Summary: Childhood obesity is one of the most important world health crises that we currently face. Our children are developing health challenges that will impact them for the rest of their lives.  Obesity strains the body’s mechanisms of homeostasis, leading to dysfunction and disease.  Will our children have a shorter lifespan than us?

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Preface: A Personal Struggle

September is National Childhood Obesity Month. Let me begin by revealing that this is a personal theme for me: I struggled with being overweight during my childhood and into my adulthood. Sometime around 3rd or 4th grade, I gained a greater amount of weight than I was able to keep up with. The name-calling, shaming and criticisms toward me followed – often by the people closest to me – “nerd”, “look at those love handles”, “ripple” – and I became more defensive of these attacks as I grew.

I could never understand the statement, “sticks and stones may break my bones but words will never hurt me” – because the hurt was what I felt. My self-esteem was stifled and I grew distrustful of others. I shifted my attention to my studies because this was an area in which I could excel with a little more effort, maybe to the detriment of my body – not that this had to be the formula. Though, I made it through those challenging years “on a wing and a prayer” thanks to strong supportive figures in my life, who showed tenacity and dedication.

As a child, I often visualized what would it be like to be healthy and fit – but missed the mark. I had a few short successes (one was when I literally had my mouth wired shut, preventing solid food from entering!). As an adult, I sought to find the “missing link” in my understanding of how to become healthy, and this ultimately propelled me toward medical school.

My mother was diagnosed with diabetes when she was in her early forties. As I learned from medical books, I recall getting frustrated with all the complications that diabetes causes. I grew fearful of my state of health – but I had some bumps in the road – reasons to postpone. I had to study for boards; I had to prepare a talk to give to residents and faculty; I had to work a week of long hours, seeing patients worse off than me. In my early thirties, I took a chance. I bulldozed past my dislikes and hang-ups about eating the “right” foods, maybe equipped with a little knowledge of what healthy foods were. I ate whole foods, and I turned down breaded foods, pasta, soda, and desserts.

I was able to finally lose weight — not just the 10 pounds that I dreamed of — but 60 pounds! I felt so many changes come over my body through this gradual process and I felt like I got my life back on the path of health – only to realize that I was still a ways from being WELL. Is WELLNESS even attainable?

I am reminded of a story that goes like this: There were three hikers walking along a river — one of them sees someone gesturing for help in the river — one hiker jumps in to save the person and brings them ashore. Another hiker discovered yet another person struggling to stay afloat in the water. While that hiker jumps in to save them, the third hiker decides to head up along the banks of the river to discover the source of the problem – to discover the dock that had broken with many people struggling to stay on.

That is my goal in writing about childhood obesity in a children’s short story, Pepe Finds His Way. The main character of the story Pepe deals with some of the very struggles that I faced growing up. With help from his parents, family doctor and a school counselor and a leap of faith, he took a chance – and “finds his way”.

As parents, we are tasked with finding the right balance between setting barriers and providing support, protection from harm, and room to grow. In our many daily responsibilities, sometimes we can do as parents are put on the side or reduced to minimal acknowledgments. We forget to provide those little nuggets of support to our children. Pepe can succeed by taking a chance and from the support of his family and community and learns a tremendous amount about himself from this.

As we understand the factors behind childhood obesity, we should take this lesson as we find ways in which we can both protect our children from the harms of obesity and allow them to flourish.

Childhood Obesity: Understanding and Addressing a Looming Crisis

According to the Centers for Disease Control and Prevention (CDC), about one in five children in the United States between the ages of 6 and 19 is obese.  Over the last 30 years, obesity rates for children ages six to 11 have more than doubled – and more than quadrupled for those ages 12 to 19, mirroring similar trends in adults. Children are now projected to have shorter lifespans than their parents – a first in centuries – because of obesity.   

The rise in prevalence of childhood obesity is not a dilemma exclusive to more developed countries. The majority (35 million) of the estimated 42 million overweight children worldwide are actually found in developing countries.  Children who are obese or overweight are likely to remain that way as adults.  

Along with carrying excess weight comes an increased risk of developing chronic health conditions, such as diabetes mellitus and heart disease – and at an earlier age. These conditions decrease quality of life and increase health expenditures from hospitalizations, clinic visits, and medications.  For these reasons, preventing and managing obesity in childhood represents a critical public health initiative.     

This chapter will outline the definition of childhood obesity, the possible reasons behind the increase in prevalence, the health risks, and several ways to address it. 

What is Childhood Obesity?

One way to determine obesity is through body mass index (BMI) determinations. BMI is a tool used to determine an individual’s risk factors, using weight and height parameters. Any child whose is higher than the 85th percentile of BMI is considered overweight; a child is higher than the 95th percentile is considered obese. The result is compared with children in the same age groups. Obese children, therefore, are those whose BMIs are higher than 95 percent of their peers.

Body mass index has some disadvantages in determining obesity, as it does not differentiate the distribution of weight (e.g. muscle and bone versus adipose tissue). Other measurements such as body fat analysis and skin fold thickness can be useful.

The Dangers of Obesity in Children

Obesity represents a serious threat to the health and wellness of our youth. Such individuals are highly susceptible to a myriad of chronic health conditions. The harms of obesity cut deeply. Not only is the body affected, but also the mind, as it can hamper a child’s developing self-esteem and self-confidence. Furthermore, obesity can be stigmatized and impact a child’s social development and opportunities.

1. Diabetes mellitus and metabolic conditions
 

Obese children are at a four times higher risk of developing type-2 diabetes mellitus, and the risk is proportionate to excess weight. Diabetes is a medical disorder in which the body is not able to metabolize glucose properly, leading to excess glucose in the blood. The endocrine system normally permits only a narrow range of glucose levels in the blood (homeostasis), between blood sugars of 70-100. In Type II diabetes, the activity of insulin is impaired by excess adipose (fat) tissue, a condition known as insulin resistance. There is also a depletion of pancreatic beta-islet cells, resulting in decreased production of insulin. This leads to higher blood glucose levels, as insulin is no longer able to manage it. A host of problems ensue, including cardiovascular, kidney, nerve, eye and immune dysfunctions.

Although most obese children will not develop diabetes during their childhood, the pancreas compensates with increased levels of insulin for glucose homeostasis. This can lead to various metabolic changes such as acanthosis nigricans, increased triglycerides and low HDL and conditions such as Polycystic ovarian syndrome (PCOS). Therefore, a normal glucose test result in a child may provide a false reassurance, as underlying decompensation in obesity continues.
 
Fortunately, these conditions are largely preventable and reversible through diet and lifestyle changes, as the gradual weight loss leads to a stabilizing of the endocrine dysfunction. Literally, as the adage goes, an ounce of prevention is better than a pound of cure.
 

2.      Heart Disease

Within an obese child is a heart that has an increased workload, under the strain of greater adipose tissue. Consequently, heart muscle tissue increases in size (hypertrophy) and blood pressure elevates, as the heart gradually remodels to maintain homeostasis. After a certain point, this compensation becomes unstable, leading to conditions such as diastolic dysfunction and a decrease in cardiac output.

Obesity, with its multiple co-associated heart disease risk factors, leads to the development of atherosclerosis and puts children at an increased risk of developing heart disease as adults. In a Norwegian cohort study of 227,000 adolescents, those in higher BMI categories (>85% percentile) had a relative risk of 2.9 (males) and 3.7 (females) of having death due to ischemic heart disease at the end of the follow-up period (mean 34.9 years) (Bjorge et al).
 

3.      Asthma

Asthma is a condition that is characterized by reversible inflammation of the airways of the lungs. Obesity is the most common co-morbid condition in asthma. Co-morbidity refers to when two diseases occur in the same individual at the same time. Thirty-eight percent of people with asthma are also obese.
 
An article by Baffi et al. published in The Journal of Asthma Research and Practice in 2015 sought to explain factors behind the asthma and obesity connection. Although the reasons are not completely clear, altered airway mechanics in obesity, systemic and airway inflammation, and metabolic changes may contribute to this airway inflammation. In obesity, a child is also at an increased risk for more severe bouts of asthma.
 

4.      Sleep Disorders

The extra adipose tissue in the oropharynx (throat), neck and chest wall can contribute to obstruction of air movement during sleep.  Snoring is common and sleep apnea may develop. This condition obstructs airflow and reduces the oxygenation of blood.  The heart compensates to some degree.  The sleep state is impaired from the process, and sleep efficiency is disrupted. Daytime fatigue, impaired attention and an increased association with further obesity result.

5.      Joint Pain

An obese child is susceptible to developing stiffness and pain in their joints, as well as having a limited range of motion. This is a direct result of carrying excess weight. With every step taken, an estimated force of 1 and 1/2 times the total body weight is produced (e.g a 100-pound child places 150 pounds of weight on his knee with each step). Ongoing increased force on the tendons and joints may lead to injuries and the development of osteoarthritis later on as adults (joint degeneration). Accordingly, weight loss can mitigate the development of worsening joint problems.
 

6.      Social and Psychological Problems

Children and teenagers who are obese are highly susceptible to social and psychological problems, such as loneliness, anxiety, sadness, and depression. The correlation of obesity and depression centers around sham, parental separation and parental employment in a Swedish study on depression in 4703 adolescents ages 15 to 17, who were asked to report their BMI and fill out a psychological assessment survey (SALVe).  These factors suggest that social stressors are a pervasive antagonist to depression in obesity. An obese child may be subjected to negative social interactions, including stigma and bias, bullying and exclusion. This can lead to shame and perpetuate the problem with the psychological fallout of increased risk of eating disorders, depression, anxiety, suicide, addiction and abusive behavior.

 7.      Obesity Increases Cancer Risk       

Cohort studies have shown associations with obesity and numerous cancers (National Cancer Institute), such as found in the breast, cervix, colon, esophagus, gastric, endometrium, pancreas, kidney, liver, ovaries, prostate, thyroid, and bone marrow (multiple myeloma and Hodgkin’s lymphoma).  The mechanism of increased cancer risk may be related to chronic inflammation associated with obesity, insulin resistance and higher insulin levels (insulin is a growth factor) and immune dysfunction associated with obesity. 

Causes of Obesity

There are a number of factors that can predispose a child to obesity. Culprits include a decline in activity, dietary and other lifestyle changes, genetics and epigenetics (which are also not completely static risk factors), psychological issues, and environmental. It is generally agreed upon that the most significant factors behind childhood obesity are poor dietary intake, physical inactivity, and more sedentary behavior (child and parent alike!).

Dietary Factors

A child’s diet has changed very much over the last few decades, in keeping with what has happened in the dietary patterns of adults. Not only have the portion sizes of food served and packaged increased, the number of restaurants has increased (*by 75% between 1977 and 1991), as the US American palate became more sensitized to higher fat and sugar diets. Which macro-nutrient is the culprit behind obesity, excess fat or sugar, or even both?

Fats
In 1977, in an effort to reduce cardiovascular disease which was increasing, dietary guidelines recommending a “low-fat diet” were released. This led to food industry changes to produce foods that were low in fat or “fat-free” with not a similar significance toward the carbohydrate content. While the U.S ate foods that were more processed and low in fat but laden in sugar, an obesity crisis sparked like none other.

While fats are vital to the body for the formation of cellular membranes, myelin sheath and production of steroid hormones, there are different forms of fat, those that are a result of processing and those that are found naturally, “bad fats” and “good fats”, respectively. Bad fats, like trans-fats and saturated, typically include hydrogenated oils and animal fats (lard). Trans-fats are used in a wide array of products as they help ensure that those foods are less likely to spoil. You can find good fat (or polyunsaturated fats) in sources such as avocados, olive oil, nuts, fatty fish, flaxseed, and sunflower seeds.

Childhood obesity correlated with a higher percent fat intake in some studies. Though, it is possible this higher fat intake was proportionate with an increase in carbohydrate intake or that there were other influences (e.g. parental habits) that led to obesity. To the extent that a higher fat diet – the Mediterranean diet (46% of total energy from “good” fat) can lead to weight reductions, raises some speculation as to how responsible fat is in childhood obesity.

Sugars

Several studies have found an association with obesity and an increased consumption of sugar-sweetened drinks, such as soft drinks, fruit juices and sports drinks. Coinciding with the rise of the obesity epidemic are increases in total caloric intake from sugary drinks, which increased by 60 percent in children ages 6 to 11 from 1989 to 2008. One can of soda averages about from 150 calories per day, while children are taking in larger bottles of up to 250 calories – with sugars comprising all of these calories. For those of you whose children (and you) tried a boba tea and got hooked — there are plenty of good reasons — one 16 ounce boba tea may have from 250 to 400 calories – that is about 60 to 90 grams of sugar in 16 ounces!

Consuming your daily intake in liquids with refined sugars and high fructose corn syrup is harmful, with harm increasing by dose. These drinks have a straight ticket to absorption in the duodenum and rapid shift of glucose in the liver and bloodstream (see diabetes section), necessitating a compensatory rise in insulin production. Because of such a multitude of health harms that are caused by sugary drinks, maybe the surgeon general ought to label in the back of soda cans that the consumption of sugary drinks has been linked to obesity, diabetes and other chronic health risks, in essence that the consumption of sugary drinks is harmful to your health.

Controlling Obesity in Children

Managing obesity comes down to making better diet and lifestyle choices, such as:
1.      Get your child involved in the process (Read labels or eat food that doesn’t need them!)  

Involve your children in their wellness journey. Take them to the grocery store and have them pick wholesome foods that they prefer. Maybe they can try samples of foods they may not be aware that they would like. Maybe instruct them on how to prepare and cook the food. Another idea would be to work with your child in determining the preparation of vegetables s/he likes best. If your child has already become used to consuming large quantities of sugar, it could take some time for their taste buds to adjust. Consider replacing those highly-processed and high-sugar foods with fruits, nuts and vegetables. Fruits are especially convenient since they are sweet, nutritious, and leave the child feeling satisfied thanks to the fiber.
 
2.     Carbohydrate and Portion Control
 
A greater intake of processed carbohydrates leads to excess weight. It is as simple as that. A lot of foods that are labeled as ‘fat-free’ are laden with sugar. Processed foods, in particular, are full of carbohydrates, long chains of sugar molecules. This is why nutritionists generally advise against consuming a significant amount of processed foods, preferring a whole foods, plant-based diet. A good rule of thumb is that as food is less processed, there will be less salt and sugar added and less ingredients on the label – even to the point that there are no labels!

Cutting down on the amount your child eats in a single meal will help in reducing their weight since the body will start mobilizing fat stores to make up for the reduction. A good strategy would be serve a meal with several small plates, so as to give the illusion of more food. Ensure that your child is having at least three meals a day. Less than this will encourage snacking or overeating. Also, watch the TV time snacking, keep snack food out of sight and out of bedrooms, as they all encourage overeating.
 
3.      Reduce Sedentary Time
 
A recent report revealed that teenagers are spending an average of 9 hours a day in front of a screen, whether it is smart phones, computer, or TV. They also spend about 70 percent of their time in school sitting down. As such, children today spend most of their time sitting down.
 
Leading a sedentary lifestyle predisposes an individual to risks of obesity, diabetes, cardiovascular disease, and even early death.
 
Parents are advised to limit the amount of time spent in front of all screens to two hours per day. Also, consider removing the TV in their bedroom since kids with TVs in their bedroom have typically been found to be overweight.
 
4.      Encourage Exercise
 
The CDC recommends that children should get at least 60 minutes of exercise every day. This should include activities such as running, jumping, aerobic exercises, and strength training. Ensure that the activities get the child breathing hard.

Sometimes (who am I kidding – all the time) screen time can compete with exercise and outdoor time. It is frightening to think that an average child spends less time outdoors than a prisoner. Researchers in “forest bathing,” a direct translation from the Japanese shinrin yoku, have determined countless benefits of getting outside, particularly into nature, including stress reduction, improved sleep and improved mood. How beneficial that would be a child – and sharing it with his/her parents! You can also imagine how the feast of the senses a child realizes in nature can’t be duplicated playing a video game.
 
5.      Check their Mental Health
 
Look for signs of stress and anxiety in your child as they can take to snacking as a coping mechanism. A child grapples with a lot of stress growing up – how they relate to their parents, fears and anxieties about change, and determining how they relate to others. As such, try and be aware of everything that is going on within your child’s life. They should know that you are also their friend and ally in addition to being their parent or guardian. Seek professional help for them if you have to.
 
6.      Lead by Example
 
Kids normally adopt their parents’ lifestyles. Therefore, if you also lead a sedentary lifestyle, barely get any exercise, and indulge in a poor diet, your child is more than likely going to follow this example. If you are leading a healthy lifestyle, it is much less likely that your child will end up being obese.
 
If you do not want them watching TV or playing video games for hours on end, consider limiting your own TV and smartphone time as well – and set those limits for your children. Additionally, be active and ask them to join you in your exercise routines. Also, teach them how to prepare meals so that they do not resort to snacking when you are not around.

7. Leverage a team to address the situation of sugary drinks in school cafeterias and vending machines,etc. Some communities have been successful in reducing total sugary drink consumption through the use of informative ads and commercials, informing the general public of the harms. A list of other options, including charging a sugar tax on each can, is provided.

Conclusion

The majority of contributors to obesity in children are highly-manageable, but cannot be addressed successfully in a vacuum. Start with prioritizing physical and mental health in you and your children. A proactive approach towards leading a healthier lifestyle on the side of the parent and partnering with your children on their health journey are often a good start. There will always be ways in which poor dietary options, sugar-laden food and drink can find their way to your child’s plate (birthday parties, cafeteria food, vending machines, fast foods,etc). With a greater understanding of which foods promote obesity and why, a child may be more likely to consume less of these foods – and replace with them healthier options.

“Child hunger and child obesity are really just two sides of the same coin. Both rob our children of the energy, the strength and the stamina they need to succeed in school and in life. And that, in turn, robs our country of so much of their promise.”

— Michelle Obama

Thanks for reading this. If you have found useful, please share it. A link to a helpful summary in the form of a patient education hand-out is provided.

References:

Bjørge T, Engeland A, Tverdal A, Smith GD. Body mass index in adolescence in relation to cause-specific mortality: A follow-up of 230,000 Norwegian adolescents. Am J Epidemiol. 2008;168:30–7.

Chinali M, de Simone G, Roman MJ, Lee ET, Best LG, Howard BV, et al. Impact of obesity on cardiac geometry and function in a population of adolescents: The Strong Heart Study. J Am Coll Cardiol.

Sahoo, K. et al.  Childhood Obesity: causes and consequences.  J Family Med Prim Care.  2015 Apr-Jun; 4(2):187-192.