Childhood Obesity Examining the childhood obesity epidemic and current community intervention strategies Whitney Lundy wmlundy@crimson.ua.edu
Introduction Childhood obesity in the United States is a significant health problem. Roughly one-third of children and adolescents in the United States are overweight or obese, with children of minority and low socioeconomic status disproportionately at-risk. The health consequences of pediatric obesity are severe; some complications are potentially irreversible. Multi-faceted, community-based prevention and treatment programs are needed that target families in at-risk populations and environments. Background A staggering 31.8% of children and adolescents 2-19 years of age have a BMI for age greater than the 85 th percentile on the CDC growth charts; 16.9% of children and adolescents ages 2-19 have a BMI for age above the 95 th percentile. 1 Considerable ethnic and racial inequalities exist in the prevalence of obesity. Hispanic, Mexican-American, and non-hispanic black males have obesity prevalence rates of 23.4%, 24.0%, and 24.3% respectively, compared to 16.1% of non- Hispanic white males ages 2-19. 1 Among females ages 2-19, obesity prevalence rates for Hispanics, Mexican-Americans, and non-hispanic blacks are 18.9%, 18.2%, and 24.3%, versus 11.7% of non-hispanic white females. Additionally, children in low-income families are at much greater risk of becoming obese than their peers in a higher socioeconomic status. 2 Children who are obese have a significantly increased risk of a variety of diseases and health conditions normally seen in a much older population, including non-alcoholic fatty liver disease, type 2 diabetes, insulin resistance, and hypertension. Nearly half of obese juveniles have at least one of the conditions that contribute to metabolic syndrome. 3 Pulmonary disorders such 1
as asthma and sleep apnea affect a greater percentage of obese juveniles than their normal weight peers. 3 Overweight and obese children are also more likely to experience self-esteem and discrimination issues, social isolation, and depression than their normal-weight peers. 4 Several Healthy People 2020 objectives address the health of children and adolescents, specifically the Nutrition and Weight Status objectives. 5 These objectives address goals such as increasing produce and whole grain consumption, reducing food insecurity among children and families, and increasing physician and school involvement. These objectives can be examined more closely at the Healthy People 2020 website, www.healthypeople.gov. The Healthy People objectives provide a solid framework for community nutritionists to rely upon when designing and implementing programs directed at childhood obesity intervention. Screening/Treatment/Prevention Screening for pediatric obesity occurs primarily via primary care providers. As of 2010, however, 20 states required school-based BMI screening, and another 9 states recommended school-based BMI screening. 6 School-based screening may help alleviate any screening disparities that exist due to lack of routine medical care. BMI is calculated using a child s weight and height. CDC Growth Charts are used to plot the child s calculated BMI on the corresponding gender-specific BMI-for-age chart. 7 Overweight is defined as a BMI at or above the 85 th percentile but below the 95 th percentile on the growth chart; Obesity is defined as a BMI at or above the 95 th percentile on the growth chart. The Academy of Nutrition and Dietetics has established evidence-based treatment guidelines for overweight and obese children ages 2-5 and ages 6-12, and adolescents ages 12-19. 8 2
Evidence-based practice supports implementation of multi-component weight loss programs for pediatric patients. Multi-component programs typically include reduced-calorie diets for juveniles 6 years and older, physical activity, and behavioral and family-based counseling. Treatment programs currently address modifiable risk factors of pediatric overweight and obesity, such as nutrition education, family involvement, physical inactivity, screen time, and peer support through group programs. Diet and Lifestyle A number of diet and lifestyle factors contribute to the prevalence of pediatric overweight and obesity. Children who sleep 8 hours or less each night, children of parents engaging in restrictive feeding practices, and children of obese parents are all nearly twice as likely to be obese. 9 Increased screen time contributes to obesity; the American Academy of Pediatrics recommends children and adolescents limit screen time to no more than two hours per day. 10 Screen time refers to time spent watching TV, playing video games, or working on a computer. Socioeconomic status affects obesity prevalence; families in low-income neighborhoods may have limited access to healthy, affordable foods, along with a safe place to play and engage in physical activity. Parental lack of nutrition knowledge is believed to also contribute to a child s weight status. 2 Processed and prepared foods are readily accessible and inexpensive, compared to the cost and availability of healthier food items. Nutrition education that very simply distinguishes healthy food choices from unhealthy options is imperative. Emphasis should be placed on fruits, vegetables, whole grains, low-fat dairy or dairy alternatives, and lean protein options in place of 3
overly refined, processed foods devoid of nutrients. Because food costs and preparation time are major barriers for many families, programs or classes that teach families how to fit healthy food into their budget and time or ability constraints could prove extremely effective. Diet guidelines for families should be clear, concise, and fairly simple for a family to implement. An example of a successful family-friendly diet is the Traffic Light Diet. Developed by Leonard H. Epstein, the Traffic Light Diet is an effective approach to teaching healthy eating habits. 11 Similar dietary approaches can be applied in a wide array of community settings, and can easily be incorporated into the curriculum of existing treatment and prevention programs. Educational Programs and Recommendations A great number of educational programs have been implemented at the national, state, and community level. Two national programs that are successfully gaining momentum nationwide are WeCan! and the National Farm to School Network. In 2005, the National Institutes of Health created a national education program called We Can!, which stands for Ways to Enhance Children s Activity & Nutrition. 12 Presently, 1,600 sites in the United States and 14 other countries are using the WeCan! education program. WeCan! offers three outreach levels for organizations to choose from; general community sites, intensive community sites, and WeCan! city/county programs. Aimed at children 8 to 13 years of age, the WeCan! program focuses on three fundamental behaviors: reduced screen time, improved food choices, and increased physical activity. Community sites receive access to science-based resources, webinars, regional training, program curricula, and printable materials. Sites can organize programs and events targeted at 4
parents and caregivers, juveniles, or families. The myriad of options help community sites employ a multi-faceted approach to address childhood obesity within their area, tailoring the program to the at-risk populations and appropriate risk factors within their community. The National Farm to School Network (NFSN), founded in 2007, strives to connect farms, schools, and communities throughout the country. The NFSN operates in 38,629 schools nationwide, spanning all 50 states. 13 In addition to providing nutritious food at the school level and supporting farmers, the NFSN s objectives include educating children and adolescents about nutrition, health, and agriculture, providing educational sessions and introduction to farmers markets for parents and community members. Community dietitians can get involved with the NFSN on multiple levels. Connecting schools with the NFSN could greatly benefit children and adolescents, particularly those suffering from food insecurity or with limited access to fresh produce options. Through the Child Nutrition Reauthorization Act, Farm to School program grants will soon be available for individuals wishing to develop these programs in their area. 13 Conclusion Childhood obesity is a condition affecting millions of children nationwide, the health consequences of which are severe and lifelong. Limited access to healthy foods, safe play areas, and nutrition-related knowledge and services negatively affect the weight status of many children. Community nutritionists can significantly improve the health and nutrition status of children and adolescents through the implementation and promotion of community-based, multi-faceted nutrition education and physical activity programs. 5
Works Cited 1. Ogden, C.L., Carroll, M.D., Kit, B.K., Flegal, K.M. Prevalence of obesity and trends in body mass index among U.S. children and adolescents, 1999-2010. JAMA. 2012;307(5):483-490. 2. Cluss, P.A., Ewing, L., King, W.C., Reis, E.C., Dodd, J.L., Penner, B. Nutrition knowledge of lowincome parents of obese children. TBM. 2013;3:218-225. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3717981/. Accessed January 18, 2014. 3. Han, J.C., Lawlor, D.A., Kimm, S.Y.S. Childhood Obesity 2010: Progress and Challenges. Lancet. 2010 May 15;375(9727):1737-1748. 4. CDC. Obesity United States, 1999-2010. In: CDC Health Disparities and Inequalities Report United States, 2013;62(Suppl 3). http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a20.htm. Accessed January 18, 2014. 5. Healthy People 2020 Topics and Objectives. Healthy People 2020 website. http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx. Updated November 13, 2013. Accessed January 18, 2014. 6. Linchey J, Madsen KA. State requirements and recommendations for school-based screenings for body mass index or body composition, 2010. Prev Chronic Dis 2011;8(5):A101. http://www.cdc.gov/pcd/issues/2011/sep/11_0035.htm. Accessed January 24, 2014. 7. About BMI for Children and Teens. Centers for Disease Control and Prevention website. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. Updated September 13, 2011. Accessed January 18, 2014. 8. Pediatric Overweight Evidence Analysis Project. Evidence Analysis Library, Academy of Nutrition and Dietetics website. http://andevidencelibrary.com/topic.cfm?cat=4102. Copyright 2014. Accessed January 18, 2014. 9. Dev, D.A., McBride, B.A., Fiese, B.H., Jones, B.L., Cho, H, on behalf of the STRONG Kids Research Team. Risk Factors for Overweight/Obesity in Preschool Children: An Ecological Approach. Childhood Obesity. October 2013;9(5):399-408. http://online.liebertpub.com/doi/full/10.1089/chi.2012.0150. Accessed January 24, 2014. 6
10. Carlson, S.A., Fulton, J.E., Lee, S.M., Foley, J.T., Heitzler, C., Huhman, M. Influence of Limit- Setting and Participation in Physical Activity on Youth Screen Time. Pediatrics. July 2010;126(1):e89-e96. http://pediatrics.aappublications.org/content/126/1/e89.full. Accessed January 21, 2014. 11. The Traffic Light Diet and Treating Childhood Obesity. Evidence Analysis Library, Academy of Nutrition and Dietetics website. http://andevidencelibrary.com/evidence.cfm?evidence_summary_id=250033. Copyright 2014. Accessed January 18, 2014. 12. We Can! Ways to Enhance Children s Activity & Nutrition. National Heart, Lung, and Blood Institute. Organization website. http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/. Updated December 9, 2013. Accessed January 21, 2014. 13. National Farm to School Network. Organization website. http://www.farmtoschool.org/. Accessed January 21, 2014. 7