New Epidemic: Pediatric Overweight

By Irene Takahashi, M.D.

As a pediatrician, I frequently think about the health risks facing today’s children. Among these are asthma, accidents, and the occasional serious unforeseen illness. However, a new problem has emerged as probably the greatest health risk: pediatric overweight (the new terminology agreed on by the Centers for Disease Control and the American Academy of Pediatrics for pediatric obesity)..

 Today 16 percent of our children ages 6 to18 years of age are overweight (defined as a Body Mass Index (BMI) at or above the 95th percentile); and 33 percent are at risk of being overweight (defined as BMI between the 85th and 95th percentiles for age and sex). The prevalence of overweight 2 to 5 year olds has doubled in the past 30 years. There has been a three-fold increase in the prevalence of overweight children over age 5 during this same time. As adults, these children probably will be more overweight and at an earlier age than any previous generation. Unfortunately the known complications of adult obesity therefore will occur with greater frequency and at younger ages.

Even now we are seeing increased morbidity in our pediatric population, secondary to overweight: hypertension, sleep apnea, pseudotumor cerebri, slipped capital femoral epiphysis (SCFE), hyperlipidemia, cholelithiasis, hepatic steatosis, ovarian hyperandrogenism, insulin intolerance, and a spike in rates of Type II diabetes mellitus. In a period of five days, I had two 10-year-old female patients with SCFE and my partner had a similar patient two weeks before. Then there is the emotional toll: poor self-esteem and depression. The stigmatization of obesity is so strong that a study showed children would rather play with a child who has a facial deformity, a missing hand, or is in a wheelchair than play with an overweight child.1 Severely overweight children and adolescents have more than a five-fold increased risk of reporting a low health-related quality of life—a risk similar to children diagnosed with cancer.2

How Did We Get This Way?

The answer to how this happened is complicated and multifactorial. Although genetic factors contribute to the problem, there clearly are several significant behavioral risk factors for childhood overweight including

•   Inadequate exercise: 80 percent of 5th, 7th, and 9th graders in California fail to

     meet the minimum fitness standards. 

•   Poor consumption of fruits and vegetables: In California, of 7th, 9th, and 11th

       graders surveyed, less than half reported eating fruits or vegetables at least once a

    day in the past week; 

•   Excessive consumption of soft drinks: The average consumption of soft drinks by

    12 to19 year olds is more than 20 ounces a day; 

•   Excessive TV viewing: More than 25 percent of children in California reported

     averaging four or more hours of TV watching each day.

Interestingly, it appears that TV watching is more of a problem with childhood overweight than video/computer games. Unless the child is doing DDR (Dance, Dance, Revolution, a very fun and aerobic video game) there appears to be no obvious difference in level of activity. However, with video/computer games, the child at least burns calories with his/her busy hands and is unable to snack at the same time. The child on the computer also is not bombarded with food ads. Food is the most heavily advertised product on television, and 40 percent of ads during children’s programming are for food, most of which is of limited nutritional value.

Start Early

Prevention is one of the hallmarks of pediatrics: On a daily basis we deal with prevention of infection and injury. When it comes to pediatric overweight, it is clear that prevention and early intervention are the preferred strategies vs. treat-ment. Why?

•   Weight-loss programs are rarely successful with maintenance of weight loss;

•   Most “diets” are unsustainable;

•   Healthy lifestyles improve health outcomes regardless of weight lost;

•   The majority of the U.S. population is at risk;

•   Prevention is less costly in the long run; and

•   By 7 to 12 years old, overweight children may already have self-esteem issues.

We need to start early. During pregnancy: We want appropriate weight gain, glycemic control, and tobacco cessation to prevent larger or smaller than average infants for gestational age. From birth to one year: The infant should drink breast milk and have minimal or no juice intake and no junk food (you’d be surprised how young french fries are introduced into the diet). From one to two years: The toddler should be weaned from the bottle at 12 months, TV should be limited, food should not be used as a reward, and the “clean the plate” rule should be avoided. This also is a time to talk about a parent’s weight management, if appropriate—a difficult task. From two to five years: Low-fat/nonfat milk should be introduced at 2 years of age (did you know that a cup of “whole milk” has the same amount of fat as 1-1/2 hamburger patties?), and there should be no TV in the bedroom; this is the age to begin early intervention.

Role of Pediatrician

So what is the pediatrician’s role in addressing overweight children? Studies show that when a physician personally talks to the patient about smoking, there is more success in getting that patient to quit. I think we have the same obligation to discuss pediatric overweight with patients and parents. At every visit, no matter how brief, we need to bring up the matter of childhood overweight by following the AIM model, a strategy developed at Kaiser Permanente:

Advise all families about the importance of healthy eating and physical activity. Encourage parents and children to

•   get up and play hard—at least 30 to 60 minutes a day,

•   cut back on TV and video games—no more than one hour a day and remove TV

     from bedroom,

•   eat five helpings of fruits and vegetables a day, and

•   cut down on sodas and juice drinks—no more than one cup a day and drink

     water when thirsty.

Identify kids at risk (BMI 85-95 percent) or already overweight (BMI >95 percent). Begin screening at 2 years of age. Determine whether the child is experiencing an early adiposity rebound where the BMI is starting to rise from its nadir prior to 5 years of age. Although BMI tables, Web and palm calculators are available, I prefer to use a calculator wheel (www.trowbridge-associates.com) and then plot the point on BMI growth charts.

Motivate families to make small, manageable changes:

1. ask permission to discuss the child’s weight,

2. show child’s BMI on growth curve,

3. educate on the medical complications of obesity,

4. assess readiness to change,

5. explore ambivalence and do brief negotiation (a counseling style that provides an

    effective and structured approach to behavior change counseling in brief clinical 

    encounters), 6. give educational materials,

7. refer to a weight-management program if available or schedule regular follow-up.

Overweight prevention in schools is finally getting attention. We, as physicians, need to take the initiative to support legislation that will help prevent pediatric over-weight. Last year several Kaiser pediatricians testified in Sacramento in support of SB 677, a bill that banned the sale of soda and sugary drinks in elementary and middle schools during school hours. The bill passed and will be put into effect in 2005, but unfortunately, the bill was “watered down” to exclude high schools. However, several districts, Los Angeles and Oakland among them, have approved even stricter bans, including sales at high schools. Contrary to previously held beliefs, schools that eliminated soda and sugary drinks have shown an increase in revenues.

Although pediatric overweight is a problem that is not easily solved, pediatricians play a critical role in addressing it: They have a high degree of credibility and a long-term relationship with families. We can sensitively provide objective information about the child’s weight and address weight as a health issue rather than simply an issue of personal appearance. We can assess behaviors, identify children at risk, and educate and motivate children and families to make small but meaningful lifestyle changes. We need to work with schools and legislators to make schools healthier places for all children. Tackling the problem of pediatric overweight may seem overwhelming, but how can we not make the effort? 

Dr. Takahashi is a pediatrician in Daly City.

FOOTNOTES:

1. J Latner, A Stunkgard. Getting Worse: The Stigmatization of Obese Children. Obes Res 11(3): pp 452-456 (March 2003)

2. Schwimmer et al. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289:1813-1819.