Thursday, April 7, 2011

Childhood Obesity - a paper for school

Turned this in for my Master's program, got 100%!  It is such an important issue, I wanted to share.

Childhood Obesity:  A Public Health Concern
Definition of Childhood Obesity
            Childhood obesity is defined as a Body Mass Index (BMI) greater than or equal to the 95th percentile, as plotted on World Health Organization (WHO) growth charts, in children of the same age and gender (Dolinsky,  Siega-Riz, Perrin, & Armstrong, 2011).  The Centers for Disease Control and Prevention (CDC) agree that BMI is a practical and acceptable method to screen for childhood obesity (CDC, 2011).  BMI is a calculated number found by dividing the weight in kilograms by height in meters squared.  The growth chart used is an important distinction.  Both the CDC and the WHO produce charts.  CDC charts have been commonly used by U.S. clinicians.  However, the WHO charts are more inclusive of breastfed infants as a basis and therefore, in 2010, the CDC themselves recommended U.S. clinicians utilize the WHO growth charts as a measure of standardized growth (Dolinsky, et al., 2011).  Further, their recommendations suggest the 2nd and 98th percentiles as the cutoffs for unhealthy growth (Dolinksy, et al., 2011).  Although the CDC recommends use of the WHO charts, it is unknown how many U.S. providers actually utilize them.

Prevalence and Trends
            Data from 2007  shows that 17 percent of kids aged 2-19 are obese (Centers for Disease Control and Prevention, 2011).  Even more disturbing are the trends.  For preschool  children (ages two to five), the rate of obesity doubled, increasing from 5% to over 10% between 1980 and 2007 (CDC, 2011).  Likewise, the same is true for six to eleven year olds.  The data shows an even greater increase in obesity with the incidence increasing from 6.5 to 19.6% for the same time frame (CDC, 2011).  For pre-teens and teens aged 12-19 the rate more than tripled, rising from 5% to 18.1% (CDC, 2011). 
            Critical to recognizing these trends also is the tendency for overweight or obese children to become obese adults.  The CDC recognizes one study that shows 80% of children who were obese at age 10-15 are obese at age 25[vjc2] .  The CDC cites another study that showed kids that were obese at age 8 were more likely to be morbidly obese as adults (CDC, 2011).  [vjc3] Additionally, one in seven low-income preschoolers are obese.  However, the trend among this group is slowing showing an increase from 12.4% in 1998 to 14.6% in 2008 (CDC, 2011).
Significance of Childhood Obesity
            Obesity can have devastating health effects.  Paoletti (2007) lists many health consequences of obesity in children.  These include low self-esteem, type 2 diabetes, precocious puberty, male gynecomastia,  high cholesterol, high triglycerides, hypertension, DVT/PE [vjc4] risk,  asthma, obstructive sleep apnea, gallstones, stress incontinence, and degenerative joint disease.  This list only partially represents all the altered health conditions described by Paoletti (2007).  Medical professionals well know the sequelae of diseases such as diabetes, hypertension, and high cholesterol.  In fact, the CDC (2011) reports that 15% of new diabetes cases are type 2 diabetes in children and adolescents.  This is significant as type 2 diabetes was rarely reported in this group in the 1980s (CDC, 2011).  Renal failure, blindness, peripheral vascular disease, atherosclerosis, and hypertensive heart disease render staggering disability to those affected.  Such disability has immeasurable consequences on quality of life and productivity.  As  costs for medical care are increasing, so do the financial consequences of obesity.  The CDC (2011) cites an increased cost difference of over 68 billion dollars between 1998 and 2008.
Assets and Challenges
            Children, as nature intended, are dependent upon adults in their lives for nurturing, love, and care.  This is one of the challenges related to childhood obesity.  Food choices are often related to food availability.  Unfortunately, obese parents tend to have obese kids (Cutting, Fisher, & Grimm-Thomas, 1999).  Children inherit genetic information and experience the eating environment of their parents.  Cutting, et al (1999) found that maternal obesity was positively associated with daughters' overweight.  Danielzik, Langnase, Mast, Spethmann, & Muller (2002) found a correlation between an elevated parental BMI and an elevated BMI in their 5-7 year old children.  These authors also state that an unhealthy parental BMI is more of a predictor of childhood obesity as the age of child advances beyond seven.  So, obesity can be a legacy - passed down from one generation to the next.  Children do not have control over food availability and meal preparation.  They need to be taught limits in many areas of life, including food.  If these parental controls are not in place, perhaps combined with a genetic predisposition, the stage is set for obesity.
            This liability can also be an asset.  Kids are born with an open minded palate, becoming accustomed to foods given to them.  Children are also flexible and resilient.  If a change in eating habits is needed, children may be initially resistant  but they will eventually conform, provided their caregivers give consistent and healthy choices.  These caregivers must also model healthy eating habits and an active lifestyle.  To their credit, children are born with a love to play and most children love to be outdoors.  This natural tendency can lead to physical activity and sports-related play, given the proper environment.  In the simplest sense, obesity can be combated by more energy output than input.
Making a Difference
            The agreement in the literature is that the key to impacting childhood obesity is prevention.  In 2007, 15 health professional organizations got together to form the Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity (Paoletti, 2007).  This committee produced the following recommendations for pediatric health care providers, as noted by Paoletti (2007) and Barclay (2008).
  • An annual BMI measurement from ages two to eighteen.
  • Encouraging at least 60 minutes of vigorous activity for all children on most days of the week.
  • Limiting sweetened beverages to not more than one serving a day.
  • Limiting television viewing and other screen time to two hours per day.
  • Advising a limit on fast food consumption to once per week.
  • Suggesting families eat meals together as much as possible, preferably every day.
  • Assessing dietary patterns in the home at each well child visit.
  • Assessing physical activity levels and prevalence of sedentary behaviors.
  • Obtaining a focused family history for prevalence of obesity and obesity related conditions, such as type 2 diabetes, cardiovascular disease, and hypertension.
  • Lab work based on BMI and family history.  This may include a fasting lipid panel and renal function tests.
These recommendations are certainly foundational, and should be ongoing.  As with most preventative measures, early intervention is key (Paoletti, 2007).  For kids, this intervention must begin with parents to help them teach healthy eating habits, how to understand food labels,  and understand the link between dietary choices and disease (Paoletti, 2007).  Also crucial is helping parents see the importance of integrating fun, diverse activity into the family's daily lifestyle.  Encouraging parents to place a limit on the amount of television and video games also effectively reduces sedentary behavior.  As a healthcare provider, contact with families can be limited to a few short visits.  Reinforcing this information at each visit but continuing to be motivational and positive can often bring families from resistance to change.
            Although the dietary environment begins at home, it is reinforced daily at school.  Though the issue of nutrition in schools is multi-factorial, school health policy is also an important player in the obesity game.  Many schools are limiting or not offering physical education programs and extracurricular activities.  Meals served at school are chosen more on a fiscal basis and nutritional definitions have become looser.  Contents of vending machines at high schools are often chosen based on profit, not nutrition.  Changing these school-related policies requires a united voice among those caring for children as well as a partnership with parents.[vjc6] 
            The trend in childhood obesity is increasing.  Once it exists, childhood obesity is difficult to combat and often leads to a lifelong battle with "the bulge."  The association of obesity with disease states may lead to significant disability and decreased productivity of the younger generation, adversely affecting our nation's future.   Healthcare providers, parents, and educational professionals need to partner to affect relevant policy.  A combination of education and prevention is the only true solution to the epidemic of childhood obesity. 

Barclay, L. (2008).  AMA recommends 4-stage approach to treatment of childhood obesity. 
            American Family Physician, 78, 56-63.

Ben-Sefer, E., Ben-Natan, M., & Ehrenfeld, M. (2009).  Childhood obesity:  current literature,             policy and implications for practice.  International Nursing Review, 56, 166-173.

Centers for Disease Control and Prevention (2011, January 21).  CDC grand rounds:  Childhood          obesity in the united states.  Morbidity and Mortality Weekly Report, 60(2), 42-45.

Centers for Disease Control and Prevention (2011).  Childhood overweight and obesity. 
            Retrieved from

Cutting, T.M., Fisher, J.O., Grimm-Thomas, K., & Birch, L.L. (1999).  Like mother, like          daughter:  familial patterns of overweight are mediated by mothers' dietary disinhibition.
            [Abstract].  American Journal of Clinical Nutrition, 69(4), 608-613.

Daneilzik, S., Langnase, K., Mast, M., Spethmann, C., & Muller, M. (2002).  Impact of parental          bmi on the manifestation of overweight 5-7 year old children.  European Journal of          Nutrition, 41(3), 132-137.

Dolinsky, D.H., Siega-Riz, A.M., Perrin, E., & Armstrong, S.C. (2011, January).  Recognizing             and preventing childhood obesity:  Challenging pediatricians with averting this epidemic             even in their littlest patients.  Contemporary Pediatrics, 32-41.

Mukamal, K.J., Wee, C.C., & Miller, M. (2009).  BMI and rates of suicide in the united states:            An ecological analysis.  Obesity, 17, 1946-1950.  doi: 10.1038/oby.2009.122

Heitmann, B.L., Koplan, J., & Lissner, L. (2009).  Childhood obesity:  successes and failures of            preventative interventions.  Nutrition Reviews, 67(Suppl. 1), S89-S93.

Li, J. & Hooker, N.H. (2010).  Childhood obesity and schools:  Evidence from the national       survey or children's health.  Journal of School Health, 80(2), 96-103.

Paoletti, J. (2007, November).  Tipping the scales:  What nurses need to know about the           childhood obesity epidemic.  RN.  Retrieved from

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