese children at least 30 minutes per day. Height, body weight, waist circumference, systolic blood pressure, and diastolic blood pressure were taken for each subject before and after intervention.

RESULTS

Of the 184 children enrolled, 139 (75.5%; 86 boys) completed the study. Weight, body mass index (BMI), waist circumference, and hip circumference all decreased after a 6-month intervention, despite a 2.1 cm increase in height. Systolic and diastolic pressures decreased by 16.6 and 13.3 mmHg compared with baseline levels. Of the 139 children, 103 (74.1%) who had blood pressure in the normal range (<90th percentile for age and sex) were taken as a response group. The other 36 children who remained hypertensive showed no obvious differences in anthropometric measurements and were taken as a non-response group. Weight, BMI, BMI%, waist circumference, hip circumference and blood pressure in the 139 children showed significant differences after the intervention compared with baseline values. Weight, BMI, BMI%, waist circumference, and hip circumference were positively correlated with both systolic and diastolic blood pressures; they were correlated more strongly with systolic pressure than with diastolic pressure.

CONCLUSIONS

Diet-oriented intervention can decrease blood pressure in most obese children with hypertension. Weight, height, BMI, BMI%, waist circumference, and hip circumference are closely associated with blood pressure.

Promoting growth interpretation and lifestyle counseling in primary care

OBJECTIVE

To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits.

STUDY DESIGN

The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes.

RESULTS

The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change.

CONCLUSIONS

The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.

Correlates for poor sleepers in a Los Angeles high school

BACKGROUND AND PURPOSE

We explored sleep patterns including morning-evening preference and their associations with other lifestyle determinants among high school students.

PARTICIPANTS AND METHODS

We conducted a cross-sectional survey of students grades 9-12 from a private high school in the United States. One hundred and thirty-one students completed an online survey comprising 23 original, investigator-created questions, a mood scale, the Pittsburgh Sleep Quality Index (PSQI), and the Horne-Ostberg Morningness-Eveningness Questionnaire (MEQ).

RESULTS

We found that 80% of students reported a sleep deficit. As defined by the PSQI, 69% of girls and 58% of boys in this sample were poor sleepers. Eveningness was a strong predictor of poor sleep, particularly among students aged 15 years (odds ratio [OR] 9.92; 95% confidence interval [CI], 1.52-64.8), among whom poor sleep quality was also associated with a higher body mass index (BMI) (OR, 6.97; 95% CI, 1.01-48.2).

CONCLUSIONS

Our pilot study suggests that morningness-eveningness is a strong predictor of sleep quality among high school students.

Potentially protective factors associated with healthful body mass index in adolescents with obese and nonobese parents: a secondary data analysis of the third national health and nutrition examination survey, 1988-1994

OBJECTIVE

To identify factors potentially protective against obesity in 12- to 16-year-olds with one or two obese parents, and those with no obese parents.

DESIGN

A secondary analysis of the Third National Health and Nutrition Examination Survey, 1988-1994.

SUBJECTS/SETTING

A nationally representative sample of healthful weight, at-risk, or overweight adolescents with measured heights and weights (n=1,890). Subsamples with any obese parent (body mass index > or =30) and no obese parents (both with body mass index <25) were analyzed.

STATISTICAL ANALYSES PERFORMED

Bivariate analyses examined the association of predictor variables (demographics, nutrient intake, and physical activity) on the outcome. Logistic regressions examined the likelihood of being healthful weight. SUDAAN software (release 7.5, 1997, Research Triangle Institute, Research Triangle Park, NC) was used to account for the sample design.

RESULTS

Overall, 71% of subjects had a healthful weight, 29% were at risk or overweight. Factors associated with healthful weight included having two nonobese parents (odds ratio [OR]=5.4), only father obese (OR=4.9), only mother obese (OR=3.3), higher reading scores (OR=1.02), lower water consumption (OR=1.8), more exercise programs (OR=2.8), and higher energy intake (OR=2.0). For adolescents with any obese parent, factors potentially protective against obesity included being female (OR=2.2), higher household education (OR=1.1), lower water consumption (OR=2.0), and eating breakfast some days (OR=3.1) or everyday (OR=4.0). For adolescents with no obese parents, potentially protective factors included older age (OR=1.2), not having asthma (OR=2.6), more exercise programs (OR=6.1), and higher energy intake (OR=2.9). All P<.05.

CONCLUSIONS

Interventions targeted at adolescents who are at risk because they have parents with obesity should employ a family approach focused on regular breakfast consumption.

Essverhalten und psychosoziale Anpassung bei Kindern mit Übergewicht

Zusammenfassung. Die Anzahl übergewichtiger Kinder ist in den vergangenen Jahren deutlich angestiegen. Aufgrund der vielfältigen medizinischen und psychosozialen Folgebelastungen des Übergewichts, der hohen Persistenzraten sowie der geringen Effektivität von Gewichtsreduktionsmaßnahmen im Erwachsenenalter besteht ein dringender Handlungsbedarf dahingehend, effektive Interventionsmethoden für übergewichtige Kinder bereitzustellen. Die vorliegende Arbeit soll hierzu einen Beitrag leisten: Über das konkrete Essverhalten der Kinder in Hinblick auf verschiedene Außenbedingungen (Stress, Familie) und die Folgebelastungen des Übergewichts im psychopathologischen und psychosozialen Bereich ist noch sehr wenig bekannt. Daher werden zunächst empirische Ergebnisse aus verschiedenen Studien zu diesen Bereichen vorgestellt. Zusammenfassend lassen sich die Ergebnisse der im Rahmen dieser Arbeit referierten Studien dahingehend interpretieren, dass sich übergewichtige Kinder in wesentlichen Punkten gar nicht so sehr von ihren normalgewichtigen Altersgenossen unterscheiden und dass hinsichtlich verschiedener Ressourcen keine qualitativen Abweichungen nach unten bestehen. Vor dem Hintergrund der Ergebnisse werden Möglichkeiten zur Optimierung von Interventionsmethoden diskutiert.

Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity

BACKGROUND

Obesity has become the most common pediatric chronic disease in the modern era. Early prevention and treatment of childhood and adolescent obesity is mandated. Surprisingly, however, only a minor fraction of obese children participate in weight reduction interventions, and the longer-term effects of these weight-reduction interventions among children have not been elucidated.

OBJECTIVE

To examine prospectively the short- and long-term effects of a 3-month, combined dietary-behavioral-physical activity intervention on anthropometric measures, body composition, dietary and leisure-time habits, fitness, and lipid profiles among obese children.

METHODS

In this randomized prospective study, 24 obese subjects completed the 3-month intervention and were compared with 22 obese, age- and gender-matched, control subjects.

RESULTS

At 3 months, there were significant differences in changes in body weight (-2.8 +/- 2.3 kg vs 1.2 +/- 2.2 kg), BMI (-1.7 +/- 1.1 kg/m2 vs -0.2 +/- 1.0 kg/m2), body fat percentage (from skinfold tests; -3.3 +/- 2.6% vs 1.4 +/- 4.7%), serum total cholesterol level (-24.6 +/- 15.1 mg/dL vs 0.8 +/- 18.7 mg/dL), low-density lipoprotein cholesterol level (-23.3 +/- 15.2 mg/dL vs -3.7 +/- 17.3 mg/dL), and fitness (215 +/- 107 seconds vs 50 +/- 116 seconds) in the intervention group versus the control group. After a 1-year follow-up period, there were significant differences between the intervention group (n = 20) and the control group (n = 20) in body weight (0.6 +/- 6.0 kg vs 5.3 +/- 2.7 kg), BMI (-1.7 +/- 2.3 kg/m2 vs 0.6 +/- 0.9 kg/m2), and body fat percentage. There was a significant increase in leisure-time physical activity among the intervention participants, compared with a decrease among the control subjects.

CONCLUSIONS

Our data demonstrate the short- and longer-term beneficial effects of a combined dietary-behavioral-physical activity intervention among obese children. These results highlight the importance of multidisciplinary programs for the treatment of childhood obesity and emphasize their encouraging long-term effects.

Overweight children in Beirut: prevalence estimates and characteristics

OBJECTIVE

To estimate, for the first time, overweight prevalence and associated characteristics in a representative sample of prepubertal children in Beirut, Lebanon's capital.

DESIGN

A cross-sectional study with a home interview including measurements of weight and height and a structured questionnaire.

SUBJECTS

A total of 234 children aged 6-8 years in Beirut: 131 boys, 103 girls.

METHODS

Prevalence of overweight and obesity was based on the international cut-off points for body mass index (BMI) by age and gender proposed by the International Obesity Task Force. The characteristics of overweight examined were: age, gender, household and family size, single- vs. two-parent family, parents' level of education and profession, physical activity and dietary intake of children.

RESULTS

Prevalence of overweight and obesity was 26% and 7% respectively in boys, 25% and 6% in girls. Overweight was significantly associated with low physical activity (P < 0.05) and mother's BMI (P < 0.05).

CONCLUSIONS

This study identified a high proportion of overweight in 6- to 8-year-old children in Beirut. Reduced physical activity was the most significant factor associated with childhood overweight. Further studies in different regions in Lebanon are necessary to identify national characteristics; prevention efforts will be designed accordingly.

Evaluation of lipid profile in adolescents during long-term use of combined oral hormonal contraceptives

The study evaluated the effects of the long-term use of a combined oral hormonal contraceptive containing 30 microg ethinyl estradiol and 75 microg gestodene in adolescents. Thirty-three volunteers, aged from 14 to 19 years, who used the oral contraceptive for three consecutive years, were studied. Evaluation of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides was made before use and after 1, 2 and 3 years. During the 3-year study period, total cholesterol, HDL-C, LDL-C and triglyceride levels were significantly higher than previous measurements, but average values did not exceed the normal range. Compared to the first year, the second- and third-year cholesterol, HDL-C, LDL-C and triglyceride levels were not significantly different.

Guidelines help clinicians identify risk factors for overweight in children

The pediatric office has an important role in national efforts to reverse rising trends in the prevalence of childhood overweight. Overweight may be established at a young age and is difficult to reverse. Lifestyle choices associated with overweight are common and their development may begin in very young children. Therefore, there is a necessity to apply a preventive strategy that addresses all children to promote healthy lifestyle choices from birth onward and to develop an intervention strategy that works by changing family habits so that healthy lifestyle habits are reinforced. It is crucial to develop, evaluate, and apply new systems and practical approaches to aid in this effort in the pediatric practice setting.

Disease severity at time of referral for pediatric failure to thrive and obesity: time for a paradigm shift?

The percent of ideal body weight at first visit to pediatric referral clinics was compared by chart review between patients with failure to thrive and obese patients. Results indicated that underweight children were mildly underweight, whereas the overweight children were severely so. In primary care settings, underweight children may be referred more aggressively than overweight children.

Preventing pediatric obesity: assessment and management in the primary care setting

PURPOSE

To review the literature on and discuss the role of the primary care provider in assessing and managing overweight children before they become obese.

DATA SOURCES

Selected research, national guidelines and recommendations, and the professional experience of the authors.

CONCLUSIONS

The focus of primary care involves early detection and family interventions that are designed for lifestyle modifications, specifically for improved nutrition and an increase in regular physical activity, to achieve optimal child health. Early identification and management of children who exceed a healthy weight for height, gender, and age will prevent the increasing incidence of pediatric obesity. Early prevention and management of pediatric overweight and obesity will also decrease the potential for associated medical and psychosocial problems.

IMPLICATIONS FOR PRACTICE

Pediatric obesity has risen dramatically in the United States during the last two decades; it is a significant child health problem that is preventable and largely under-diagnosed and under-treated. It is essential to discuss prevention of obesity with parents at every well-child visit; treatment should be initiated when patterns of weight gain exceed established percentiles for increasing height for age and gender.

Prevention and treatment of childhood obesity

Obesity has reached epidemic proportions among children and youth in the United States. Surveys indicate that the number of overweight children aged 6 to 17 years has doubled within three decades. In the decade between the late 1970s and the late 1980s, the prevalence of overweight increased from 7.6% to 10.9% for children aged 6 to 11 years, and from 5.7% to 10.8% for adolescents aged 12 to 19 years. Data for 1999 indicates that the epidemic is continuing to increase, so that 13% of 6- to 11-year-old children and 14% of 12- to 19-year- old children are currently overweight (body mass index > or = 95th percentile for age/gender). This article reviews newer concepts related to etiologic factors, comorbidities, and strategies for prevention and treatment.

Exercise as a modality in the treatment of childhood obesity

In a review of the literature, Glenny et al determined that family therapy and lifestyle modification seem to be effective in the prevention and treatment of childhood but not necessarily adult obesity. Furthermore, research indicates that obese children are better able to maintain weight loss over a long-term period than are adults. Based on the limited research in the treatment of obesity in children, approaches should include family interventions with nutrition and physical activity education, structured exercise, and behavior modification. These interventions should be delivered by a team of health care experts in a nurturing, nonintimidating environment; however, obese children respond differently physiologically and emotionally to exercise than do normal-weight children. Therefore, obese children may experience negative consequences to participation in activities considered appropriate for normal-weight children. In clinical settings, specialized exercise programs based on appropriate theories that include specific recommendations for children with varied obese conditions have been shown to enhance safety, efficacy, and compliance during pediatric obesity treatment. Optimal results may be achieved by combining programs to reduce sedentary behaviors based on similar theories with specialized, structured exercise prescriptions. When used in conjunction with appropriate dietary prescriptions and consistent behavior modification, exercise serves as a promising modality that may reverse obese conditions during childhood and, perhaps, prevent the onset of adult obesity.

Evaluation and management of hypertension in childhood

Hypertension, a relatively uncommon problem in childhood except in certain groups of children, is an important cardiovascular risk factor that can have significant health implications, especially the tendency for an elevated blood pressure in childhood to predict the development of adult hypertension. Common causes of childhood hypertension include renal and cardiac disease, as well as essential hypertension in adolescents. Given these factors, it is usually possible to evaluate the hypertensive child in a focused manner that should reveal not only the underlying cause of hypertension, but also its severity. Treatment should incorporate non-pharmacologic approaches as well as antihypertensive medications, and should take into account other cardiovascular risk factors such as hyperlipidemia. This review highlights these and other important issues in the evaluation and management of hypertensive children, and provides practical guidance to the practitioner involved in caring for such patients.

Care giver perception of children's obesity-related health risk: a study of African American families

OBJECTIVE

To examine care giver perception of children's weight-related health risk in African American families.

RESEARCH METHODS AND PROCEDURES

One-hundred and eleven families (representing 48 boys and 63 girls) screened for participation in a diabetes prevention study participated. Care givers completed a health awareness questionnaire that assessed their perception of the child's weight, eating habits, appearance, exercise habits, and health risk. The care givers also reported each subject's family history of obesity, diabetes, and other chronic diseases. After a physical examination, height and weight were used to compute an age- and sex-adjusted body mass index for each child.

RESULTS

Despite the fact that a substantial number of children were obese (57%) and super-obese (12%), only 44% of the care givers perceived the child's weight to be a potential health problem. Regression analysis showed that 21% of the variance in parental perception of obesity-related health risk could be predicted by child age, body mass index, perception of frame size, and perception of exercise habits.

DISCUSSION

A number of reasons for the apparent minimization of child health risk are discussed, including cultural differences in the acceptance of a large body habitus, lack of knowledge about the connection between childhood obesity and future health risk, and an optimistic bias in the perception of personal health risk.

Public health interventions for the prevention and treatment of obesity

Epidemic obesity is one of the few undesirable consequences of humanity's mastery of the environment. This article reviews public health approaches to preventing and treating obesity. The most encouraging efforts to date have been interventions targeting children in both medical and community surroundings. Treating and preventing obesity in adults has been less successful. It is suggested that taking an environmental health perspective on the obesity problem may facilitate the advancement of scientific understanding of this important health issue.

The prevention education program (PEP). A prospective study of the efficacy of family-oriented life style modification in the reduction of cardiovascular risk and disease: design and baseline data

We describe design and baseline data of the Prevention Education Program (PEP), a home-based and family-oriented intervention program, aimed to assess and improve cardiovascular risk factors in school children and their families during an intervention period of 10 years. Started in 1994 in the German town of Nuremberg, currently 37 elementary schools (22 control and 15 intervention schools) are enrolled including 1740 families (1740 first graders, 3046 parents, and 1521 siblings). Major cardiovascular risk factors as well as dietary behavior are evaluated yearly using structured interview, physical examination, laboratory analysis, and seven-day-dietary protocols. The intervention package is applied to all families from intervention schools using regular home visits, health curricula and group sessions. Primary outcome is any reduction in cardiovascular risk factors by dietary intervention and health education compared to the control group getting only written information on the individual risk profile. The presented baseline data showing a high prevalence of cardiovascular risk factors in adults and in their children underline the need for such an intervention program in Germany.