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Because children grow at different rates and at different times, it becomes harder to distinguish if a child is overweight compared to establishing overweight in adults. To determine if a child is within an un-healthy weight range, a doctor will use certain criteria to measure a child’s height and weight. The body mass index (BMI), expressed as body weight in kilograms divided by the square of height in meters (kg/m2), is a weight-for-height index. The BMI is the standard obesity assessment in adults, and its use within the pediatric population has limited research to support its effectiveness is still considered the standard measure of overweight in children. The International
(Illustrated by GGS Information Services/Thomson Gale.)
Task Force on Obesity approved that BMI provides a reasonable index of adiposity and provides a reliable measure across pediatric age groups.
A children’s BMI score is the criteria used by medical professionals to determine an un-healthy weight. Any child who’s BMI falls between the 85th and 95th percentile for age and sex should be evaluated for secondary complications of obesity, including hypertension and dyslipidemias. An extensive change in BMI would also call for evaluation and possible treatment of the child. Although the degree of change that indicates risk has not been defined, an annual increase of three to four BMI units is thought to reflect concern due to possible increases in a child’s body fat.
In the United States and elsewhere in developed countries, the prevalence of childhood obesity has drastically risen in the past several decades.
Since the 1960s, the prevalence of obesity in children has been assessed by several nationally representative surveys. These include the National Health Examination Survey Cycles I to III and the National Health and Nutrition Examination Surveys I to III. Based on these surveys, the obesity among children is
estimated to be 25–30%. Furthermore, they estimated the proliferation of obesity has increased by 54% in children six to 11 years of age and by 39% in adolescents 12 to 17 years of age. Morbid obesity jumped 98% and 64% within these groups, respectively. Hispanic, Native American and black children tend to have higher rates in relation to other populations.
Because of these statistics, weight loss diets for children have surfaced. Although weight loss in children is a hot debate in the medical field, there are times when a child’s weight should be evaluated and possibly treated by medical professionals who specialize in weight loss for children.
Childhood obesity can cause complications in many organ systems. These obesity-related medical conditions include cardiovascular disease; type 2 diabetes mellitus, and degenerative joint disease.
Orthopedic complications include slipped capital femoral epiphysis that occurs during the adolescent growth spurt and is most frequent in obese children. The slippage causes a limp and/or hip, thigh and knee pain in children and can result in considerable disability.
Blount’s disease (tibia vara) is a growth disorder of the tibia (shin bone) that causes the lower leg to angle inward, resembling a bowleg. The cause is unknown but is associated with obesity. It is thought to be related to weight-related effects on the growth plate. The inner part of the tibia, just below the knee, fails to develop normally, causing angulation of the bone.
Overweight children with hypertension may experience blurred margins of the optic disks that may indicate pseudotumor cerebri, this creates severe headaches and may lead to loss of visual fields or visual acuity.
Research shows that 25 out of 100 overweight, inactive children tested positive for sleep-disordered breathing. The long-term consequences of sleep-disordered breathing on children are unknown. As in adults, obstructive sleep apnea can cause a lot of complications, including poor growth, headaches, high blood pressure and other heart and lung problems and they are also potentially fatal disorders.
Abdominal pain or tenderness may reflect gall bladder disease, for which obesity is a risk factor in adults, although the risk in obese children may be much lower. Children who are overweight have a higher risk for developing gallbladder disease and gallstones because they may produce more cholesterol, a risk factor for gallstones. Or due to being overweight, they may have an enlarged gallbladder, which may not work properly.
Endocrinologic disorders related to obesity include noninsulin-dependent diabetes mellitus (NIDDM), an increasingly common condition in children that once used to be extremely rare. The link between obesity and insulin resistance is well documented and which is a major contributor to cardiovascular disease.
Hypertension (high blood pressure), and dyslipi-demias (high blood lipids), conditions that add to the long-term cardiovascular risks conferred by obesity are common in obese children.
Childhood obesity also threatens the psychosocial development of children. In a society that places such a high premium on thinness, obese children often become targets of early and systematic discrimination that can seriously hinder healthy development of body image and self-esteem, thus leading to depression and possibly suicide.
In all of these examples, it is recommended that the primary clinician should consult a pediatric obesity specialist about an appropriate weight-loss or weight maintenance program.
Only a small percentage of childhood obesity is associated with a hormonal or genetic defect, with the remainder being environmental in nature due to lifestyle and dietary factors. Although rarely encountered, hypo-thyroidism is the most common endogenous abnormality in obese children and seldom causes massive weight gain.
Of the diagnosed cases of childhood obesity, roughly 90% of the cases are considered environmental in nature and about 10% are endogenous in nature.
The Division of Pediatric Gastroenterology and Nutrition, New England Medical Center, Boston, Massachusetts as well as many child organizations agree that the primary goal of a weight loss program for children to manage uncomplicated obesity is healthy eating and activity, not achievement of ideal body weight. Any program designed for the overweight or obese child should emphasize behavior modification skills necessary to change behavior and to maintain those changes.
For children with a secondary complication of obesity, improvement or resolution of the complication is an important medical goal. Abnormal blood pressure or lipid profile may improve with weight control, and will reinforce to the child and their parents/caregivers that weight control leads to improvement in health even if the child does not approach ideal body weight.
In review of much research, expert advice is that most children who are overweight should not be placed on a weight loss diet solely intended to lose weight. Instead they should be encouraged to maintain current weight, and gradually “grow into” their weight, as they get taller. Furthermore, children should never be put on a weight-loss diet without medical advice as this can affect their growth as well as mental and physical health. In view of current research, prolonged weight maintenance, done through a gradual growth in height results in a decline in BMI and is a satisfactory goal for many overweight and obese children. The experience of clinical trials suggests that a child can achieve this goal through modest changes in diet and activity level.
For most children, prolonged weight maintenance is an appropriate goal in the absence of any secondary complication of obesity, such as mild hypertension or dyslipidemia. However, children with secondary complications of obesity may benefit from weight loss if their BMI is at the 95th percentile or higher. For children older than 7 years, prolonged weight maintenance is an appropriate goal if their BMI is between the 85th and 95th percentile and if they have no secondary complications of obesity. However, weight loss for children in this age group with a BMI between the 85th and 95th percentile who have a nonacute secondary complication of obesity and for children in this age group with a BMI at the 95th percentile or above is recommended by some organizations.
When weight loss goals are set by a medical professional, they should be obtainable and should allow for normal growth. Goals should initially be small; one-quarter of a pound to two pounds per week. An appropriate weight goal for all obese children is a BMI below the 85th percentile, although such a goal should be secondary to the primary goal of weight maintenance via healthy eating and increases in activity.
Components of a Successful Weight Loss Plan Many studies have demonstrated a familial correlation of risk factors for obesity. For this reason, it is important to involve the entire family when treating obesity in children. It has been demonstrated that the long-term effectiveness of a weight control program is significantly improved when the intervention is directed at the parents as well as the child. Below describes beneficial components that should be incorporated into a weight maintenance or weight loss effort for overweight or obese children.
- Attainable and safe weight-loss; a rate of 1 to 4 lb per month.
- Dietary management goals should be provided; specify total number of calories allotted per day, broken down into percentage of calories from fat, protein and carbohydrates.
- Physical activity recommended should match the child’s fitness and mobility level, with an ultimate goal of 20 to 30 minutes per day of structured movement.
- Behavior modification techniques should be incorporated; self-monitoring tools, nutritional education, identification and modification of stimulus controls, family role modeling, positive reinforcements and non-food rewards.
- Encourages and supports family involvement; family involved in individual or class session, encouraged to attain healthier eating patterns and lead an active lifestyle.
Adverse effects of childhood weight loss may include gall bladder disease, which can occur in adolescents who lose weight rapidly. Another concern is inadequate nutrient intake of essential or non-essential nutrients. Linear growth may slow during weight loss. However, impact on adult stature appears to be minimal. Loss of lean body mass may occur during weight loss. The effects of rapid weight loss (more than 1 pound per month) in children younger than 7 years are unknown and are thus not recommended.
There is a clear association between obesity and low self-esteem in adolescents. This relation brings other concerns that include the psychological or emotional harm a weight loss program may infer on a child. Eating disorders may arise, although a supportive, nonjudgmental approach to therapy and attention to the child’s emotional state minimize this risk. A child or parent’s preoccupation with the child’s weight may damage the child’s self-esteem. If weight, diet, and activity become areas of conflict, the relationship between the parent and child may deteriorate.
- Respect a child’s appetite: children know when they are full and do not need to finish every bottle or meal.
- Prepare and supply fresh, non-processed foods often. Avoid sugared foods when possible.
- Limit the amount of high-calorie foods kept in the home. Do not supply sodas; sugar flavored drinks, candy, cakes, cookies in the home.
- Provide low fat foods such as, lean proteins, and low-or non-fat dairy products and choose lower fat options for foods when available. Skim milk may safely replace whole milk at 2 years of age.
- Choose high fiber foods by selecting whole grains, legumes and fresh fruit and vegetables.
- Do not provide food for comfort or as a reward, instead use positive reinforcement.
- Do not “force” a child to eat their meal in order to get dessert.
- Limit amount of sedentary activities such as television viewing, computer time, and video games to two hours or less per day.
- Encourage active play by offering the support needed for the child to be active.
- Establish regular family activities such as daily walks, and other outdoor or indoor activities.
Once the need for obesity treatment has been identified, a medical professional may suggest one or more options. Consultation with a dietitian / nutritionist that specializes in children’s needs is often a valuable part of obesity treatment.
Behavior therapy involves changes in diet and physical activity habits that promote weight maintenance or loss. Some behavioral therapy strategies for children and adolescents should include parent and family involvement. And should be supervised by a medical professional.
DRUG TREATMENT. The U.S. Food and Drug Administration has not yet approved the use of any drugs to treat obesity in children. However, clinical trials are under way.
SURGERY. Surgical procedures such as gastric bypass have been performed successfully on adolescents. However surgery for adolescents is usually considered only when severe medical conditions are present that can improve with the surgery and other treatment options have failed.
BMI age-for-growth charts for the United States are available at http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm.
Encourages kids to get physically active. http://www.verbnow.com/.
Healthy eating and physical activity tips for kids and parents. http://www.kidnetic.com/.
Information about nutrition and fitness for kids. http://www.kidshealth.org/.
MyPyramid Plan. MyPyramid replaces the Food Guide Pyramid. Available from the U.S. Department of Agriculture (USDA) at www.mypyramid.gov.
The Shapedown Pediatric Obesity Program. http://www.shapedown.com.
The Weight-control Information Network (WIN) www.niddk.nih.gov/health/nutrit/pubs/parentips/tipsforparents.htm.
Megan C.M. Porter, RD, LD