EPSDT Care for Kids Newsletter

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EPSDT Care for Kids Newsletter

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Spring 2011

Pediatric Overweight and Obesity Survey
Andrew Petersen, MD, University of Iowa Children’s Hospital

Pediatric overweight is defined as having a BMI-for-age at or above the 85th percentile but lower than the 95th percentile. Obesity is defined as having a BMI-for-age at or above the 95th percentile. In the most recent National Health and Nutrition Examination Survey (NHANES 2007-2008), 16.9% of children and adolescents were at or above the 95th percentile and 31.7% were at or above the 85th percentile of BMI for age. It is estimated that by 2015, 75% of U.S. adults will be overweight or obese and 41% will be obese.

Adult obesity leads to approximately 200,000 excess deaths per year in the U.S. The pediatric obesity epidemic has the potential to significantly increase morbidity and early mortality as the current generation of overweight children matures. Metabolic syndrome (elevated triglycerides, low HDL cholesterol, central obesity, insulin resistance, and high blood pressure) in childhood predicts cardiovascular disease in adults. Obesity increases the risk of esophageal, thyroid, renal, endometrial and breast cancers and it has been suggested that the pathogenesis of these diseases begins with obesity of childhood. Several studies have demonstrated that obesity during childhood and adolescence commonly persists into adulthood, making it an attractive target for interventions aimed at reducing mortality in adults.

The health related quality of life associated with obesity is worse than that of:

Cystic fibrosis
Epilepsy
Diabetes mellitus
type 1
Inflammatory bowel disease

The burden of disease from pediatric obesity is not limited to adults. Overweight and obese children and adolescents report lower quality of life than normal weight children. In one recent study, the health-related quality of life (HRQOL) associated with obesity was worse than the HRQOL in cystic fibrosis, inflammatory bowel disease, epilepsy, type 1 diabetes mellitus, and was comparable to the HRQOL following renal transplantation. The prevalence of asthma is higher in obese children and adolescents. Obesity is a risk factor for musculoskeletal injuries. Children and adolescents with overweight or obesity are less likely to participate in physical activities and have an increased incidence of musculoskeletal complaints. In addition, the prevalence of metabolic syndrome among overweight and obese children and adolescents is increasing.

Severe obesity (BMI greater than 99th percentile) in children is also increasing with 4% of children (two million children between the ages of 1 and 18 years) classified as severely obese. This is particularly concerning because, in addition to the health consequences, severely obese children and adolescents are more likely to have serious co-morbidities such as obstructive sleep apnea, type 2 diabetes mellitus, pseudotumor cerebri, and hepatic steatosis. In one large analysis, 59% of children with a BMI at or above the 99th percentile had a least two additional cardiovascular risk factors and 88% went on to have an adult BMI at or above 35kg/m2. It has been suggested that in some limited cases, severe obesity may be a sign of medical neglect and may require removal from the home to protect the child from harm.

The majority of pediatricians report feeling frustrated when trying to treat obesity. In one survey, 45% of pediatricians reported not feeling competent in responding to a patient’s questions regarding treatment options for obesity and 61% did not feel prepared to use motivational interviewing techniques to change behavior.

A recent Cochrane Review analyzed 64 randomized controlled trials of lifestyle interventions for the treatment of pediatric and adolescent overweight and obesity. On meta-analysis, statistically significant improvements in age- and sex-normalized BMI (BMI-SDS) were seen at 6- and 12-month follow-ups in children 12 years and older. In those less than 12 years of age, statistically significant improvements were seen at 6 months, but not at 12-month follow-up. Effect sizes were very small, especially in younger children, bringing into question the clinical significance of these interventions. The authors note that many studies included in the analysis suffered from methodological problems including low power, high dropout rates, and poor accounting of missing data.

Another problem in pediatric overweight and obesity research has been poor durability of effects. Several studies have demonstrated statistically significant improvements in BMI-SDS at 6 months but not at 12-month follow-up. One notable example is a 2005 study by Carrel et al. They performed a 9-month school-year intervention using a fitness-oriented gym class and demonstrated improved cardiovascular fitness, loss of body fat, and improvement in insulin sensitivity compared to controls in traditional gym class. However, when subjects were re-tested after the 3-month summer break, fitness levels had decreased, fasting insulin levels had increased, and body fat had increased to pre-intervention levels. Clearly, interventions aimed at treating pediatric overweight and obesity must be designed for sustainability.

There are, however, reasons to be optimistic about the future of pediatric overweight and obesity treatment. The 2009 Cochrane Review does conclude that family-based combined dietary, physical activity, and behavioral lifestyle interventions appear to be effective for treating pediatric overweight and obesity. This is the first update to this review that has concluded any effectiveness from lifestyle interventions.

The most recent NHANES data suggest that the prevalence of pediatric overweight and obesity has been leveling off since 1999. A recent study of California school-based BMI data demonstrated a peak in the prevalence of overweight and obesity among 5th, 7th, and 9th grade students in 2005 with a steady decline since 2005. White boys and girls, in particular, have shown dramatic improvements and have returned to 2001 prevalence rates for all BMI cut points. Only black and American Indian girls demonstrate ongoing increases in overweight and obesity prevalence. This peak in overweight and obesity in California is particularly heartening because it seems to follow the 2005 implementation of many policies and programs designed to address the pediatric obesity problem in California.

Although family-centered interventions have the largest evidence base for obesity treatment, motivational interviewing has gained wide acceptance because it is less time consuming for the clinician and has been demonstrated effective for similar problems, including tobacco use, alcohol abuse, and risk-taking behavior among adolescents. Motivational interviewing has been identified as a potentially useful strategy for the treatment of pediatric obesity but has not yet been systematically evaluated.

Clinicians have a tall task in addressing pediatric and adolescent obesity. Clearly we cannot solve this problem on our own, but must partner with schools, communities, families, and individual patients to find ways to help children and adolescents reach and maintain a healthy weight. Advocating for healthy food choices, opportunities for physical activity and sustainable lifestyle changes should remain an important part of our daily work.

Resources

Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164-192.
Oude L H, et al. Interventions for treating obesity in children. Cochrane Database System Review 2009(1): CD001872.
Madsen KA, et al. Disparities in peaks, plateaus, and declines in prevalence of high BMI among adolescents. Pediatrics. 2010.
For a complete bibliography, contact andrew-r-peterson@uiowa.edu.

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