Childhood obesity has become a growing epidemic nationally and worldwide. Obesity is the most common pediatric disease in the majority of the world except for the former Soviet Union and sub-Saharan Africa (Sweeting, 2007) and the most common nutritional disorder in school-age children (Gortmaker, Must, Perrin, Sobol, & Deitz, 1993). Given the magnitude of this problem, the impact on life span development is enormous. Obesity affects the physical and mental well-being of children resulting in substantial life-long repercussions. The causes are multifactorial and differ from child to child. The identification of abnormal developmental weight gain is challenged by limited diagnostic tools and a lack of recognition by parents and practitioners. Nevertheless, significant effort has been devoted to studying methods of managing this newly emerging childhood disease. By addressing the psychological as well as physical aspects of this condition, successful treatment regimens have been developed.
Childhood obesity has been a concern for many years in the United States. According to the Surgeon General, 12.5 million children and adolescence between the ages of 2 and 17 are overweight. This represents 17.1 % of the children within that age range. The National Health and Nutrition Examination Survey (NHANES) project studied childhood obesity by focusing on two separate intervals. The first interval studied was from 1971 to 1974 while the second interval was between 2003 and 2004. From the first time interval to the second there were substantial increases in the prevalence of overweight children within all age groups. The percent of overweight pre-school children (age range from 2 – 5 years old) increased from 5 % to 13.9 % from the first time interval to the second. This increase was from 4 % to 18.8 % in school-age children (age 6 – 11 years old) and from 6.1 % to 17.4 % in adolescents (12 – 19 years old) (Ogden, 2006). African-American and Hispanic children have had the largest increase in childhood obesity out of all other races (Weiss & Kaufman, 2008).
Obesity is defined as the pathological excess of body fat (Sweeting, 2007). It is commonly defined as weighing over 20 % greater than expected body weight and this definition has frequently been applied to both adults and children. According to the Centers for Disease Control and Prevention, overweight children are defined statistically by having a body mass index (BMI) greater than the 95th percentile on the BMI-for-age-growth charts although this does not apply to children under the age of 2. While there are specific definitions for “overweight” and “obese” which will be presented later in this manuscript, authors vary as to how they define these terms in the literature. Therefore, the use of the terms “overweight” and “obese” in this manuscript is based on the primary source definitions.
Clinical Presentation
Childhood obesity has devastating long-term effects on children that extend well into adolescence and adulthood. The most common problem associated with obesity is insulin resistance. This leads to altered glucose metabolism, dyslipidemia, hypertension, type II diabetes mellitus, and long-term vascular problems. Obesity also causes chronic low grade inflammation in the heart creating severe cardiovascular problems (Weiss & Kaufman, 2008). According to the National Health and Nutrition Examination Survey, other complications related to obesity are sleep related issues such as habitual snoring, and obstructive sleep apnea syndrome. These problems make sleeping difficult for children and adolescence which creates difficulties with learning.
Metabolic syndrome is a group of diseases related to obesity that until recently was only considered to effect adults. Due to increases in childhood obesity, studies now indicate that metabolic syndrome can be identified in early childhood (Cruz & Goran, 2004; Weiss & Kaufman, 2008). This syndrome is comprised of obesity, type II diabetes mellitus, cardiovascular disease, dyslipidemia, high blood sugar, and hypertension (Cruz & Goran, 2004; Weiss & Kaufman, 2008). This syndrome is thought to be caused by insulin resistance that is related to the presence of obesity. The prevalence of this syndrome is approximately 30% for those children that fall into the greater than 95th percentile on the BMI-for-age growth charts (Cruz & Goran, 2004).
The physical of effects on the body start early, but continue to have debilitating effects on the body well through out adulthood. Every body system has complications associated with obesity. Cardiovascular disease is one of the most severe and devastating diseases associated with obesity. Gynecologic health is affected by experiencing early menarche, an increased frequency of irregular and anovulary cycles, and earlier menopause. Reproduction rates are decreased with obesity. Free-testoterone levels are decreased in men with obesity while estrogen levels are increased. Gallbladder disease is an issue especially for adult, overweight women. Cancer incidences are increases by obesity. Men have higher risks of developing prostate cancer and colorectal cancer while women are at greater risk for endometrial, post menopausal breast cancer, and colorectal cancer. Osteoarthritis, gout, and acanthosis nigricans, which is darkening of the skin folds on the neck, elbows, and in between fingers and toes, have increased incidences with obesity. Alterations in the liver also occur manifesting as fatty infiltration (Bray, 1998).
While discussing the impact of obesity on children, it is of extreme importance to discuss the psychosocial and psychological effects. The associated stigmata and social acceptability of obesity is extremely damaging to children. Studies have found that obesity affects social relationships, academic achievement, self-esteem, self-worth, and behavior in a negative manner. Obese children are four times more likely to have impaired school function, behavioral problems in school, and miss more days of school than healthy, normal weight children (Schwimmer, Burwinkle, & Varni, 2003; Reilly, 2003). These children are discriminated against by peers. Peers would prefer to play with a non-obese individual than an obese individual even if there is a medical reason for the obesity (Yanovski & Yanovski, 2003).
The self-perception of children with weight problems is very poor. According to studies by Schwimmer, the perceived quality of life is decreased for obese children and their families. Children view their body as one of the components that are important to their significant others, creating a further negative self-image (Jelaliah & Saelans, 1999). Studies have found that obese children base their perceptions on what their parents think of them (Hughes, Farewell, Harris, & Reilly, 2007). Schwimmer et al. (2003) also reported obese children having lower impaired health-related perceptions of their quality of life as compared to children diagnosed and currently being treated for cancer.
Social settings are difficult for obese children due to their own self-image and self-esteem. Girls at the age of 10 or 11 have a more difficult time dealing with body-image disturbances due to the increase of adipose tissue that is caused by puberty (Jelaliah & Saelans, 1999). Excessive body weight and obesity have become a societal stigma and therefore it is ingrained into children that they should also be thin. In a prospective study by Gortmaker et al., men and women were followed for seven years after their adolescence. Successes in social settings were negatively correlated with obesity. Women who were overweight were less likely to be married, less educated, and achieving lower household income compared to women who were not overweight. Men were less likely to be married if they were overweight than those with normal weights.
Depression and anxiety are important problems to screen for in obese children. Reduced self-esteem and confidence, along with a negative body image put these children at a substantial risk for psychological problems. The practitioner should perform a behavioral assessment frequently to ensure a healthy as possible psyche.
The causes of childhood obesity differ from person to person. The ultimate cause of obesity is an imbalance of energy or caloric intake with energy expenditure (Gortmaker et al., 1999). Essentially, more calories are consumed than are used for the body’s daily activities. There are many changes that have occurred in the past fifteen years for the massive incline of overweight children. Children have more sedentary life styles. Time spent with computers and games have increased, while outdoor activities have decreased. A negative correlation between a child’s age and time spent outdoors has been identified. This decreased activity level is positively correlated with obesity.
Studies involving twins have found the risk of obesity to be highly genetic (Wardle, Gutrie, Sanderson, Birch, & Plomin, 2000). Children adopted into an obese family tend to be of a healthy weight versus children born into an obese family. Obese parents demonstrate five times the risk of birthing obese children compared to parents within a normal weight range (Wardle et al., 2000).
There are genetic syndromes that can cause obesity. Examples of pleiotropic syndromes that are monogenic in nature are: Fragile X syndrome, Borjeson-Forssman-Lehman Syndrome, Albrights hereditary osteodystrophy, Bardet-Biedt syndrome, Laurence-Moon-Biedl, Ahlstrom, Cohen, and Carpenter Syndrome (Bray, 1998; Sadaf, 2005). Chromosomal disorders are extremely rare but can be associated with obesity. Examples of these disorders are Prader-Willi syndrome, SIM 1, and WAGR (Sadaf, 2005). Genetics are estimated to cause 40% of obesity, while environmental causes account for 60% (Atkinson, 2000). Most hereditary human obesity is polygenic involving more than 200 genes and gene markers (Atkinson, 2000).
Environmental changes have had the largest effect on the increase in obesity. Shifts in societal norms have increased the frequency of two income households, which has resulted in more frequent meals out of the home. These meals usually contain more fat and calories than meals cooked at home. Fast food restaurants are too available and convenient. Another culprit adding to obesity is the “super size” options that are now available for just a few pennies more. Companies are misleading consumers; foods that are “low fat” or “no-fat” foods are not necessarily low in calories. Food commercials that are high in fat and sugar are the most common advertisements during children’s programs (Gortmaker et al., 1999). Increased calorie consumption is on the rise, while daily physical activity is declining (Blumenthal & Hendi, 2002).
Decreased physical activity is associated with the environmental factors and is partially to blame for the cause and increase in obesity. The labor saving devices that are used continuously prevent people from getting up to even change the channel on the television. Examples of these are remote controls, cell phones, and devices such as the clapper, which is to turn lights on and off with a clap. Other contributing factors are the decreased amount of sidewalk and park availability. In the United States, we are dependent upon motor vehicles rather than walking or riding bikes. Children face all of these challenges adding to the incidence of obesity (Blumenthal & Hendi, 2002). This issue of decreased physical activity is cyclical in nature. Children need to go outside and play, but obese children do not have the same energy level as normal weight children. Children need to play with friends, but obese children are frequently discriminated against. Subsequently, obese children tend to continue their sedentary life styles and therefore often become more obese.
Various psychological and medical conditions may result in increased body weight and obesity. Obsessive compulsive eating disorder is prevalent in children (Jarry & Vaccarino, 1996). Other psychological disorders that contribute to the obesity statistics are seasonal affective disorder and depression (Atkinson, 2000). These disorders can be treated with pharmaceuticals, but unfortunately, pharmaceuticals are also to blame for obesity. Glucocorticoids, hypoglycemic agents, antidepressants, central nervous system agents, and sex hormones have all been associated with increased weight gain. Hypothyroidism, insulinomas, Cushing Syndrome, hypogonadism, and hyperthyroidism are examples of endocrine disorders that can cause obesity. Hypothalmic damage to the brain from motor vehicle accidents, tumors, surgery, or infection can also result in increased body weight (Atkinson, 2000).
Parenting plays an enormous role in obesity. Obese parents are prone to have children who prefer spending most of their time involved with sedentary activities (Wardle et al., 2000). These children of obese parents also prefer vegetables less at mealtime and spend less time outside when compared to children of normal weight parents (Wardle et al., 2000). Parents have an early influence in a child’s life related to food. When to eat, the extent to which feeding occurs, feeding in response to hunger or distress, what the foods are, and the portion sizes are decided by parents or caregivers (Ventura & Birch, 2008). In some observational studies, restricting foods from children were associated with greater weight gain (Ventura & Birch, 2008). More lenient parenting involving poor child-parent communication skills and poor behavioral control has also been related to children with higher BMI’s (Ventura & Birch, 2008).
Diagnosis
BMI is a tool that the Center for Disease Control (CDC) and the American Academy of Pediatrics (AAP) use for screening of potentially overweight children and adolescents. BMI is a number that is calculated using an accurate weight and height of a child. BMI is not a direct measurement of fat; therefore it is considered a reliable screening tool, but not a diagnostic tool. It is inexpensive, easy to calculate, and highly reproducible. There is a calculation that is used specifically for children. Once an accurate weight and height are obtained, it is imperative that the numbers be converted into either pounds and inches, or kilograms and meters. Fractions may not be used, and must be converted into decimals. For English measurements, the BMI is calculated by dividing weight in pounds by the height in inches squared. This number is multiplied by a conversion factor of 703. The formula is: weight (lbs.) / [height (in)] x 703. If using the metric system, the multiplying conversion number is 10,000. Therefore, the formula being: weight (kgs.)/ [height (m)] x 10,000. Once the BMI is calculated, the number is then plotted on charts that are specific for the sex and age of the child. These charts are called BMI-for-age growth charts. These charts are used to assess the growth and size patterns of children in the United States. The numbers may be compared to other children the same age and the same sex. There are separate charts for boys and girls due to different fat distributions (Sweeting, 2007).
The CDC does not offer a healthy weight range for children due to frequent height increases and constant variances in weight ranges with each month. Therefore BMI is a tool that is utilized for evaluating whether a child is underweight, at a healthy weight, at risk for being overweight, or overweight. Table 1 demonstrates the weight categorization by percentile BMI. Screening for potential weight problems begins at the age of two. If a child falls into the overweight or at risk for becoming overweight groups, it is an excellent indication that further evaluation is needed by a pediatrician or practitioner.
Since this epidemic of childhood obesity continues to grow at alarming rates, a committee has been formed to help prevent, assess and treat the disease. This committee is referred to as the expert committee. This expert committee has been put together by the American Medical Association, the U.S. Department of Health and Human Services’ Health Resources and Service Administration and the Center for Disease Control and Prevention. It consists of representatives from fifteen health professional organizations that collaboratively are multidisciplinary. The multidisciplinary team involves nursing, medicine, psychology, and epidemiology and is sensitive to cultural diversities (Washington, 2008). The purpose of this committee is attempted to provide practical guidelines for practitioners (Washington, 2008).
The expert committee has suggested changing the guidelines of BMI categories. Table 2 demonstrates these changes in weight class characterization. They suggest that children between the 85th and 95th percentile be considered overweight rather than at risk for overweight. If a child is at or above the 95th percentile, they should be classified as obese, rather than overweight. Their reasons for this change are clinical in nature. Overweight refers only to high body weight which includes lean muscle mass, where as obesity refers to the actual excess amount of adipose tissue along with lean tissue. Since childhood obesity is so prevalent, they are also recommending creating a 99th percentile, which would be referred to severely obese (Table 2) (Washington, 2008).
Recommendations currently exist for a child’s BMI that is at or above the 85th percentile. These include medical and behavioral risks assessments. Waist circumference measurement is an excellent indicator of comorbidities from obesity, but they are not currently recommended for children (Washington, 2008). Skinfold measurement is also not recommended for overweight and obese children due to distribution of adipose tissue. The expert committee has a detailed list of questions for the medical risk assessment that are to be obtained by the practitioner. These include questions about the following areas and systems: sleep, endocrine, respiratory, nervous system, gastrointestinal, genetic disorders, skin, orthopedic, psychiatric, and cardiovascular. A complete history and physical is also performed.
Laboratory studies for a child between the 85th and 94th percentile initially includes a lipid panel. If they are found to have any positive risk factors such as weight related problems, then a fasting glucose level and liver function studies are obtained. If a child is in the 95th percentile or greater, even without risks factors, then a lipid panel, fasting blood glucose, liver function studies, and a blood urea nitrogen (BUN) are obtained (American Medical Association, 2008).
The behavioral assessment must be completed in congruence with the physical assessment. These assessments are pertinent due to genetic and environmental issues involved in childhood obesity. A comprehensive look into lifestyle habits of the entire family is a necessity for the practitioner. Some of these items include; a detailed list of foods in the household, when meals are consumed and how frequent, what parental controls are involved, and the child’s likes and dislikes of certain food groups. Another piece of information that is relevant is how frequently the family eats out of the home. Physical activities of the child and family are important to document, considering obesity is due to an imbalance of energy intake related to energy expended. Another important aspect of the behavioral assessment is to evaluate the ability of the child and the family to modify the behaviors contributing to the obesity. This behavioral assessment will assist the practitioner and the nutritionist with initializing a focused plan for the child and the family.
A huge problem with the diagnosis of childhood obesity is that many practitioners are not concerned early enough about having a BMI greater than 85th percentile (Blumenthal & Hendi, 2002). Many pediatricians or health care providers have not initiated the recommendations. According to Dorsey, Wells, Krumholz, and Concato (2005), some of these reasons include resistance from the client and family members, poor knowledge of the disease, lack of time, and poor reimbursement for these particular services. As stated above, the CDC and AAP recommendations urge practitioners to be aggressive in their diagnosis of overweight or obese children.
Treatment
Effective treatments of childhood obesity are multidisciplinary. The most effective treatment plans involve the child, family or caregiver, the child’s physician, a nutritionist, a registered dietician and counseling. Many studies have been conducted focusing on various treatment modalities including medications, counseling, inpatient treatment centers, family-based therapy and bariatric surgery.
The CDC recommends a staged approach to curing the epidemic of child hood obesity that encourages weight loss at a gradual rate. The four described stages are Prevention Plus, Structured Weight Management, Comprehensive Multidisciplinary Intervention, and Tertiary Care Intervention. The first stage of Prevention Plus involves basic changes in eating habits. Children are encouraged to eat three meals a day consisting of five servings of fruits and vegetables, and to drink water. Drinks with sugar are discouraged. Physical activity is suggested at least one hour a day, while drastically decreasing television and computer game time (Washington, 2008).
The Structured Weight Management Stage is initiated if after three to six months the child shows no improvement during the first stage. This stage is more structured. Support is offered to the child and the family. A counselor is used to assist with parenting skills and motivation for the family. Dieticians help the family unit develop structured meals and snacks using a planned daily menu. Television and game time is further discouraged. The Comprehensive Multidisciplinary Intervention Stage concentrates more on behavioral changes. Doctor visits occur more frequently, including counselors, dieticians and nutritionists. For the severely obese children, it may be necessary for them for move to the fourth stage which is the Tertiary Care Intervention. These children should be mature enough to understand the risks of there obesity. It requires more intense behavioral modification with family involvement. The older the child is the less family is involved because they must make their own choices to be successful (Washington, 2008).
Studies have shown that treatment programs that involve teaching behavioral modification methods have been successful (Dorsey et al., 2005). Continuous reinforcement in these behavior changes contribute to the success of the treatment plan. One multicomponential behavior treatment study associated more positive outcomes with behavioral modification of eating and physical activity as compared to education alone. Family based therapies and intense parent training in behavioral modification and physical activity are important for this treatment (Jelaliah & Saelans et al., 1999).
A study by Caroline Braet and colleagues (2004) consisted of a 14 month evaluation of inpatient treatment centers for children and adolescents between the ages of 7 and 17 diagnosed with obesity. The mean age was 12.7 with the mean body mass being 32.5. It involved a 10 month stay in a treatment facility with concentrations on healthy eating habits, moderate exercise, and cognitive-behavior techniques. The children were only able to go home every two weeks for a weekend. The treatment facility was a controlled environment with a school in the center of it. The healthy eating habits consisted of three meals a day and two snacks per day. Water was suggested, but they were able to choose between water and juice. The only other choice they had with meals was portion size. They could choose to pick large or normal portions. The exercise program encouraged organized sports for two hours a day, with four hours of additional guided exercise consisting of swimming, cycling, jogging and abdominal exercises.
Cognitive-behavior therapy was utilized for the first four months and was comprised of four to six children per group. The concept of energy balance between intake and expenditure was taught through a therapist. The children learned how to use self-regulation skills including self-observation, self-instructions, self-evaluation, and self-rewards. Each child had their own personal design and goals. They worked with a therapist evaluating how they would react to difficult eating situations. Emotional situations associated with cognitive techniques were analyzed. This helped the children cope with their underlying cause of eating.
The results of this study were promising for inpatient treatment centers. The children lost a significant amount of weight with 82% of them losing 10% of their weight. After the 14-month follow-up, 44.1% were still overweight, but were continuing to use their healthy habits they had learned. One third of the children remained obese. While the overall weight loss demonstrated in this study was modest, the results were more encouraging than comparable adult studies. Braet and colleagues also found correlation with weight loss and increased self-esteem, increase in school competency, and a decrease in emotional problems. The authors suggest different treatment programs for separate age groups. They also recommend instructing families and children that weight loss is not a quick process. It is not just about weight loss, rather a change to create a healthy lifestyle (Braet, Tanghe, Decaluwe, Moens, Rossel, & Yves, 2004).
Weight loss surgery is referred to as bariatrics. Specifically, gastric bypass surgery or gastric banding surgery has been used in adults since the 1960’s, but has become much more prevalent due to the devastating effects of obesity and the recognition of the positive impact of bariatric surgery. Further, many insurance companies have now agreed to reimburse for the procedure leading to more patients pursuing this option. Bariatric surgery was first introduced to the adolescent age group in the 1980’s. Strict guidelines are followed if an adolescent is to be considered for bariatric surgery. Females must be at least 13 years of age, and males must be at least 15. Candidates must have a BMI greater than or equal to 40 kg/m2 with at least one diagnosis of a comorbidity related to obesity, or have a BMI greater than or equal to 50 kg/m2. They must also have the emotional and cognitive maturity to understand the restrictions and implications of a post-bariatric surgery diet. The adolescents must attempt weight loss in a behavior based program for at least 6 months without success prior to being considered for surgery (Dorsey et al., 2005). The American College of Surgery and The American Society for Bariatric Surgery are exploring the option of performing bariatric surgery on children at a younger age due to the effects of obesity and the excellent outcomes that have come from bariatrics on adolescents (Inge, Xanthakos, & Zeller, 2007).
Medications for obesity are unavailable to children under the age of 12. There are currently two medications that are Food and Drug Administration approved. Orlistat is a drug that binds with the dietary fat causing fat to be discarded through feces. This drug is available for children 12 and over. The other medication is Sibutramine, which works with serotonin. This medication is used for children 16 and over. These medications have been found to be much more successful in weight loss when incorporated with diet and exercise (Dorsey et al., 2005).
Dietary restrictions are always beneficial in weight loss. Low calorie diets have been successful for children and their families (Dorsey et al., 2005) Other dietary suggestions include restricted carbohydrate diets that are high in protein, which is similar to the Atkins diet. These diets restricted in carbohydrates and high in protein intake have been associated with increased weight loss and decreased cholesterol and triglycerides.
When discussing obesity concerning school-age children, school lunches play a major role. There is a national program for evaluating school lunches called the National School Lunch Program (NSLP). The NSLP plays an important role in developing children’s eating habits. The Physicians Committee for Responsible Medicine (PCRM) has worked with dieticians reviewing food in 18 major school districts evaluating healthiness of their food. They are also partly responsible for educating children about good nutritional habits. The NSLP grades schools on three criteria including obesity and chronic disease prevention, health promotion, and nutrition adequacy. Results of their evaluations demonstrate that school lunches are improving, but many are continue to serve unhealthy food to children. There are currently 4 states that have instituted programs to fight obesity. California, Florida, Hawaii, and New York have created resolutions to address the need for more nutritious school lunches. One such resolution consists of offering an optional vegetable entrée with emphasis on healthy plant choices such as fruits, grains, legumes, and vegetables. Further, it is becoming more common for elementary schools worldwide to implement health conscious meals and encourage children to spend more time outdoors playing (Gortmaker et al., 1999). Unfortunately there are difficulties with lunch programs being successful. These healthier options are often more costly to the school districts and families.
Conclusion
Childhood obesity is a nationally growing crisis. It affects a child’s mental, physical, and cognitive outlook. Physicians, elementary schools, parents and children need to be educated in prevention and management of obesity. Practitioners need to recognize the social and physical implications that obesity has on a child’s future. An aggressive approach to early recognition and diagnosis is paramount. Continuous education and reinforcement must be started during the early pre-school years for those children at risk of becoming overweight or obese. Healthy eating habits and a healthy lifestyle are key aspects to a child’s well being. Parenting styles and their lifestyles clearly reflect on a child’s health. Educational needs of families need to be assessed for the ability to understand the implications of childhood obesity. Treatment options with the greatest success require an evaluation and change in habits to facilitate creating a healthy lifestyle. A multimodality approach applying psychosocial principles, nutritional support, medical management, and surgery provides the greatest likelihood of success.

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Table 1
Weight Category by Percentile Range According to the Centers for Disease Control and American Academy of Pediatrics

Weight Category Percentile Range
Underweight Less then the 5th percentile
Healthy weight 5th percentile to less than the 85th percentile
At risk of overweight 85th percentile to less than the 95th percentile
Overweight Equal to or greater than the 95th percentile

Table 2
Weight Category by Percentile Range According to the Expert Committee

Weight Category Percentile Range
Underweight Less than the 5th percentile
Healthy weight 5th percentile to less than the 85th percentile
At Risk for Overweight 85th percentile to the 95th percentile
Obesity Greater than 95th percentile to 99th percentile
Severe Obesity At or above the 95th percentile

This paper is written by Kimberly B. Martin, a Graduate student at Liberty University, during the counseling course “Human Development COUN 502,” Taught by Dr. Anthony Centore with www.thriveboston.com