Clinical Topic

Publication Date

October 24, 2024

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Obesity

What is obesity?

Obesity is an increasingly common situation that affects approximately one in five children globally. Obesity in childhood predicts future weight status and is associated with an increased risk for health problems.

How is obesity defined?

Body mass index (BMI) is a calculation based on a child’s height and weight. BMI is plotted on a standardized chart according to the child’s age and sex. Based on the position of the BMI on the chart, someone’s weight status can be classified as underweight, within normal limits, or overweight.

Obesity is categorized into 3 classes based on the BMI value plotted on the age and sex-specific growth curves. A BMI value at or above the 95th percentile is labeled as obesity. Severe obesity is BMI value > 120% of the 95th percentile. Class 2 obesity is defined as a BMI value >120% to <140% of the 95th percentile. Class 3 obesity is defined as a BMI value > 140% of the 95th percentile.

What happens if obesity persists and/or worsens?

Children with obesity have a higher risk to develop other disorders including:

  • type 2 diabetes (too much sugar in the blood)
  • high blood pressure (hypertension)
  • high cholesterol (too much fat in the bloodstream)
  • fatty liver disease (too much fat in the liver that can lead to liver dysfunction)
  • obstructive sleep apnea (trouble breathing while sleeping which can interfere with daytime attentiveness)
  • vitamin D deficiency
  • early puberty (particularly in girls) and advanced skeletal age
  • polycystic ovary syndrome (in girls)
  • joint pain (especially hip/knee pain)
  • behavioral/mental health concerns

These potentially serious problems can begin in childhood and continue into adulthood. Studies that have followed children to adulthood have shown that children with obesity usually remain obese as adults. Some doctors obtain fasting bloodwork and urine samples to check for high glucose and/or high cholesterol levels. In addition, for some children and adolescents, bloodwork to check liver function, puberty status, and vitamin D levels may also be obtained

What causes obesity?

Obesity can be due to excessive intake of high calorie/low nutrient foods and limited physical activity. Socio-economic factors such as decreased access to healthy foods, limited opportunities for physical activity, and too much time viewing screens (TV, computers, electronic games) may influence the development of obesity. Insufficient knowledge regarding healthy foods and the importance of physical activity contributes to the development of obesity.

In rare instances, inherited genetic variants may contribute to monogenic obesity. Monogenic obesity is usually evident in early childhood. Certain medications such as steroids and some antidepressant/anxiety drugs are associated with increased food consumption and obesity. Rarely, hormone problems cause obesity; typically these patients show decreased height growth.

How is obesity treated?

The initial and most important treatment for obesity focuses on education about healthy food choices and regular physical activity. Treatment plans include detailed recommendations for changes in eating habits and exercise. A healthy diet includes a variety of vegetables and fruits, whole grains (barley, bulgur, quinoa, whole grain bread, etc.), lean protein (fish, skinless chicken, beans, nuts, etc.), and low fat or fat-free dairy products (milk, yogurt and cheese).  Sugary beverages such as juice, soda, sweet tea, chocolate, or strawberry milk should be limited or completely avoided. Carbohydrate intake (chips, cookies, cakes, snacks, candy) should be limited.

The energy content of food is expressed as calories in a specific food portion (measured by weight or volume). For most individuals, decreasing the daily calorie intake is an important part of the treatment plan. Measured portion sizes are central to healthy eating. A nutritionist can discuss and teach you and your child about healthy eating. Through this conversation, a healthy personalized eating plan for your child can be designed.

Eating plans, diet fads and meal supplements are readily available. Social media and the internet offer tools for weight loss. Importantly, some plans may not be safe for children. In addition, not all plans work for everyone.

Exercise and activity are essential for good health and can help with weight loss. Children between the ages 3 and 5 years old should be physically active throughout the day. Children aged 6 through 17 years should be active with moderate to intense activity for at least 60 min a day. However, without any change to eating habits, exercise alone will not lead to much weight loss.

Additional approaches to help with your child’s eating habits and physical activity include:

  1. Caregivers as role models: You are highly influential in shaping your child’s attitudes towards eating and exercising. If you eat healthy foods and participate in daily physical activity, your child will likely adopt similar eating habits and exercise routines.
  2. Create a positive food environment: Make fruits, vegetables, and nutritious food readily available. To reduce temptation, avoid keeping unhealthy snacks and beverages at home.
  3. Have structured meals and snacks: Encourage your child to have 3 meals a day and 2 small healthy snacks in between the meals. Discourage skipping a meal as it can cause overeating. Also, grazing, or frequent eating may cause increased hunger and decreased fullness feeling which can result in overeating. Having specific eating times is important to keep a healthy eating routine. Ideally, meals should be social family gatherings.
  4. Involve your child with grocery shopping and meal prepping.
  5. Minimize eating out and “take-out” foods.
  6. Limit screen time and avoid eating during screen time.
  7. Have at least one meal a day that the family eats together.
  8. Do not use food as a reward or punishment.
  9. Make physical activity fun. Find activities that your child enjoys.
  10. Encourage better sleep habits. On average, children need 9-11 hours of sleep per night. Screen should be “turned off” at least 30-60 minutes before bedtime.

What about stigma and bullying?

Sadly, some children and adolescents are bullied and teased by their peers, teachers, and coaches. Being bullied about weight may lead to poor self-esteem, further weight gain, self-isolation, and poor quality of life. Parental support and healthy life-style interventions are essential. Some children and adolescents benefit from individualized counseling.

What about medications?

While diet and exercise are often helpful, some children and adolescents are unable to lose much weight. For these individuals, medications can be added to their lifestyle routine to treat severe obesity. The use of medications is limited to children >12 years of age. To date, orlistat, liraglutide, semaglutide, and phentermine/topiramate are FDA approved for use in children >12 years of age. These medications have side-effects and need to be used in conjunction with healthy lifestyle interventions to be effective.

What about weight loss (bariatric) surgery?

Weight loss (bariatric) surgery has worked for some adults and teens with severe obesity. Currently, the American Academy of Pediatrics suggests consideration of bariatric surgery in children greater than 12 years with class 2 obesity and a co-morbidity (diabetes, fatty liver, hypertension, dyslipidemia, or sleep apnea) or class 3 obesity alone. However, complications such as recurrence of obesity, micronutrient/vitamin deficiencies, and gall-bladder problems are common.

Conclusions

Healthy food choices, appropriate serving sizes, regular physical activity, minimized screen time, and good sleep routines are ways to achieve a healthy BMI. Talk to your child’s doctor regarding your concerns and for more information. A multidisciplinary approach including participation by your primary care physician, nutritionist, psychologist/behavioral health/social worker, and endocrinologist is beneficial especially for children and adolescents with severe obesity. Websites such as https://www.cdc.gov/nutrition/index.html or https://www.aap.org/en/patient-care/institute-for-healthy-childhood-weight/ are available to provide information for children at different ages and stages of growth.