Childhood obesity

Childhood Obesity: An Updated Review

BACKGROUND

Childhood obesity is an important and serious public health problem worldwide.

OBJECTIVE

This article aims to familiarize physicians with the evaluation, management, and prevention of childhood.

METHODS

A PubMed search was conducted in May, 2021, in Clinical Queries using the key terms "obesity" OR "obese". The search included clinical trials, randomized controlled trials, case-control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to English literature and children. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Most obese children have exogenous obesity characterized by a growth rate for height above the 50th percentile, normal intelligence, normal genitalia, and lack of historical or physical evidence of an endocrine abnormality or a congenital syndrome. Obese children are at risk for dyslipidemia, hypertension, diabetes mellitus, non-alcoholic fatty liver disease, obstructive sleep apnea, psychosocial disturbances, impaired quality of life, and shorter life expectancy. The multitude of serious comorbidities necessitates effective treatment modalities. Dietary modification, therapeutic exercise, and behavioral modification are the fundamentals of treatment. Pharmacotherapy and/or bariatric surgery should be considered for obese individuals who do not respond to the above measures and suffer from a serious comorbid condition.

CONCLUSION

Childhood obesity, once established, is often refractory to treatment. Most treatment programs lead to a brief period of weight loss, followed by rapid re-accumulation of the lost weight after the termination of therapy. As such, preventive activity is the key to solving the problem of childhood obesity. Childhood obesity can be prevented by promoting a healthy diet, regular physical activity, and lifestyle modification. Parents should be encouraged to get involved in school and community programs that improve their children's nutritional status and physical activity.

Factors Affecting Dyslipidemia among Korean Adolescents: An Analysis Using the 8th Korea National Health and Nutrition Examination Survey (2021)

A high prevalence of dyslipidemia has recently been shown not only in adults, but also in adolescents. When occurring in adolescence, dyslipidemia is a risk factor for cardiovascular disease in adulthood. This study aimed to identify significant factors affecting dyslipidemia in South Korean adolescents. We used data from the third year of the 8th Korea National Health and Nutrition Examination Survey (KNHANES VIII-3) on 381 Korean adolescents aged 12-18 years. The data were analyzed using frequency analysis, descriptive statistics, the Rao-Scott χ test, the t-test, and univariate and multivariate logistic regression using complex sample analysis. On a weighted population basis, 28.1% of the adolescents among the participants were identified as the group with dyslipidemia. Obesity, waist circumference, serum uric acid, and alanine aminotransferase (ALT) were significantly related to the prevalence of dyslipidemia. Physical activity 4-7 days a week was related to a decrease in the prevalence of dyslipidemia only in male adolescents. The results of this study can be used as evidence for the risk assessment of adolescent dyslipidemia and the establishment of systematic health management guidelines according to risk factors for the prevention of adolescent dyslipidemia.

Examining Shared Pathways for Eating Disorders and Obesity in a Community Sample of Adolescents: The REAL Study

Several psychosocial models have been proposed to explain the etiology of eating disorders (EDs) and obesity separately despite research suggesting they should be conceptualized within a shared theoretical framework. The objective of the current study was to test an integrated comprehensive model consisting of a host of common risk and protective factors (socio-environmental, psychological, and behavioral) expected to explain both eating and weight disorders simultaneously in a large school-based sample of adolescents. Data were collected from 3,043 youth (60% female, 14.00 ± 1.61) from 41 schools in the Ottawa region, Canada. Working with interested school staff, validated self-report scales in the form of a questionnaire booklet were administered to participating students to assess several understood risk and protective factors common to both eating disorders and obesity. Anthropometric measurements of weight and height were taken at the end of the questionnaire administration period by trained research staff. Structural equation modeling with cross-validation was used to test the hypothesized model. Findings demonstrated that dysregulated eating was associated with both eating disorder and weight status with diet culture and emotion dysregulation directly associated with some of these disordered eating patterns. It equally pointed to how lifestyle made up of high sedentary behaviors, low vigorous exercise and varied eating patterns contributed to both emotion dysregulation and poor body image which subsequently affected eating issues and weight status simultaneously, signaling the complex interplay of psychosocial factors that underlie these concerns. This study provides evidence for an integrated psychosocial model consisting of socio-environmental, psychological, and behavioral factors may best explain the complex interplay of risk and protective factors influencing eating disorders and obesity. It equally highlights understanding the direct and indirect effects of some of the most salient risk factors involved in eating and weight-related concerns, including the strong effects of diet culture and stressors such as weight-based teasing, providing interventionalists evidence of important risk factors to consider targeting in eating disorder and weight-based prevention efforts.

The "Adipo-Cerebral" Dialogue in Childhood Obesity: Focus on Growth and Puberty. Physiopathological and Nutritional Aspects

Overweight and obesity in children and adolescents are overwhelming problems in western countries. Adipocytes, far from being only fat deposits, are capable of endocrine functions, and the endocrine activity of adipose tissue, resumable in adipokines production, seems to be a key modulator of central nervous system function, suggesting the existence of an “adipo-cerebral axis.” This connection exerts a key role in children growth and puberty development, and it is exemplified by the leptin–kisspeptin interaction. The aim of this review was to describe recent advances in the knowledge of adipose tissue endocrine functions and their relations with nutrition and growth. The peculiarities of major adipokines are briefly summarized in the first paragraph; leptin and its interaction with kisspeptin are focused on in the second paragraph; the third paragraph deals with the regulation of the GH-IGF axis, with a special focus on the model represented by growth hormone deficiency (GHD); finally, old and new nutritional aspects are described in the last paragraph.

Insulin-like growth factor-II in adipocyte regulation: depot-specific actions suggest a potential role limiting excess visceral adiposity

The IGF system has an important role in growth and development. IGF-II is a recognized fetal growth promoter. However, its physiological postnatal role remains uncertain, although it is maintained in the circulation at a substantially high level throughout life. IGF-II has been strongly linked to obesity in genetic studies, and more recent evidence suggests a metabolic role. We examined fat depot differences in IGF-II's action on differentiation and metabolism. We speculate a specific effect on visceral adipocytes in relation to the differential distribution of insulin receptors between visceral and subcutaneous fat depots. We used a previously established adipocyte, cell culture system of matched pairs of visceral and subcutaneous fat biopsies from 20 normal weight children undergoing routine surgery for nonmalignant, nonseptic conditions. Preadipocytes were differentiated for 14 days in the presence or absence of IGF-II. Oil Red O staining, Western blotting, and reverse transcription polymerase chain reaction techniques were employed to assess levels of adipogenesis markers and levels of the insulin receptor and insulin receptor isoforms. Our data indicate that IGF-II promotes preadipocyte differentiation in subcutaneous preadipocytes but showed a protective, opposing effect restricting visceral preadipocyte differentiation, confirmed by reductions in the differentiation markers peroxisome proliferator-activated receptor gamma and adiponectin and in triglyceride staining. Additionally, IGF-II reduced mRNA expression of the insulin receptor in adipocytes and downregulated insulin receptor isoform A and glucose transporter 4 abundance and corresponding glucose uptake in visceral adipocytes. In conclusion, IGF-II is a regulator of preadipocyte differentiation and metabolism by acting as a differential modulator of fat accumulation favoring less visceral fat deposition in children.

Perception and practice of breastfeeding in public in an urban community in Accra, Ghana

Background

Reported stigmatization and confrontation (verbal and aggressive), of women when breastfeeding in public spaces constitutes a barrier to the recommendation to breastfeed infants on demand. While such stigma of breastfeeding in public has been reported more commonly in Western country media, there is no documented evidence of this stigma in developing country settings. The current study describes community perception and experience of breastfeeding in public in Accra, Ghana. A secondary objective is to explore factors associated with breastfeeding in public.

Methods

A mixed methods design comprising a survey (n = 300), five Focus Group Discussions (FGD) with lactating women (n = 50), and nine In-Depth Interviews (IDI) with adult males (n = 5) and female health workers (n = 4) were also conducted. All data were collected between May and June, 2016 in the Ayawaso-West Sub-Metropolis, Accra. Data on sociodemographic characteristics; obstetric and breastfeeding history; and also perception, experience, and practice of breastfeeding in public, were collected. FGDs and IDI data were triangulated with survey data and presented using descriptive and analytical statistics and content analysis.

Results

Majority of the survey respondents (92%) reported ever practicing breastfeeding in public. However, some reported feeling uncomfortable (52%), embarrassed (27%), or stigmatized (15%). Nevertheless, 72% of respondents felt they should be able to breastfeed anywhere. Almost all respondents (81%) reported covering their breasts when breastfeeding in public, and 70% felt private places should be used when they breastfed in public. Women in FGDs and IDI mentioned that they bottle feed their children in public places as a way to overcome the challenges of breastfeeding in public. Otherwise, they breastfeed in public because their children need to feed. Women were more likely to breastfeed in public if they reported support from a spouse (OR 3.99, 95% CI 1.50, 10.57) or other family members (OR 3.27, 95% CI 1.31, 8.18).

Conclusions

Although women reported discomfort associated with breastfeeding in public, the practice is common. Awareness creation is needed to empower women to comfortably breastfeed and to sustain societal support of breastfeeding in public.

Childhood and adolescent obesity definitions as related to BMI, evaluation and management options

In North America, 30% of children are overweight or obese. Child obesity is a precursor to adult health risks. Diagnosis of childhood obesity is difficult. The best measurement is BMI percentile charts. Obesity in children and adolescents can be treated by diet and activity changes. Family involvement in healthy lifestyle changes is best for weight loss and prevention.

Total body fat, abdominal fat, body fat distribution and surrogate markers for health related to adipocyte fatty acid-binding protein (FABP4) in children

BACKGROUND

The aim of the study was to assess possible relationships between adipocyte fatty acid-binding protein (FABP4) and total body fat (TBF), abdominal fat, body fat distribution, aerobic fitness, blood pressure, cardiac dimensions and the increase in body fat over 2 years in a community sample of children.

METHODS

A cross-sectional study was used in a community sample of 170 (92 boys and 78 girls) children aged 8-11 years. TBF and abdominal fat (AFM) were measured by dual-energy X-ray absorptiometry (DXA). TBF was also expressed as percentage of total body mass (BF%), and body fat distribution was calculated as AFM/TBF. Maximal oxygen uptake (VO2PEAK) was assessed by indirect calorimetry during a maximal exercise test and scaled to body mass. Systolic and diastolic blood pressure (SBP and DBP) and pulse pressure (PP) were measured. Echocardiography was performed. Left atrial (LA) size was measured, and left ventricular mass (LVM) was calculated. A follow-up DXA scan was available in 152 children (84 boys and 68 girls). Frozen serum samples were analyzed for FABP4.

RESULTS

Partial correlations, with adjustment for sex, between FABP4 vs. ln TBF, ln BF%, ln AFM, AFM/TBF and VO2PEAK were (r=0.69, 0.68, 0.69, 0.49 and -0.39, p<0.05 for all). Moreover, SBP, PP, LVM and LA were also weakly correlated with FABP4 (r=0.23, 0.22, 0.28 and 0.21, p<0.05 for all). Correlations between FABP4 vs. increase in TBF and AFM over 2 years were 0.29 and 0.26, p<0.05, for both. (Increase in percent body fat or change in fat distribution were not correlated.) Conclusions: Findings from this community-based cohort of young children show that increased body fat and abdominal fat, more abdominal body fat distribution, low fitness, more LVM and increased LA, increased SBP and PP were all associated with increased levels of FABP4. Increase in TBF and abdominal fat over 2 years were also associated with increased levels of FABP4.

Accuracy of rapid sequence intubation medication dosing in obese patients intubated in the ED

OBJECTIVE

There are limited data regarding appropriateness of sedative and paralytic dosing of obese patients undergoing rapid sequence intubation (RSI) in the emergency department. The goal of this study was to compare rates of appropriate succinylcholine and etomidate doses in obese and nonobese patients.

METHODS

Retrospective review using a database of endotracheally intubated patients using RSI in an urban, tertiary care academic emergency department, from November 2009 to June 2011. Dosing for succinylcholine and etomidate was calculated as milligrams per kilogram of total body weight (TBW) for each patient, defining appropriate dosing as succinylcholine 1-1.5 mg/kg TBW and etomidate 0.2-0.4 mg/kg TBW. Logistic regression analysis was used to estimate the association between appropriate dosing and World Health Organization body mass index classification.

RESULTS

A total of 440 patients were included in the study, 311 (70.7%) classified as nonobese and 129 (29.3%) as obese. two hundred thirty-three (56%) received an inappropriate succinylcholine dose and 107 (24%) received an inappropriate etomidate dose. Obese patients were more likely to be underdosed with succinylcholine (odds ratio [OR], 63.7; 95% confidence interval [CI], 17.8-228.1) and etomidate (OR, 178.3; 95% CI, 37.6-844.7). Nonobese patients were more likely to be overdosed with succinylcholine (OR, 62.5; 95% CI, 17.9-250) and etomidate (OR, 166.7; 95% CI, 37.0-1000).

CONCLUSION

Obese patients were more likely to be underdosed during RSI compared with nonobese patients, whereas nonobese patients were more likely to be overdosed with RSI medications. Most obese and nonobese patients were inappropriately dosed with RSI medications, suggesting that physicians are not dosing these medications based on weight.

Ultrasound measurement of pediatric visceral fat thickness: correlations with metabolic and liver profiles

PURPOSE

Abdominal obesity is a fundamental factor underlying the development of metabolic syndrome. Because of radiation exposure and cost, computed tomography or dual-energy X-ray absorptiometry to evaluate abdominal adiposity are not appropriate in children. Authors evaluated whether ultrasound results could be an indicator of insulin resistance and nonalcoholic fatty liver disease (NAFLD).

METHODS

We enrolled 73 subjects (aged 6-16 years) who were evaluated abdominal adiposity by ultrasound. Subcutaneous fat thickness was defined as the measurement from the skin-fat interface to the linea alba, and visceral fat thickness (VFT) was defined as the thickness from the linea alba to the aorta. Anthropometric and biochemical metabolic parameters were also collected and compared. The subjects who met 2 criteria, radiologic confirmed fatty liver and alanine aminotransferase >40, were diagnosed with NAFLD.

RESULTS

There was a strong positive correlation between VFT and obesity. VFT was highly correlated with the homeostasis model assessment for insulin resistance score (r=0.403, P<0.001). The area under the curve for VFT as a predictor of NAFLD was 0.875 (95% confidence interval [CI], 0.787-0.964). VFT of 34.3 mm was found to be the discriminating cutoff for NAFLD (sensitivity, 84.6%; specificity, 71.2%, respectively).

CONCLUSION

Ultrasound could be useful in measuring VFT and assessing abdominal adiposity in children. Moreover, increased VFT might be an appropriate prognostic factor for insulin resistance and NAFLD.

Exercise training at the intensity of maximal fat oxidation in obese boys

The objectives of this study were to explore the effects of 10 weeks of exercise training at the intensity of maximal fat oxidation rate (FATmax) on body composition, cardiovascular fitness, and functional capacity in 8- to 10-year-old obese boys. This is a school-based interventional study. Twenty-six obese boys and 20 lean boys were randomly allocated into the exercise and control groups. Measurements of body composition, FATmax through gas analyses, predicted maximal oxygen uptake, and functional capacity (run, jump, abdominal muscle function, and body flexibility) were conducted at baseline and at the end of experiments. Two exercise groups participated in 10 weeks of supervised exercise training at individualized FATmax intensities, for 1 h per day and 5 days per week. FATmax training decreased body mass (-1.0 kg, p < 0.05), body mass index (-1.2 kg/m(2), p < 0.01), fat mass (-1.2 kg, p < 0.01), and abdominal fat (-0.13 kg, p < 0.01) of the trained obese boys. Their cardiovascular fitness (p < 0.05) and body flexibility (p < 0.05) were also improved after training. The lean boys showed improvements in cardiovascular fitness after training (p < 0.05). FATmax training increased the FATmax in obese boys from 0.35 ± 0.12 g/min to 0.38 ± 0.13 g/min, but this change was not statistically significant. In addition, there was no change in daily energy intake for all participants before and after the experimental period. Results of this study suggest that FATmax is an effective exercise training intensity for the treatment of childhood obesity.

Gestational weight gain and the risk of offspring obesity at 10 and 16 years: a prospective cohort study in low-income women

OBJECTIVE

To study the association between gestational weight gain (GWG) and offspring obesity risk at ages chosen to approximate prepuberty (10 years) and postpuberty (16 years).

DESIGN

Prospective pregnancy cohort.

SETTING

Pittsburgh, PA, USA.

SAMPLE

Low-income pregnant women (n = 514) receiving prenatal care at an obstetric residency clinic and their singleton offspring.

METHODS

Gestational weight gain was classified based on maternal GWG-for-gestational-age Z-score charts and was modelled using flexible spline terms in modified multivariable Poisson regression models.

MAIN OUTCOME MEASURES

Obesity at 10 or 16 years, defined as body mass index (BMI) Z-scores ≥95th centile of the 2000 CDC references, based on measured height and weight.

RESULTS

The prevalence of offspring obesity was 20% at 10 years and 22% at 16 years. In the overall sample, the risk of offspring obesity at 10 and 16 years increased when GWG exceeded a GWG Z-score of 0 SD (equivalent to 30 kg at 40 weeks); but for gains below a Z-score of 0 SD there was no relationship with child obesity risk. The association between GWG and offspring obesity varied by prepregnancy BMI. Among mothers with a pregravid BMI <25 kg/m(2) , the risk of offspring obesity increased when GWG Z-score exceeded 0 SD, yet among overweight women (BMI ≥25 kg/m(2) ), there was no association between GWG Z-scores and offspring obesity risk.

CONCLUSIONS

Among lean women, higher GWG may have lasting effects on offspring obesity risk.

Childhood Obesity: Causes, Consequences, and Management

One-third of North American children are overweight or obese. Pathologic obesity accounts for only a small percentage of these cases. The vast majority are the result of a complex interaction of genetic and hormonal, nutritional, physical activity, and physical and social environmental factors. Obesity increases the risk for various cardiometabolic, pulmonary, and psychosocial complications for children, which often continues into adulthood. Multidisciplinary care, focusing on family-centered behavior change, is an evidence-based, essential part of the treatment, along with pharmacologic and surgical options for more complex cases. Prevention and early intervention strategies are key to reversing the obesity epidemic.

Step-count guidelines referenced on 60-minutes of moderate/vigorous physical activity

The purpose of this study was to establish step-count guidelines for sixth-grade students and assess the ability of step-counts to discriminate between students achieving and not achieving 60-minutes of moderate to vigorous physical activity daily. 201 sixth-grade students completed the study. They wore a pedometer and an accelerometer at the waist level for one full day. ROC curves were used to establish step-count guidelines and determine the diagnostic accuracy of step-counts. Sixth grade students need 12,118 steps/day to reach adequate daily levels of physical activity. The AUC indicated good diagnostic accuracy of step-counts. Suggested step-count guidelines can be a useful tool for identifying children who need to increase their daily levels of physical activity. The step-count cutoff proposed in this study is adequate for discriminating between sixth grade students reaching and not reaching recommended levels of physical activity.

Assessing child care providers' knowledge and attitudes regarding support of breastfeeding in a region with low breastfeeding prevalence

BACKGROUND

Working mothers who place their infants into out-of-home child care face many challenges to sustaining breastfeeding. Child care providers, who are in frequent close contact with young families, may be potential resources for promoting breastfeeding.

OBJECTIVES

This study focused on identifying child care providers' attitudes toward and knowledge about breastfeeding as well as providers' perceptions about strategies to increase breastfeeding rates among mothers of infants in child care centers.

METHODS

Seventy-five providers from 11 child care centers in the Baton Rouge, Louisiana, area were surveyed using paper and pencil questionnaires. Self-reported demographics, attitudes, knowledge, and perceptions about breastfeeding were collected.

RESULTS

Responses demonstrated a generally positive attitude toward breastfeeding among child care providers but a knowledge deficit in terms of the health impacts and proper handling of breast milk. A minority of providers reported that their center's staff currently receives breastfeeding education, but most providers believed that measures to promote the use of breast milk in their center should target parents rather than the center staff.

CONCLUSION

Child care providers need resources about the benefits of human milk, proper handling of expressed milk, and ways to make centers more breastfeeding friendly. Many providers feel ineffective in supporting breastfeeding and are unaware of the role they may play in mothers' infant feeding decisions. Though child care providers do not appear to believe they can influence parents' decisions about breastfeeding, educating and empowering them could play an important role in increasing breastfeeding rates.

Prevention of metabolic disorders and reproductive performance deficits by the blockade of Angiotensin II AT1 receptor in female rats fed with cafeteria diet

Besides the well-known detrimental effects of obesity on cardiovascular and metabolic function, studies have shown that obesity is also associated with impaired reproductive function in women. Alterations in Angiotensin II (Ang II) have been associated with obesity and with female reproduction. The aim of the present study was to evaluate the reproductive and metabolic effects of Ang II AT1 receptor blockade with losartan in an animal model of obesity, in which female rats were offered a palatable, high calorie diet from weaning to adulthood. Sexual behavior, ovulation rates and preovulatory levels of the hormones estradiol, progesterone, LH and prolactin were analyzed. Retroperitoneal and perigonadal fat pads, triglycerides and cholesterol (total, HDL and LDL), and insulin resistance were analyzed. Losartan prevented increases in fat pad storage, insulin resistance, as well as triglycerides and LDL levels induced by cafeteria diet intake. Losartan also prevented ovulatory deficits and loss of preovulatory surges of progesterone and LH in cafeteria-fed female rats probably through the prevention of the increase in body weight and body fat. No alterations in sexual behavior were observed. These results suggest, for the first time, that Ang II contributes to the development of the deleterious effects of obesity on preovulatory surges of LH and progesterone and on the reduction of ovulation in obese female rats.

Cardiovascular Risk in Children and Adolescents with Type 1 and Type 2 Diabetes Mellitus

Rising rates of both type 1 and type 2 diabetes mellitus in children have led to increased concern regarding cardiovascular disease (CVD) risk during childhood. Diabetic children face prolonged exposure to hyperglycemia, and have increased risk of both microvascular and macrovascular disease. These circumstances may result in a generation of young adults presenting with cardiovascular outcomes, a tremendous personal and public health toll. In this article, we review CVD risk in type 1 and type 2 diabetes, discuss aspects of pathophysiology, and review current methods of CVD risk assessment. We also identify crucial areas in need of future research in order to devise effective prevention and treatment of CVD risk in children.

Body fat, abdominal fat and body fat distribution related to cardiovascular risk factors in prepubertal children

AIM

We analysed whether total body fat (TBF), abdominal fat and body fat distribution are associated with higher composite risk factor scores for cardiovascular disease (CVD) in young children.

METHODS

Cross-sectional study of 238 children aged 8-11 years. TBF and abdominal fat mass (AFM) were measured by Dual-Energy X-Ray Absorptiometry. TBF was expressed as a percentage of body weight (BF%). Body fat distribution was calculated as AFM/TBF. Maximal oxygen uptake (VO(2PEAK) ), systolic and diastolic blood pressure (SBP, DBP), and resting heart rate (RHR) were measured. Mean arterial pressure (MAP) and pulse pressure (PP) were calculated. Left atrial diameter (LA) was measured, and left ventricular mass (LVM) and relative wall thickness (RWT) were calculated. Z-scores were calculated. Sum of z-scores for SBP, DBP, MAP, PP, RHR, LVM, LA, RWT and -VO(2PEAK) was calculated in boys and girls, separately, and used as composite risk factor score.

RESULTS

Pearson correlations between ln BF%, ln AFM and AFM/TBF versus composite risk factor score for boys were r = 0.56, r = 0.59 and r = 0.48, all p < 0.001, and for girls r = 0.45, r = 0.50 and r = 0.48, all p < 0.001.

CONCLUSION

Total body fat, abdominal fat and body fat distribution were all associated with higher composite risk factor scores for CVD in young children.

Body fat, abdominal fat, and body fat distribution is related to left atrial diameter in young children

In adults, the size of the left atria (LA) has important prognostic information. In obese adults, adolescents and children enlargement of LA have been observed. This has not been investigated on a population-based level in young children. We therefore assessed if total body fat mass (TBF), abdominal fat, and body fat distribution were related to LA diameter. Cross-sectional study of 244 children (boys = 137 and girls n = 107) aged 8-11 years, recruited from an urban population-based cohort. Dual-energy X-ray absorptiometry (DXA) measured total lean body mass, TBF, and abdominal fat mass (AFM). Body fat was also calculated as a percentage of body mass (BF%). Body fat distribution (AFM/TBF) was calculated. Echocardiography was performed with two-dimensional guided M-mode. LA diameter was measured and left ventricular mass (LVM) was calculated. Systolic blood pressure and diastolic blood pressure were measured and maturity assessed according to Tanner. There were significant (P < 0.05) univariate correlations for all children between TBF (r = 0.40), BF% (r = 0.32), AFM (r = 0.41), and AFM/TBF (r = 0.41) vs. LA diameter. Multiple regression analyses with the inclusion of possible confounders such as lean body mass, blood pressure, gender, age, and Tanner stage revealed that TBF, AFM, and AFM/TBF were all independently related to LA diameter. Differences in the different body fat measurements explained 6-9% of the variance in LA size. These results demonstrated that both total body fat, AFM, and body fat distribution are already at a young age negatively and independently associated to LA diameter.

High physiological omega-3 Fatty Acid supplementation affects muscle Fatty Acid composition and glucose and insulin homeostasis in obese adolescents

Obese adolescents have high concentrations of saturated fatty acids and low omega-3 long-chain polyunsaturated fatty acids (LCUFAs) in plasma phospholipids. We aimed to investigate effects of omega-3 LCPUFA supplementation to obese adolescents on skeletal muscle lipids and glucose and insulin homeostasis. Twenty-five obese adolescents (14–17 years old, 14 females) completed a randomized double-blind crossover study supplying capsules containing either 1.2 g omega-3 LCPUFAs or placebo, for 3 months each with a six-week washout period. Fasting blood glucose, insulin, leptin, adiponectin, and lipids were measured. Intravenous glucose tolerance test (IVGTT) and euglycemic-hyperinsulinemic clamp were performed, and skeletal muscle biopsies were obtained at the end of each period. The concentrations of EPA, DHA, and total omega-3 PUFA in muscle phospholipids increased in both sexes. In the females, omega-3 LCPUFA supplementation improved glucose tolerance by 39% (P = 0.04) and restored insulin concentration by 34% (P = 0.02) during IVGTT. Insulin sensitivity improved 17% (P = 0.07). In males, none of these parameters was influenced by omega-3 supplementation. Thus, three months of supplementation of omega-3 LCPUFA improved glucose and insulin homeostasis in obese girls without influencing body weight.

Aerobic fitness in prepubertal children according to level of body fat

AIM

The purpose of this study was to investigate the relationship between maximum oxygen uptake (VO(2PEAK) ) and body fat in young children on a population-based level.

METHODS

Participants were 586 children (311 boys and 275 girls) aged 6.8±0.4 years, recruited from a population-based cohort. VO(2PEAK) was measured by indirect calorimetry during a maximal exercise test. Percent body fat (BF%) was estimated from skinfold measurements.

RESULTS

  Significant relationships existed between BF% and absolute values of VO(2PEAK) (mL/min), VO(2PEAK) scaled by body weight (mL/min/kg) and VO(2PEAK) by allometric scaling (mL/min/kg(0.71) ), whereas no relationships were detected for VO(2PEAK) scaled to fat-free mass (FFM) (mL/min/FFM). Person correlation coefficients for boys were 0.26, -0.38, -0.19 and -0.01 NS and for girls 0.33, -0.42, -0.21 and -0.03 NS, respectively. Significant differences in VO(2PEAK) existed between different quartiles of BF%, with the exception when VO(2PEAK) was scaled to FFM.

CONCLUSION

 Our findings document the coexistence of two known risk factors for disease at a young age on a population-base and confirms that VO(2PEAK) was scaled to FFM represents a body fat independent way of expressing fitness.

Associations of the growth hormone receptor (GHR) gene polymorphisms with adiposity and IGF-I activity in adolescents

OBJECTIVE

To explore the genetic effect of the GH receptor (GHR) on obesity and related metabolic parameters in Hong Kong Chinese adolescents.

CONTEXT

Obesity is a growing global epidemic. Increasing evidence suggests that the GH-IGF-I axis plays an important role in regulating adiposity and insulin sensitivity.

DESIGN

We examined the associations of genetic variants of GHR with serum IGF-I and IGFBP-3 levels as well as obesity-related metabolic traits in Hong Kong Chinese adolescents.

PATIENTS

Nine hundred and eighty-one randomly selected Hong Kong Chinese adolescents from 14 schools.

MEASUREMENTS

We genotyped 17 single nucleotide polymorphisms (SNP) at GHR and measured serum IGF-I and IGFBP-3 levels as well as obesity-related metabolic traits including fasting plasma glucose, insulin and lipid levels.

RESULTS

There were significant associations between rs4410646 and the body composition (P = 0.0044) and blood pressure factor scores (P = 0.00017). Carriers of the CC genotype had lower body mass index, percentage body fat, waist and hip circumferences than AC and AA genotype carriers (P = 0.00030-0.0094). There was also association between rs7703713 and the IGF-I activity factor score (P = 0.0033). The GA and AA carriers of rs7703713 had higher serum IGF-I, higher serum IGFBP-3 and higher IGF-I/IGFBP-3 molar ratio (P = 0.00069-0.025). Haplotype analysis did not increase the significance of associations.

CONCLUSION

Our results support the role of GHR gene polymorphisms in modulating adiposity and IGF-I activity in adolescents. Examination of interactions of these SNPs with lifestyle, environmental and perinatal factors may provide further insights into their long-term effects on obesity and metabolic risks.

Objectively measured physical activity and body mass index in preschool children

Aim. To examine the association between objectively measured physical activity (PA) and body mass index (BMI) in preschool children. Methods. The study comprised 281 children (55.9% boys) aged from 4 to 6 years. PA was measured by accelerometer. Children were categorized as non-overweight (NOW) and overweight/obese (OW) according to the sex-adjusted BMI z-score (<1 and >/=1, resp.). Results. Total and moderate intensity PA were not associated with BMI. We observed that a higher proportion of OW children were classified as low-vigorous PA compared to their NOW peers (43.9 versus 32.1%, resp., P > .05). Logistic regression analysis showed that children with low-vigorous PA had higher odds ratio (OR) to be classified as OW compared to those with high-vigorous PA (OR = 4.4; 95% CI: 1.4-13.4; P = .008) after adjusting for BMI at first and second years of life and other potential confounders. Conclusion. The data suggests that vigorous PA may play a key role in the obesity development already at pre-school age.

Objectively measured physical activity and body mass index in preschool children

Aim. To examine the association between objectively measured physical activity (PA) and body mass index (BMI) in preschool children. Methods. The study comprised 281 children (55.9% boys) aged from 4 to 6 years. PA was measured by accelerometer. Children were categorized as non-overweight (NOW) and overweight/obese (OW) according to the sex-adjusted BMI z-score (<1 and >/=1, resp.). Results. Total and moderate intensity PA were not associated with BMI. We observed that a higher proportion of OW children were classified as low-vigorous PA compared to their NOW peers (43.9 versus 32.1%, resp., P > .05). Logistic regression analysis showed that children with low-vigorous PA had higher odds ratio (OR) to be classified as OW compared to those with high-vigorous PA (OR = 4.4; 95% CI: 1.4-13.4; P = .008) after adjusting for BMI at first and second years of life and other potential confounders. Conclusion. The data suggests that vigorous PA may play a key role in the obesity development already at pre-school age.

Role of maternal vitamin B12 on the metabolic health of the offspring: a contributor to the diabetes epidemic?

There is increasing evidence, in humans and other mammals, that periconceptional nutritional status influences health in adulthood. This is called ‘foetal programming’ and is likely to be mediated through DNA methylation. Micronutrients, especially B vitamins such as folic acid and vitamin B12 play crucial roles in providing methyl groups for such reactions. This is called epigenetic regulation and may provide some clues to the epidemic of type 2 diabetes and cardiovascular disease. Evidence from mandatory folic acid fortification studies suggests that in the presence of adequate folic acid, neural tube defects due to B12 deficiency have tripled. Such ‘imbalance of high folic acid and low vitamin B12’ in the elderly causes cognitive impairment. A longitudinal study of young women in India showed that children born to those with ‘high folic acid and low B12’ had higher adiposity and insulin resistance. In addition to increased levels of folic acid, B12 deficiency is increasing in countries with mandatory folic acid fortification. Studies on the prevalence of vitamin B12 deficiency during pregnancy and in women of childbearing age, plus the effects of B12 supplementation are therefore urgently needed. This article reviews the role of vitamin B12 during pregnancy on the offspring’s metabolic risk.

Subclinical metabolic abnormalities associated with obesity in prepubertal Mexican schoolchildren

Childhood obesity has increased to epidemic levels and is considered a public health problem due to its association with a number of metabolic abnormalities, which are being detected at earlier stages of life. The objective was to evaluate the association between the presence of subclinical metabolic abnormalities (SMA) and obesity in a sample of pre-pubertal Mexican schoolchildren. Children of both sexes and 6 to 13 years old were questioned for signs of puberty, underwent anthropometric measurement and had their Body Mass Index (BMI) calculated. Two groups were formed: those with obesity (case group) and those with normal weight paired by age and chosen randomly (control group). Fasting insulin, glucose and cholesterol were measured. 92 children were included, 46 in each group, mean age 9.9 and 9.5 years old, respectively (p = 0.97). A higher frequency of hyperinsulinism was found in the case group: Fasting insulin > 15 mU/ml, 75% vs. 21% (case group vs. control group, respectively); fasting glucose to insulin ratio < 6, 72% vs. 24%; HOMA IR > 2.7, 83% vs. 14%; and decrease in QUICKI (< 0.3), 80% vs. 19% (p = 0.000). Hypercholesterolemia was 25% vs. 15% (p = 0.22), impaired fasting glucose 28% vs. 8% (p = 0.01), and family history of diabetes mellitus (DM) 35% vs. 9% (OR = 5.6; 95% CI = 1.5-22.2; p = 0.002). In this sample of Mexican schoolchildren, obesity was associated to a higher frequency of SMA, such as hyperinsulinism and impaired fasting glucose, and to a family history of DM.

Hypothalamic regulation of food intake and clinical therapeutic applications

Current estimates suggest that over 1 billion people are overweight and over 300 million people are obese. Weight gain is due to an imbalance between energy expenditure and dietary intake. This review discusses the hypothalamic control of appetite and highlights key developments in research that have furthered our understanding of the complex pathways involved. Nuclei within the hypothalamus integrate peripheral signals such as adiposity and caloric intake to regulate important pathways within the central nervous system controlling food intake and energy expenditure. Firmly established pathways involve the orexigenic NPY/AgRP and the anorexigenic POMC/CART neurons in the arcuate nucleus (ARC) of the hypothalamus. These project from the ARC to other important hypothalamic nuclei, including the paraventricular, dorsomedial, ventromedial and lateral hypothalamic nuclei. In addition there are many projections to and from the brainstem, cortical areas and reward pathways, which modulate food intake.

dup(19)(q12q13.2): array-based genotype-phenotype correlation of a new possibly obesity-related syndrome

Small supernumerary marker chromosomes (sSMCs) derived from the near-centromeric area of chromosome 2 are very rare. In addition, duplications of the 2p11.2-->q11.2 region have displayed considerable variability between patients harboring and lacking clinical findings. Moreover, constitutional duplication of the 19q12-->q13.2 region has previously only been described in two cases and was associated with delay of developmental milestones, corpus callosum anomalies, and obesity. Herein, we present a genotype-phenotype correlation in a patient harboring two sSMCs derived from chromosomes 2 and 14 or 22, respectively. The DNA was studied using G-banding, fluorescence in situ hybridization techniques, and array-based comparative genomic hybridization. A 48,XX,+der(2)del(2)(p11)del(2)(q11.2),+der(14)t(14;19)(q11;q12)del(19)(q13.31) or 48,XX,+der(2)del(2)(p11)del(2)(q11.2),+der(22)t(22;19)(q11;q12)del(19)(q13.31) was detected in the patient. The sSMC 14;19 or 22;19, with its centromere originating from either chromosome 14 or 22, encompassed a 13.56 megabase (Mb) 19q derived region, harboring 263 genes, and the sSMC 2 a 2.71 Mb region including 29 genes. The patient had symptoms including a ventral septal defect, bilateral grade IV urinary reflux, corpus callosum agenesis, microphthalmia, and obesity. The 19q segment contained the genes AKT2, CEACAM1, CEBPA, LIPE, and TGFB1 which are involved in adipose tissue homeostasis and insulin resistance, and could potentially contribute to the obese phenotype observed. Array-based genetic characterization and long-term clinical evaluation with attention toward weight gain in patients with chromosome 19q duplications might in the future lead to the description of a obesity-associated genetic syndrome, something that could have implications in management and treatment of patients carrying a dup(19)(q12q13.2). Whether the der(2)(p11q11.2) contributes to the phenotype remains inconclusive.

Associations of birthweight and gestational age with reproductive and metabolic phenotypes in women with polycystic ovarian syndrome and their first-degree relatives

CONTEXT

Low birthweight has been associated with metabolic and reproductive abnormalities in adults.

OBJECTIVE

The aim of the study was to examine the relationship between birthweight and gestational age and its association with reproductive and metabolic phenotypes in women with PCOS and their first-degree relatives.

DESIGN AND SETTING

We conducted a family-based study of PCOS at an academic health center.

PATIENTS OR OTHER PARTICIPANTS

A total of 1038 individuals (845 females and 193 males) from the cohort and 168 controls participated in the study.

MAIN OUTCOME MEASURES

The association between birthweight and familial phenotype was measured.

RESULTS

Self-reported and actual birthweight were highly correlated [Spearman correlation coefficient (r) = 0.81; 95% CI, 0.66, 0.89; P = 0.001) and concordant (concordance correlation coefficient = 0.86; 95% lower limit = 0.78). We noted that birthweight for both genders in PCOS families and controls fell within the 10th and 90th percentiles for gestational age based on U.S. population norms. The 50th percentiles for a gestational age of 40 wk were very similar (3409 g in PCOS, 3455 g for controls, and 3495 g for the United States). There were no significant associations between phenotype and birthweight in PCOS probands. Furthermore, there were not any significant relationships between phenotype and birthweight in female or male family members of the PCOS probands.

CONCLUSIONS

Birthweight in PCOS families mirrors control and U.S. population data, even corrected for gestational age, and has no substantive association with reproductive and metabolic abnormalities in women with PCOS, their female relatives, or their male relatives.

Effects of meals high in carbohydrate, protein, and fat on ghrelin and peptide YY secretion in prepubertal children

CONTEXT

Ghrelin and peptide YY (PYY) are two hormones produced by the gastrointestinal tract that have effects on appetite. However, little is known about their secretion in response to meals high in individual macronutrients in prepubertal children.

OBJECTIVE

We sought to understand how meals high in carbohydrate, protein, and fat affect serum concentrations of total ghrelin and total PYY, hypothesizing that these macronutrients would exert differential effects on their secretion.

DESIGN AND SETTING

This was a cross-sectional study at one tertiary care center.

SUBJECTS

Subjects were 7- to 11-yr-old healthy normal-weight (NW) and obese (OB) volunteers recruited from local advertisements.

INTERVENTIONS

After an overnight fast, the subjects were given a breakfast high in carbohydrate, protein, or fat at 0800 h. Blood samples for total ghrelin and total PYY were taken at baseline, 30 min, and hourly from 0900 to 1200 h.

MAIN OUTCOME MEASURE

We assessed postprandial ghrelin suppression and PYY elevation, as well as changes in reported hunger and satiety, after the three test meals.

RESULTS

After the high-protein meal, ghrelin declined gradually in both groups over the study period without subsequent increase, whereas ghrelin suppressed more rapidly to a nadir at 60 min after the high-carbohydrate meal in both NW and OB children, followed by rebound in ghrelin levels. Similarly, after the high-protein meal, PYY concentrations increased steadily over the course of the morning in both groups without decline, whereas PYY levels peaked 30 min after the high-carbohydrate meal in both NW and OB subjects with significant decline thereafter. Ghrelin and PYY responses to the high-fat meal were somewhat intermediate between that observed with high carbohydrate and high protein. The OB children reported higher hunger and lower satiety after the high-carbohydrate meal compared to the NW subjects, whereas appetite ratings were similar between the groups after the high-protein and high-fat meals. Additionally, within the OB group, area under the curve (AUC) analysis revealed significantly greater PYY response, as well as lower AUC hunger and higher AUC satiety, to the high-protein meal than the high-carbohydrate and high-fat meals.

CONCLUSIONS

The patterns of secretion of ghrelin and PYY in our study of prepubertal children suggest that they may play a role in the effectiveness of high-protein/low-carbohydrate diets in promoting weight loss.

Obesity in children is associated with increased health care use

BACKGROUND

The prevalence of obesity in children has steadily risen during recent years in developed countries. There is increasing data associating this rise in obesity with a rise in morbidity. In adults, data show clear association between obesity and health care use. This study examined the effects of obesity on health care use in children of several age groups.

METHODS

The population consisted of children from Tirat HaCarmel, Israel, who are patients at the town's Clalit Health Care, Child Care Center (CCC). All obese children (body mass index [BMI] > 95%) participated and were matched by age and gender with nonobese children (BMI < 85%) who served as a control group. Children were further divided into 3 age groups: ages 4 to 7 years, 8 to 11 years, and 12 to 18 years. Health care use was measured by 4 criteria over a 2-year time period: clinic visits, emergency department visits, hospitalizations, and medication use.

RESULTS

Of more than 4000 children treated in the CCC, 363 obese children were matched to 382 control children. Obese children had significantly more clinic visits (4942 vs 4058, P < .001), had more hospitalizations (67 vs 34, P < .001), were hospitalized for longer periods (207 vs 79 days, P < .001), and used significantly more medications (5945 vs 4638, P < .001) than did the control group.

CONCLUSION

This study provides objective clinical evidence that obesity in children is associated with increased health care use. This information has clear implications for both the public health and health insurance sectors and supports the need to invest in efforts to reduce childhood obesity.

Obesity and cholesterol in Japanese, French, and U.S. children

The number of children at risk for overweight/obesity has increased dramatically in the last decade worldwide. This study compares measures of obesity (body mass index [BMI] and body fat percentage) and total cholesterol in 4,013 fourth-grade students from three countries, France, Japan, and the United States. Data were analyzed using t test, chi-square, and analysis of variance to determine differences between groups and by multiple linear regression. All variables differed significantly by group. BMI was highest in U.S. children. Body fat percentage was also highest in U.S. children and lowest in French children. Total cholesterol was highest in French children and lowest in U.S. White children. There were modest but significant associations between BMI and cholesterol in all groups except French children; associations varied by gender. Results indicate there was great variation in measures of obesity and cholesterol by country. The association between obesity and cholesterol may vary by culture, ethnicity, and gender.

Glucagon-like peptide 1 and pancreatic polypeptide responses to feeding in normal weight and overweight children

BACKGROUND

Glucagon-like peptide 1 (GLP-1) and pancreatic polypeptide (PP) are intestinal hormones that are involved in the post-prandial satiety response. We sought to assess meal-related changes in these hormones in young children and determine whether differences exist between normal weight (NW) and overweight (OW) children.

METHODS

Seven to 11-year-old healthy NW (n=20) and OW (n=12) volunteers were given a standardized breakfast and lunch following an overnight fast and had measurements of GLP-1 and PP over 9 hours. We characterized whether GLP-1 and PP changed from the pre-prandial to the post-prandial state and whether the serum levels corresponded to reported appetite.

RESULTS

GLP-1 did not increase after eating, did not decline prior to the next meal, and did not correspond to satiety ratings in either group. PP increased post-prandially in OW children after both breakfast and lunch, but in the NW group PP only increased after breakfast. PP levels did not decline in either group as the next meal approached.

CONCLUSIONS

In our study of school-age children, feeding had little effect on GLP-1 secretion and a variable effect on serum PP levels. Observed differences in the GLP-1 and PP responses between the NW and OW groups do not suggest there is an intrinsic abnormality in their secretion that causes weight gain.

The effect of puberty on insulin resistance in obese children

OBJECTIVE

Insulin resistance (IR) increases during puberty in normal children. IR is the first adverse metabolic event of obesity, and the marker of the metabolic syndrome. We aimed to study the effect of puberty on IR in obese and normal-weight children.

DESIGN

Cross-sectional evaluation of fasting glucose, insulin concentrations, and homeostasis model assessment of IR (HOMA-IR) in obese and control children throughout puberty.

PATIENTS AND METHODS

We recruited 424 obese children (207 pre-pubertal and 217 pubertal divided in Tanner stages 2-3, 4, and 5) and estimated IR using the HOMA-IR index. Data were compared to those obtained in 123 healthy normal-weight children (40 pre-pubertal and 83 pubertal divided in Tanner stages 2-3, 4, and 5).

RESULTS

In the obese children mean HOMA-IR increased progressively across Tanner stages, and was significantly higher in all groups (pre-pubertal and Tanner stages 2-3, 4, and 5) of obese than in control children. HOMA-IR was significantly correlated with BMI.

CONCLUSIONS

HOMA-IR in obese children increases at puberty more than in normal-weight children and does not return to pre-pubertal values at the end of puberty.

Prevalence of obesity among children and/or grandchildren of adult bariatric surgery patients

BACKGROUND

Clinical experience suggests that some adults who undergo bariatric surgery have children who are obese. Childhood obesity is associated with increased morbidity and mortality in later life. This study examined the prevalence of obesity among children and grandchildren (< or =12 years of age) of adult bariatric surgery patients.

METHODS

Patients in a prospective database of morbidly obese patients who underwent bariatric surgery between January 2004 and May 2007 were recruited by phone and in clinic. Patient demographics, body mass index (BMI) at surgery, and survey data were collected. The survey included questions regarding their child/grandchild's body habitus, weight, and height. Child obesity was defined as BMI percentile > or =95. Statistical significance was set at p < 0.05.

RESULTS

One hundred twenty-two patients were enrolled in this study (77% women, mean BMI 49 kg/m(2)). One hundred thirty-four out of 233 children/grandchildren identified had complete data; 41% had a BMI percentile > or =95. Only 29% of these obese children were so identified by the adult respondents. Significantly more biological children/grandchildren were obese than nonbiological (p = 0.013), and significantly more biological children were obese than biological grandchildren (p = 0.027).

CONCLUSIONS

This sample of bariatric surgery patients had a high proportion of obese preteen children/grandchildren. Obesity was most prevalent among biological children (vs. biological grandchildren and nonbiological children). Patients often did not recognize the degree of overweight in their children/grandchildren. Because families of bariatric surgery patients often include obese children, interventions aimed at all family members merit consideration.

Perspectives on pediatric bariatric surgery: identifying barriers to referral

BACKGROUND

Pediatric obesity is a growing problem affecting the health of our youth. We sought to identify the barriers to pediatric bariatric referral at a tertiary referral center.

METHODS

We performed a survey of pediatricians and family practitioners at a single institution to assess their perspectives on pediatric obesity.

RESULTS

A total of 61 physicians completed the survey (response rate 46%). All believed pediatric obesity is a major problem, and 82.0% noted an increase in the incidence during a mean period of 15 years (range 3-25). Of the 61 physicians, 88.5% used nonoperative weight loss techniques, with only 1.8% reporting satisfactory results. However, 42.6% had referred a patient (adult or pediatric) for a bariatric procedure, of whom 84.6% were satisfied with the operative outcomes. Despite the high satisfaction with bariatric procedures, 88.5% would be unlikely or would never refer a child for a bariatric procedure, and 44.3% would be somewhat or very likely to refer an adolescent.

CONCLUSION

Physicians caring for children recognize the growing problem of childhood and adolescent obesity. Despite the poor outcomes with nonoperative methods and the high satisfaction with the outcomes of bariatric procedures, physicians are still reluctant to refer children and adolescents for surgical weight loss procedures.

Hypothalamic regulation of appetite

The prevalence of obesity is steadily rising and has huge health and financial implications for society. Weight gain is due to an imbalance between dietary intake and energy expenditure and research has focused on trying to understand the complex pathways involved in controlling these aspects. This review highlights the key areas of research in the hypothalamic control of appetite. The hypothalamus consists of several nuclei that integrate peripheral signals, such as adiposity and caloric intake, to regulate important pathways within the CNS controlling food intake. The best characterized pathways are the orexigenic neuropeptide Y/Agouti-related protein and the anorexigenic pro-opiomelanocortin/cocaine- and amphetamine-related transcript neurons in the arcuate nucleus of the hypothalamus. These project from the arcuate nucleus to other key hypothalamic nuclei, such as the paraventricular, dorsomedial, ventromedial and lateral hypothalamic nuclei. There are also projections to and from the brainstem, cortical areas and reward pathways, all of which influence food intake. The challenge at present is to understand the complexity of these pathways and try to find ways of modulating them in order to find potential therapeutic targets.

Management approaches for pediatric obesity

Childhood obesity is a worldwide problem that has reached epidemic proportions, resulting in an increased prevalence of premature obesity-related morbidities, and, thus, probable increased health-care costs to treat children. The development of viable approaches to manage this epidemic is crucial. Most experts in the field of childhood obesity agree that the prevention of obesity in children should be the first line of management. Pediatricians must be adept at recognizing children at risk of obesity, calculating and plotting the BMI at all visits, using a change in the BMI to identify excessive weight gain, and monitoring for comorbidities associated with obesity. If obesity is present, the cornerstone of treatment is modification of dietary and exercise habits. Practice-based counseling and community-based programs that support and encourage lifestyle modifications have yielded promising short-term results. Children with severe comorbidities who are unable to achieve lifestyle modifications can be considered for either pharmacologic therapy or surgery, but these options should be considered as a last resort. Early intervention and prevention strategies are the most cost-effective methods of dealing with this issue.