Today we will be discussing a problem that has been running rampant throughout the United States without much thought. It affects all ages, sexes, and races, with the possibility to potentiate many long-lasting diseases. This problem is childhood obesity.
Working with a child that is obese can be very challenging for a provider. This chronic disease often requires frequent office visits, lab testing, imaging studies, reinforcement, and encouragement to the patient and family.
Unfortunately, even with the extent of care that can be provided in a primary care office, poor success rate, prognosis, and frustration within the family are very common.
The first step in treating pediatric obesity is recognizing that there is a problem. It isn’t an easy thing to say. It isn’t an easy thing for the parents to hear. But this topic should not be avoided.
Current data shows that 33% of children and adolescents in the United States are overweight or obese. Breaking this down further, 17% of school-age children are obese, 4.3% of those being severely obese (BMI >99 percentile).
Handling Pediatric Obesity in Practice
Often, in my practice, parents will be shocked when I state that their child is overweight or obese. They cannot fathom the words that have just come out of my mouth.
The next thing they state often is, “what is this BMI thing that you’re talking about?” Body mass index is calculated by the formula of:
BMI = weight in kilograms/length in meters squared.
Values that are over the 95th percentile on a patient’s growth chart are considered to be obese. When these values are over the 95th percentile, there has been a substantial likelihood that the child will have obesity that persists into adulthood.
The big question is why is this happening? If you ask most parents, the majority think that there is a thyroid abnormality (~90%) or that there is another medical condition contributing to their child’s obesity (~9%). Only seldom will parents think that environmental factor adds to the problem (~1%).
The actual reason for much of childhood obesity, as you can imagine, is quite different from the public perception. Environmental factors contribute more than 98% of the time. Medical condition comprises about 2% of pediatric obesity cases.
This is a good thing, as well as a bad thing.
Often, I will describe weight as a math equation to parents. If the intake is greater than expenditure, you will gain weight. If the expenditure is greater than intake, you lose weight.
Reasons Behind Pediatric Obesity
A common issue is that there is a prevalence of fast foods, increased portion sizes, and an increase in glycemic index in foods that are contributing to increased calories and intake.
When you add this to decreased activity time, frequency of activity, and intensity of the exercise along with increased screen time, you can see that the aforementioned “equation” is imbalanced.
In addition to inadequate dietary and exercise regimens, sleep and medications have been studied as environmental factors that are contributing to pediatric obesity.
One hour less of sleep nightly showed a two-fold increase in rate of obesity. Medications such as psychiatric drugs, seizure medications, and steroids have known adverse effects including obesity.
The last of the environmental factors I will mention is poverty. Unfortunately, in the United States individuals that have fixed budgets or low income have poor access to quality and healthy foods.In turn, families will purchase foods that are less expensive, and in turn less healthy.
As mentioned above, some medical conditions can contribute to obesity, including endocrinopathies, psychologic, and genetic syndromes.
Endocrinopathies such as hypothyroidism, Cushing’s syndrome, growth hormone deficiency, and hypothalamic obesity.
Psychologic conditions such as eating disorders and depression.
Genetic syndromes such as Prader Willi syndrome, Laurence Moon Biedl syndrome, Stein-Leventhal Syndrome, and Turner’s syndrome.
Pediatric Obesity and Health Care
The big question is with the rapidly increasing prevalence of childhood obesity leading to adulthood obesity, what is this going to do to our healthcare system and costs?
Overall, obese kids make obese adults. Obese adults are sick adults. Sick people cost a lot of money. Health care spending at an increasing rate due to chronic health conditions brought on because of obesity is unsustainable.
Childhood obesity often is a gateway to multiple chronic medical conditions as an adult.
Prediabetes and diabetes are present in 15 to 25% of overweight and obese children.Complications of type 2 diabetes in children have been seen to be more rapid as opposed to adult-onset type 2 diabetes.
Other complications include metabolic syndrome, polycystic ovarian syndrome, hypertension, hyperlipidemia, sleep apnea, Pickwickian syndrome, slipped capital femoral epiphysis, gallbladder disease, pseudotumor cerebri, non-alcoholic fatty liver disease, acanthosis nigricans, and cardiovascular disease.
There is even an increased link between childhood obesity and colon, breast, uterine, esophageal, and renal cancers.
To put the cardiovascular disease risk into picture. The overall cardiovascular health of an obese child has been seen to be equivalent to a middle-aged adult with appropriate BMI.
Obese children also have an increased risk of fatal and nonfatal cardiovascular events by middle adulthood.
Complications of Pediatric Obesity
In our practice, if a patient’s BMI is >95th percentile and has failed conservative therapy with dietary changes, seeing the dietician, and implementing exercise, I will order a metabolic workup including a CMP, TSH, A1c, and lipid panel to screen for obesity-related complications.
By far, the most common complication that I see in our practice is nonalcoholic fatty liver disease. This will initially present on the CMP with elevated AST and ALT levels. This leads to the right upper quadrant ultrasound which reveals fatty infiltration of the liver without inflammation.
More often than not, these patients will be asymptomatic. Unfortunately, these patients are commonly referred for further evaluation to pediatric gastroenterology or a larger comprehensive center for pediatric obesity.
As you can see, many medical comorbidities can attribute to obesity as a child. In addition, these diseases will often require blood work and imaging as well as specialist care. Many of which could potentially be avoided.
Estimations for 2030 predict the trend of obesity and obesity-related complications only to increase with:
An additional 65 million obese adults in the United States
An additional 6-8.5 billion cases of diabetes diagnosed
An additional 5-7.3 million cases of heart disease diagnosed
An additional 492,000-669,000 cases of cancer diagnosed
All of which causing an increase of 48-66 billion dollars in healthcare costs!
(Am Fam Physician. 2004 Jun 1;69(11):2591-2599.)
So, what can we do as providers to help impede this epidemic?
Find these children!! And most importantly do not sweep this issue under the rug.
Management for Pediatric Obesity
The USPSTF guidelines gives a grade B classification to screening for obesity in children and adolescents aged 6 to 18 years. In addition, the USPSTF recommends that obese children be referred to a “comprehensive, intensive behavioral interventions to promote improvements in weight status.”
Regarding treatment in the office, often I will implement the 5/2/1/0 rule.This should not only be recommended to that patient, but for the ENTIRE FAMILY. This is:
5 servings of fruits or vegetables daily
2 hours of screen time total daily or less
1 hour of safe and regular exercise daily
0 sugary drinks
I often will include 8 into the 5/2/1/0 (making in 8/5/2/1/0), incorporating better sleep, recommending 8 hours of sleep nightly.
Overall, pediatric obesity is a very challenging condition to treat. It takes a village of people and providers including doctors, physician assistants, nurse practitioners, nurses, schools, teachers, health departments, community programs, local governments, small businesses, and much more.
Just remember, it isn’t an easy thing to say or talk about. It isn’t an easy thing for the parents to hear. But don’t avoid it, as you have read above you could potentially save a child or young adults life in the future.