NUTRITION RESEARCH PAPER TOPIC: Obesity among adolescents
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Obesity among adolescents
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Addressing Childhood Obesity: Opportunities for Prevention
Callie L. Brown, MD1, Elizabeth E. Halvorson, MD2, Gail M. Cohen, MD, MS2,3, Suzanne
Lazorick, MD, MPH4,5,6, and Joseph A. Skelton, MD, MS2,3,7
1Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
2Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
3Brenner FIT (Families In Training) Program, Brenner Children’s Hospital, Winston-Salem, NC
4Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC
5Department of Public Health, East Carolina University, Greenville, NC
6East Carolina University Pediatric Healthy Weight Research and Treatment Center, Greenville,
NC
7Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest
School of Medicine, Winston-Salem, NC
Keywords
etiology; prevention; obesity; risk factors; pediatric; genetics; overweight
INTRODUCTION
The prevalence of obesity in the United States remains dangerously high, at nearly 10%
among infants and toddlers, 17% of children and teens, and more than 30% of adults1,2.
While the prevalence has stabilized somewhat over the past few years1, rates of severe
obesity have continued to climb, particularly in high-risk populations3. Intervening during
childhood is important due to the persistence of obesity into adulthood with associated
increased morbidity and mortality47. Comorbidities often affect children before they reach
adulthood, requiring increased diligence in evaluating and treating these conditions810 and
leading to increased healthcare expenditures11,12. The personal and emotional face of
childhood obesity is also serious: daily quality of life can be significantly worsened by
Address correspondence to: Joseph Skelton, MD Department of Pediatrics Wake Forest School of Medicine, Medical Center Blvd.
Winston-Salem, NC 27157 Tel: (336) 713-2348 Fax: (336) 716-9699 [emailprotected]
[emailprotected]
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Author manuscript
Pediatr Clin North Am. Author manuscript; available in PMC 2016 October 01.
Published in final edited form as:
Pediatr Clin North Am. 2015 October ; 62(5): 12411261. doi:10.1016/j.pcl.2015.05.013.
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obesity13. The psychosocial complications of obesity include depression, body
dissatisfaction, unhealthy weight control behaviors, stigmatization, and poor self-esteem13.
Groups have advocated for the prevention of obesity for some time, yet efforts to advance
preventative interventions may have been limited by the difficulties and expense of long-
term studies of a complex problem and increasing focus on treatments. Despite the progress
over the past 20 years, there is not a clear solution or one-size-fits-all approach. The body
of literature on proven prevention interventions is not robust, though cross-sectional and
associational studies have identified risk factors to address, and practical experience has
provided a foundation upon which to work with children and families. Childhood obesity is
incredibly complex and reflects numerous systems that impact a child’s health. Repetition of
concepts can aid in approaching an issue as complex as childhood obesity; the Ecological
Model of Childhood Obesity (Figure 1) provides a broad framework for understanding the
mediators and moderators of childhood obesity. This overview highlights evidence-based
factors on which clinicians can focus efforts to effectively prevent the development of
childhood obesity. In this chapter, we will review both general and age-specific risk factors
for pediatric obesity and discuss specific strategies for intervention at the level of the
pediatrician, school, government, and family.
RISK FACTORS
Genetic Risk Factors
Obesity is commonly known to run in families. The genetic contribution to this
observation is difficult to discern, however, as families usually share not only genetic
material but environments and habits as well. Obesity in children correlates with obesity in
their parents, and the level of obesity in children increases when both parents are obese, as
well as with increasing levels of obesity in the parents15. Indeed, it has been shown that
parental overweight is the most significant risk factor for childhood overweight 16.
Children’s food choices and eating behaviors are learned from parents at very young ages
and influence eating behaviors as children get older 17,18.
Although the vast majority of cases of childhood obesity are exogenous, a small proportion
may have endogenous causes. The following genetic disorders, both syndromic as well as
monogenic in origin, predispose children to obesity:
Syndromes: trisomy 21, Prader-Willi syndrome, Albright’s hereditary
osteodystrophy, Cohen syndrome, Bardet-Biedl syndromes, Alstrom syndrome, and
WAGR (Wilms’ tumor, aniridia, genitourinary anomalies, and retardation) 19,20.
Monogenic disorders: leptin deficiency, leptin receptor mutations,
proopiomelanocortin deficiency, preproconvertase deficiency, and melanocortin 4
receptor mutations19.
Hormonal disorders: hypothyroidism, growth hormone deficiency, Cushing’s
syndrome, hypothalamic obesity, polycystic ovary syndrome, and
hyperprolactinemia19.
Brown et al. Page 2
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Environmental/Societal Risk Factors: The child’s living environment, both in the home as
well as in the community, can contribute to a higher risk of development of obesity:
Living in lower-income, predominantly white, or non-mixed-race neighborhoods21.
Parents’ perceptions of the food and physical activity environments in their
neighborhoods
Difficulty getting to a main food store or difficulty purchasing fruits and vegetables
there (food desert)
Increased distance from parks
Perceived danger of their neighborhood21
Food insecurity, although the evidence is mixed21,22
Behavioral Risk Factors
Nutrition and DietAlthough it might seem logical that increased total energy intake
should be associated with a higher risk of childhood obesity, the evidence does not support
this relationship 16,23. Similarly, the relationship between dietary fat intake and childhood
obesity is not clearly established23. A lower intake of dairy products or calcium is associated
with childhood obesity, but the data regarding intake of fruits and vegetables is mixed and
does not indicate a strong association with childhood weight status 23,24. Beverage choice
may increase risk for childhood obesity: fruit juice, especially in large quantities 23; sugar-
sweetened beverages 23,25; and sodas 23,26,27 are all positively associated with childhood
obesity.
Some specific eating behaviors have been associated with childhood obesity. Skipping
breakfast 23,28,29; eating meals away from home, especially fast food 23; quicker eating
pace30; larger portion sizes 23; and eating in the absence of hunger 30 are all positively
associated with childhood obesity. No consistent association has been identified with
frequent snacking23,31, while eating meals as a family is inversely associated with childhood
obesity22,23.
While there can be conflicting evidence, or less-than-clear associations, clinicians can be
confident in addressing intake of unhealthy foods, such as fast food, sugar-sweetened
beverages, high-fat proteins and processed snacks, and encourage intake of healthy items,
particularly fruits, vegetables, lean meats, and sugar-free beverages. Underneath the intake
of these foods are the habits behind them, which the clinician should be cognizant of during
an interaction: foods eaten away from home, eating in the absence of hunger, snacking and
family meals. Awareness of these issues can assist clinicians in working with families to
prevent the development of unhealthy habits and build healthy ones to prevent excessive
weight gain.
Physical ActivityOverall, decreased physical activity among children is associated with
obesity 16,23,32,33. Prospective studies objectively measuring physical activity have yielded
inconsistent results; however, studies of either self-reported or parent-reported physical
activity have demonstrated an inverse relationship between physical activity and both
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childhood and future adult obesity 32. An inverse relationship exists between some specific
activity-related behaviors and childhood obesity, including sports team participation and
active commuting to school 34.
Physical inactivity and sedentary behaviors are likely associated with childhood
obesity 23,27,32, although the effect size may be small 16. Some prospective studies have
found that more hours engaged in sedentary behavior, specifically watching TV or playing
video games, was associated with an increased risk of becoming obese in the future 23,32;
however, other studies found no association between sedentary behavior and childhood
obesity35. Increased screen time, including television35 and electronic devices 36, is also
associated with childhood obesity. While increased sedentary time and decreased physical
activity are both associated with childhood obesity, they may not be inversely proportional.
Regardless, efforts to lower the former and increase the latter will be key to preventing
obesity development.
SleepWhile there is less evidence regarding sleep, it does appear that shorter sleep
duration is associated with childhood obesity 22,37. Some prospective studies have borne out
this association, both in the short term in young children 38 and in the long term, persisting
into adulthood 39. In combination with other positive household routines (eating as a family
and limiting screen time), obtaining adequate sleep has a strong inverse relationship with
obesity among preschool-aged children 40.
StressThe short- and long-term effects of stress on the development of obesity are an
emerging area for research. There are several types of stress that can affect a child: personal,
parental, and family. Each of these can increase the child’s risk for obesity independently or
in concert. Although the data is somewhat mixed, it is likely that there is a positive
association between chronic stress and the risk of childhood obesity 41. This can manifest
during childhood42 and may persist into adulthood43. In many studies, parental stress is
associated with obesity in children; this relationship is strengthened when a parent
experiences stress from more than one source41. Similarly, stress within the family is also
associated with childhood obesity41 (Box 1).
DEVELOPMENTAL APPROACH TO OBESITY PREVENTION
Many of the risk factors outlined above, related to diet, physical and sedentary activity, and
sleep, apply to children of many different ages. Other risk factors for pediatric obesity may
apply at distinct development stages, offering specific opportunities for intervention by a
primary care provider. These stage-specific risk factors have been identified as early as the
prenatal period. While obesity in either parent may increase the child’s risk, as discussed
above, the mother’s pre-pregnancy BMI and gestational weight gain have been directly
associated with obesity in infancy and early childhood4447. Maintaining gestational weight
gain within the Institute of Medicine guidelines48 (see Table 1) is especially important for
women who are overweight or obese at the time of conception and should be an important
component of prenatal counseling. Both over- and under-nutrition at this stage are thought to
affect fetal programming and predispose to future obesity and metabolic disorders19,49. One
recent meta-analysis identified a moderate association between delivery via cesarean section
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and offspring obesity, with persistence of the association into adulthood50. In addition,
maternal exposure to tobacco45,51,52 and caffeine53 have both been associated with obesity
at various points during gestation and throughout a child’s life.
Additional risk factors become evident in infancy. High birth weight and rapid infant weight
gain correlate with future childhood obesity45, although they may be difficult to address
specifically as modifiable risk factors. Many studies have attempted to determine optimal
dietary intake during infancy, but the results are conflicting. While many studies suggest that
breastfeeding is protective against the development of obesity45,54,55, others show no
relationship56,57. These differing results may be due to confounders present in the study; for
example, it has been shown that lower protein content in infant formula is protective against
obesity at 6 years, so studies on breastfeeding may differ based on the types of formula used
by control infants. Results have also been mixed when assessing the effects of duration of
breastfeeding45. It has been suggested that it is the infant’s degree of self-regulation while
breastfeeding rather than the composition of breastmilk which may be protective, so that
bottle-feeding either formula or pumped breastmilk may be associated with increased risk58.
Complementary foods represent another important dietary change during infancy, and both
the timing of introduction and food selection may impact future risk of obesity. Early
introduction of solids (defined as ages <3 to 5 months depending on the study) may be associated with increased childhood overweight59. Similarly, one systematic review concludes that higher intake of protein and energy during infancy can be associated with increased BMI60, although other studies conclude that no specific complementary foods are associated with increased risk61. Overall, the available evidence makes it difficult to establish firm guidelines for infants' dietary intake. Other exposures in infancy have also been investigated. Use of broad-spectrum antibiotics, especially with repeated exposures prior to 23 months of age, has a small but significant association with obesity in early childhood62. Studies have yielded mixed results for family socioeconomic status, maternal parity, and maternal marital status45. Finally, temperament traits identified as early as infancy, especially early negativity and lack of self-regulation, may predispose to later obesity63,64. Child temperament and parental feeding practices remain important predictors of obesity for toddlers and preschool-aged children. The concerning character traits are thought to be similar to those seen in infancy, particularly poor self-regulation and distress to limitations64. Part of the mechanism of this association may reflect parental response to the child's temperament, especially if parents initiate restrictive feeding practices given concerns over self-regulation or use emotional feeding habits, such as providing obesogenic foods to soothe a negative child61,64. Children are typically weaned from the bottle as toddlers; the timing of this transition may affect obesity risk. At earlier ages (between 1236 months), there is an association between current bottle use and obesity, but this was not seen at later ages (3760 months)65. Furthermore, an intervention centered on bottle-weaning effectively reduced total caloric intake in children but did not change overweight status66, so the degree to which prolonged bottle use contributes to obesity risk is unclear. Brown et al. Page 5 Pediatr Clin North Am. Author manuscript; available in PMC 2016 October 01. A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t Although sedentary behavior and screen time are concerns for children of all ages, one systematic review suggests that preschool children are most amenable to interventions addressing this risk factor67. Weight gain in this age group is known to be highly predictive of later obesity, with an earlier adiposity rebound (at less than 5 years old) associated with both BMI and adiposity at age 15 years68. Therefore, this is an important age group to target as effective interventions are identified. Most studies of obesity in school-aged children focus on interventions delivered within the school system, which will be discussed later under Policy and Environmental Interventions. However, some research has shown that children with overweight and obesity actually gain more weight during the summer months than during the school year69,70, suggesting that interventions outside of school should also be investigated. The primary difference noted between the school year and summertime is in the level of physical activity70. One intervention that has shown success in increasing physical activity in this age group, as well as adolescents, is exergaming, or use of electronic games designed to promote physical exercise71. While the video game experience makes activity more entertaining for children, use of exergames in several studies was found to increase energy expenditure and time spent on physical activity and to reduce waist circumference71. These findings suggest that targeting known risk factors during the summer months may be especially important for obesity prevention at this age. Use of technology for obesity prevention continues to be important in the adolescent age group. Technology-based interventions targeting both diet and exercise have been shown to be effective in this population, although there is wide variation among studies72. Peer groups also take on increased importance during adolescence, and research has attempted to determine how this influences the risk of obesity. Peers are able to influence diet and activity levels in both positive and negative ways73,74, so the inclusion of the peer group in interventions targeting adolescents is important74. Adolescence is a time of significant biological changes, most notably puberty. While there is a clear association between early puberty and obesity, it is difficult to determine cause and effect since pre-pubertal BMI influences the timing of puberty49. Some studies have demonstrated an effect of early puberty on subsequent adiposity and fat distribution, but results have been mixed49. Severe obesity in adolescence has been directly associated with poor health outcomes in adulthood75, which makes prevention in this age group especially important. In addition, as they represent the next generation of parents, establishment of healthy lifestyle habits in the adolescent population has the potential to decrease the obesity risk of subsequent generations (Box 2). ROLE OF THE PRIMARY CARE PROVIDER Primary care providers play a unique role in the prevention of obesity as they see the same patients and families, often from birth, on a regular basis (Box 3). This gives them the opportunity to provide anticipatory guidance and counseling that can influence families' nutrition and physical activity habits. As discussed above, it is well established that there are strong familial links to obesity, both genetic15,16 and environmental18. These influences do Brown et al. Page 6 Pediatr Clin North Am. Author manuscript; available in PMC 2016 October 01. A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t not dictate fate, however. By recognizing risk factors early in a child's life, primary care providers can help families make positive changes that will improve a child's weight trajectory76. Pediatricians should screen for obesity by measuring height and weight and calculating BMI at least annually7779. By following children closely over time, physicians are in the position to detect weight problems by observing trends, such as a rapidly increasing BMI, even before a child becomes overweight. When a child is discovered to be overweight or at risk for becoming overweight, physicians should provide brief counseling and suggest weight control interventions77,79. We recommend that clinicians use motivational interviewing techniques (see Figure 2)77,8083 when counseling patients and their families about making life changes. Primary care providers offer anticipatory guidance about nutrition and physical activity at each well child check. This anticipatory guidance should be age appropriate and can significantly shape how and what parents feed their children. All children, even those of a healthy weight, benefit from counseling about general health and wellness, and this does not need to be framed around weight. Recommended anticipatory guidance for each age range is outlined in table 1 23,32,77,8495. Primary care providers should advocate for their patients and families; to build community- wide efforts to prevent obesity, clinicians can look to successful models in other areas to support their efforts. The chronic care model96 provides a useful framework for pediatricians to provide care to children who are overweight or obese. The chronic care model recognizes that families' self-management is dependent on support both from the medical system and their surrounding environment, such as school, work, and the community. Ideally, primary care physicians should be connected with numerous community resources, such as nutrition and exercise programs77,96. The chronic care model has been successfully implemented by health-related organizations such as Kaiser Permanente, that provided education for providers in motivational interviewing, and Wellpoint, that distributed parental toolkits to families in clinic77. Advocating for children's health and healthcare is an important role for pediatricians to embrace on both a local and national level, examples of areas for advocacy include: Third-party reimbursement to ensure that children continue to have access to services necessary for obesity prevention and treatment, such as yearly BMI screening and well-visits with their primary care provider Funding for research to prevent childhood obesity Promotion of healthy foods and beverages and physical activities in schools and daycares Maintenance of safe neighborhoods that encourage physical activity Availability of healthy food26 Brown et al. Page 7 Pediatr Clin North Am. Author manuscript; available in PMC 2016 October 01. A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t POLICY AND ENVIRONMENTAL INTERVENTIONS Using the Socio-ecologic Model as a guide14 on a societal level, policy and environmental interventions have the potential to exert the farthest-reaching influence in thwarting obesity97. Policy changes can address physical, economic, social or communication factors and may range in scope of efforts that target: A whole population: national or state legislation; industry-wide improvements; social marketing), or Population subsets or large groups: state or regional ordinances, or Local or smaller groups: single organization or community98. Policies can be formal documented standards or laws, or informal practices (e.g. a medical office giving patients stickers vs. candy). The over-arching goals are for policies to prevent obesity by: 1) increasing awareness of and actions to change attitudes and norms to support healthy energy balance; 2) making healthy options for physical activity and nutrition readily available and, where possible, the default choices; and 3) reducing barriers to making healthy choices. For maximal impact, policy changes should be informed by the existing science of obesity prevention and established theories of behavior change, such as Social Cognitive Theory99, Self-Determination Theory100, and/or the Trans Theoretical Model of Behavior Change101, and subsequently evaluated by rigorous studies demonstrating both feasibility and effectiveness. Optimally, studies of policy are thoroughly evaluated with application of appropriate methods such as the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework102. Where large studies have not been completed, efforts should be evidence-informed and practice-tested103. Once enacted, there should be ongoing monitoring of fidelity and accountability of policies for effectiveness and use of resources, with attention to social factors that contribute to inequality in access to healthy choices. Although the body of literature assessing polices for obesity prevention is growing, there are still many areas actively under study or for which evidence is inadequate for a definitive recommendation for wide scale adoption98,104. Select examples illustrative of policies with growing support and/or evidence and ranging in scope are shown in Table 2, and for specific settings in which children spend substantial time are shown in Table 3 Notable recent progress in the policy arena has occurred in standards for food programs affecting children including application of the 2010 United States Department of Agriculture (USDA) Dietary Guidelines for Americans to schools109 and sciencebased nutrition standards for meals offered in daycare and after-school programs through the pending Child and Adult Care Food Program (CACFP). These changes are largely a result of passage of the Healthy and Hunger-free Child Act of 2010 that was motivated in large-part to curb the obesity epidemic110. The Act included several components to ensure meals served to children include more fruits and vegetables, whole grains, and less sugar and fat, while also promoting breastfeeding and increasing access to healthy beverages (water, low-fat or fat Brown et al. Page 8 Pediatr Clin North Am. Author manuscript; available in PMC 2016 October 01. A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t free milk). Related changes are evident in the revised food package offered to participant in the Women, Infants and Children (WIC) program since 2007 and broadening of educational messages and materials supported by the Supplemental Nutrition Assistance Education Program (SNAP-Ed) Programs to include emphasis on energy balance and obesity prevention. Despite progress in recent decades, there remain many areas for which evidence is insufficient or policies are lacking, emerging or facing challenges97. Although there are signs of growing partnership, remaining barriers include involvement of the food industry, marketing, and entertainment venues along with pervasive social and cultural attitudes and influences. Resistance may exist due to factors such as economic pressures or underlying fundamental political or philosophical tension between government vs. individual/parent rights and freedom of choice. Some barriers may be reduced as more evidence demonstrates links between academic performance and health/obesity status or health behaviors (to support policy changes in the school setting) or the economic benefits of a healthier population/workforce to factors such as defense preparedness and economic measures (to support changes in business and industry). Pediatricians, primary care providers and any professional or individual with an interest in obesity prevention for children can actively support efforts in policy or environmental changes through lending expertise, providing advocacy or local support, or by leading and role modeling in one's own work setting and community (Box 4). THE FAMILY While environmental pressures at the national and community level contribute greatly to a child's risk of obesity, families are the most central and enduring influence in children's lives The health and well-being of children are inextricably linked to their parents' physical, emotional and social health, social circumstances, and child-rearing practices (Schor 2003, page 1542)111. Inclusion of the family is established as the gold standard of treatment77. The same can and should be said for the prevention of obesity. As mentioned previously, a child's risk of obesity is greatly influenced by parental weight status. While the genetic contribution to the child's weight is great, the environmental influence is likely greater: parental obesity can predict genetic susceptibility, but a child's environment can determine the expression and severity of that risk112. Despite any genetic predisposition to obesity, the environment is likely the greatest potentially modifiable determinant of obesity, with the family being the most proximate of that environment. Determining exact familial components contributing to a child's weight is difficult, however, given the changing nature of families over the past few decades, and the complexity of studying and conceptualizing families113. As presently understood, family-related risk-factors for childhood obesity include114: Minority ethnic and cultural background Single parent household Lower maternal education Brown et al. Page 9 Pediatr Clin North Am. Author manuscript; available in PMC 2016 October 01. A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t A u th o r M a n u scrip t Parent obesity status and family history of obesity Poverty: receipt of supplemental food assistance Higher levels of television viewing of family, particularly during meals, amounts and locations (bedrooms) Restrictive parental feeding practices Of the risk factors above (out of a total of 22 studied), parental feeding practices and parent BMI were most associated with child weight status (child sleep duration was also determined to be significantly associated)114. These findings are preliminary, as the extensive, long-term studies necessary to link risk with later obesity development have not yet been performed. Clinicians should customize risk assessments to each family, knowing that sound anticipatory guidance can be safely provided to all families regardless of weight status and ris
