Looking at Childhood Obesity

A review of complications, causes, prevention, and treatment

By Rebecca Fahlgren, MS, OMS II

Part I | Part II | Part III

Statistics
The prevalence of childhood obesity has increased dramatically in the past 50 years.19 From 1963-1970, the National Health Examination Survey (NHES II) found that in children ages six to 11 only 3.9 percent of males and 4.3 percent of females were overweight.

From 1988-1994 the National Health and Nutrition Examination Survey (NHANES III) found that in children ages six to 11, 11.4 percent of males and 9.9 percent of females were overweight.

In 2005, among children and adolescents ages six to 19, 16 percent were overweight or obese and 31 percent were either overweight or at risk for being overweight, 4 showing that twice as many children are overweight today compared to 25 years ago.16

This means that approximately nine million American children over the age of six are obese and “the prevalence of childhood obesity is growing exponentially.” 20 The health, medical, and social impacts of childhood obesity continue into adulthood. It is likely that overweight children will become overweight adults. 4 Preventing childhood obesity is important because the earlier in life a child becomes obese increases the level of obesity in adulthood. 17

According to the American Academy of Pediatrics and the Institute of Medicine (IOM) a child’s level of obesity can be assessed by comparing the child’s body mass index (BMI) with specific charts of age and gender norms developed by the Center for Disease Control and Prevention (CDC). 21, 8

BMI is a measure calculated using height and weight and for children is expressed in the form of percentiles to represent the amount of excess body fat. 21

Excess body fat is the amount of body fat that is adequate to cause adverse health consequences. 21 The higher a child’s BMI, the greater the percentage of body fat. Therefore, BMI correlates with indicators of secondary complications of obesity including blood pressure, blood lipids, blood lipoproteins, and long term mortality. 8

Children with a BMI between the 85th and 94.9th percentiles are considered to be at risk for being overweight. Prior to 2005, children with a BMI greater than or equal to the 95th percentile were classified as overweight. 16, 21 In 2005, the IOM reclassified children between the ages of two and 18 with a BMI greater than the 95th percentile as “obese,” to convey a serious, urgent, medical problem with a need to take immediate action in the form of a multimodal treatment approach. 21

After assessing BMI using height and weight, the amount of a child’s body fat can be measured using a triceps skinfold thickness test. A skinfold thickness greater than the 95th percentile attributes a high BMI to excess fat rather than an increased lean body mass or a large body frame.

Depending upon the method of fat measurement the age and the sex of the child, the correlation coefficient between BMI and body fatness ranges from 0.39 to 0.90. However, there is some debate on the validity of skinfold thickness measure tests as a determinant of body fatness in children because no anthropometric quantification of fat distribution has been established for children.8

Physiological Energy Balance
Obesity in childhood results when equilibrium in a child’s energy intake versus output is disturbed; this idea can be represented by the energy balance equation. The energy balance equation for children is based on the state in which energy intake equals energy expenditure supporting normal growth and there is no net weight gain or weight loss, i.e., total body energy= energy intake + energy output.27

Energy intake consists of food and drink consumed and is regulated by the hunger and satiety centers of the brain. Energy output can occur through voluntary actions such as physical activity and involuntary actions such as mechanical and biochemical processes of the body. 21, 27

Body weight is controlled by precise physiologic systems with multiple pathways involved in adiposity development, regulation of food intake, and energy expenditure.17 Physiologic mechanisms that regulate and maintain energy balance are so precisely controlled that any factor that increases energy intake or decreases energy expenditure, even slightly, is likely to cause obesity. 15

The interaction of chemical signals between the brain and digestive system helps regulate appetite control and thus control energy balance. Leptin, insulin and ghrelin are key afferent signals affecting energy/food intake. Efferent pathways regulate body weight in response to afferent signals to influence appetite and energy expenditure.17

The hypothalamic arcuate nucleus contains agouti related protein (AgRP) and neuropeptide Y (NPY), anabolic proteins, and Pro-Opiomelanocortin (POMC), a catabolic protein. 17 The cleavage of POMC yields other proteins; two are ACTH and alpha-melanocyte-stimulating hormone (alpha-MSH).27 The arcuate nucleus, that releases AgRP, NPY and POMC is the first order neuronal target of leptin and insulin and projects to the lateral hypothalamic arcuate nucleus (LHA) and the paraventricular nucleus (PVN).17

The LHA and PVN contain the second order neurons involved with fine control of appetite and energy expenditure. The LHA releases anabolic polypeptides such as melanin-concentrating hormone (MCH). The PVN releases catabolic neuropeptides such as thyrotropin-releasing hormone (TRH) and corticotrophin-releasing hormone (CRH).17

In return, neuropeptides released from different areas of the body target the brainstem that communicates with the hypothalamic arcuate nucleus to release the chemicals AgRP, NPY and POMC.17 For example, the stomach releases ghrelin and bombesin related peptides and the small intestine releases cholecystokinin (CCK) and glucagon-like peptide 1 (GLP1).27 CCK, bombesin related peptides, CRH, alpha-MSH and GLP1 are some chemical signals that decrease food intake.

Signals that increase food intake are NPY, MCH and ghrelin. When food intake occurs, increased concentrations of amino acids and glucose in the blood stimulate insulin release. Insulin stimulates enzymes for glycogen synthesis and inhibits enzymes for glycogen breakdown, creating fat stores. An increase in fat stores leads to an increase in leptin. If the physiological system is properly working, leptin is then released to decrease appetite by inhibiting NPY.27

Physiologic mechanisms that promote growth and adiposity in children are constantly changing in order to support necessary physical and developmental needs. These changes are manifested as the various growth spurts that occur in childhood.

A commonly held though inaccurate assumption is that all children will lose their excess fat during these growth spurts. A child’s biochemical processes increase during periods of growth, such as when bone length is increased. This does not mean that excess fat stores will be utilized during this period. Therefore, the energy output may have increased as represented by the biochemical processes to allow growth of the child, although energy input to fuel this growth may not be taken from excess fat stores. For this reason, a child’s proclivity toward obesity is assessed by examining the consistency of the child’s BMI percentiles over time.21

Critical periods for the development of obesity occur during the first year of life and puberty.17 During infancy a rapid rate of hyperplasia and hypertrophy of adipose tissue occurs. After the first year of life a child’s BMI falls as the rapid rate of fat deposition decreases. Once a child reaches four years of age, however, BMI begins to increase.

Another period of time a child experiences changes in adiposity is during puberty. An increase in body fat following rapid maturation may predispose a child to the development of obesity. Rapid maturation is shown by markers of menarche, stage of puberty, or peak of height velocity. Research has shown that children who mature faster are more obese than children who do not mature as fast. 17

Complications and Causes of Childhood Obesity

Health Complications
Due to its increasing prevalence in the United States, childhood obesity has been ranked as a “critical public health threat.” 21 Obese children face an increased risk for serious diseases and health complications. Childhood obesity causes both immediate and long-term risks to physical health. Psychological and emotional consequences to childhood also are apparent. There are many diseases recognized as stemming from childhood obesity.

Type 2 Diabetes Mellitus
Prior to the rise in childhood obesity, immune-mediated type 1a diabetes accounted for the majority of diagnosed cases of diabetes mellitus among children and adolescents. 18 Now more than twice the number of children are diagnosed as having type 2 diabetes compared to type 1 diabetes. 16 The increasing prevalence of overweight children closely parallels the increasing number of type 2 diabetes mellitus cases in children, suggesting that obesity is a major cause in the development of type 2 diabetes mellitus in children. 18

Diabetes mellitus is classified as hyperglycemia resulting from inadequate insulin secretion or abnormal target cell responsiveness to insulin. Although glucose is the main source of fuel for the body, excess glucose is stored as fat. In order for glucose to be used as fuel, insulin is secreted from the pancreas and binds to a receptor on the cell membrane that activates a GLUT transporter. The GLUT transporter then facilitates glucose uptake by the cell.27

After a meal, when the digestive system has broken down carbohydrates into glucose; the glucose is absorbed into the blood causing a rise in blood sugar (glucose). The rise in blood sugar stimulates insulin secretion. Finally, insulin is released to bind and activate GLUT transporters that then causes glucose to be transported into the cells. This process leads to decreased blood glucose levels.27

Moreover, an individual with type 2 diabetes mellitus is said to be insulin resistant. The diminished ability of insulin-sensitive tissues, especially skeletal muscle, to respond normally to insulin at a cellular level defines insulin resistance. Visceral adiposity, or excess fat stores around internal organs, promotes insulin resistance to a higher degree than subcutaneous adiposity, excess fat stores related to the skin. Therefore, obesity is strongly related to insulin resistance.

When obesity is coupled with relative insulin deficiency or reduced insulin sensitivity a person is at risk of developing type 2 diabetes mellitus.18 Type 2 diabetes mellitus can be physically observed in children and is manifested as an overweight condition and acanthosis nigricans. Acanthosis nigricans is benign, coarse, hyperpigmented areas in the folds of the neck or axilla that is associated with insulin resistance and can be seen in children.8

Childhood onset of type 2 diabetes causes serious complications at young ages. Complications include: atherosclerotic cardiovascular disease, stroke, myocardial infarction, sudden death, renal insufficiency, chronic renal failure, limb-threatening neuropathy or vasculopathy and retinopathy leading to blindness. 18 These complications are serious and life threatening in adults as well as children. Therefore, type 2 diabetes mellitus and obesity are both related to excess fat stores and can have physical manifestations beyond being overweight and serious health complications.

Cardiovascular Disease
Obese children present many risk factors for cardiovascular disease including hypertension, dyslipidaemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction and hyperinsulinaemia. These combined risk factors have been identified in children as young as five years old.15 One study found 19 percent to 31 percent of obese children had elevated systolic or diastolic blood pressure.

Another study found children ages five to 17 who had a BMI above the 95th percentile had abnormally high lipid levels with odds ratios of 2.4 for elevated total cholesterol, 3.0 for elevated LDL cholesterol, 3.4 for reduced HDL cholesterol, and 7.1 for increased triglycerides.19 “Among adolescents and young adults who died of traumatic causes, the presence of cardiovascular disease risk factors correlated with asymptomatic coronary atherosclerosis, and lesions were more advanced in obese individuals.” 15

Moreover, risk factors that cause complications during childhood dramatically increase the likelihood of these complications persisting into adulthood. High cholesterol, elevated triglycerides and hypertension presented in childhood leads to heart disease, heart attack, stroke, and congestive heart failure earlier in adulthood. 16 A cohort study found that being overweight during childhood increased the risk of death from ischaemic heart disease in adulthood two-fold over 57 years. 15

Other Disorders
Childhood obesity is related to other disorders, such as endocrine and orthopedic disorders. Particularly in females, excess fat can cause endocrine abnormalities of the reproductive tract. Polycystic ovarian disease has been observed in obese females. Research has shown an association between obesity at age 14 and symptoms of polycystic ovarian disease in adulthood.17 Polycystic ovarian disease is commonly presented with oligomenorrhea, an irregular menstrual cycle, or amenorrhea, a suppressed or stopped menstrual cycle. 8

Hirsutism is another endocrine imbalance that can be associated with obesity. Hirsutism is heavy growth of hair that is often an abnormal distribution associated with excess androgens, or male reproductive hormones. The abnormal signaling that causes hirsutism also can result in obesity in affected children. 8

The excess weight that obese individuals have to carry and move causes orthopedic disorders.

Orthopedic consequences of obesity include slipped capital epiphysis and Blount’s disease, a growth disorder of the tibia that causes the lower legs to bow.17, 8

A slipped capital epiphysis occurs when two unfused portions on the neck of the femur (epiphyses) “slip” apart, usually during the adolescent growth spurt. If not corrected, this condition can lead to permanent damage and a limping gait.

Blout’s disease is a growth disorder of the tibia that causes the lower legs to bow again due to excess load placed on the skeleton of obese individuals. These examples demonstrate that childhood obesity affects the young person’s endocrine and reproductive system, and the still developing skeletal systems.

Early Menarche
Whether childhood obesity leads to early menarche is an area of much debate. A higher amount of body fat in females can affect sexual maturation. A longitudinal study showed that girls with an earlier onset of menarche tended to have a higher BMI and more fat than girls who had a later onset of menarche.13 This study supported the idea that obesity could lead to an earlier age of sexual maturation.

One theory is that adipose tissue contributes to the aromatization of androgens into estrogens. 13 Therefore, it has been speculated that an increased amount of adipose tissue will contribute to a greater amount of estrogens produced, which will lead to earlier menarche.

Other studies have shown that a higher percentage of body fat does not necessarily cause earlier sexual development and, instead, girls who experience early menarche do not have a greater BMI than average until after menarche had occurred.13

Respiratory Disturbances
Current research has found that obese children differ from their normal weight counterparts in terms of type, frequency, and severity of respiratory disturbances. Obese children predominantly have obstructive respiratory disturbances.

Sleep apnea and obesity hypoventilation syndrome are potentially fatal disorders that obese children can display. 8 Sleep apnea is defined as repeated periods of stopped breathing during sleep in the night, often resulting from obstructed airways. Obesity hypoventilation syndrome, also called Pickwickian syndrome, is an obstructive sleep apnea that involves soft tissue buildup around the neck area.

Studies have found obese children to have more frequent episodes of respiratory disturbances. One study showed that obese children have more respiratory disturbances during nighttime sleep than children who are not overweight or obese. Furthermore, the study showed that more obese children than non-obese children breathe through their mouth while sleeping at night. 32

Ventilation at night may be hampered when a child has enlarged tonsils. This interference is especially pronounced if a child snores heavily. 8 Reports of snoring four or more times per week were 34.8 percent for obese children, but only 15.9 percent for children who were not obese.32 Often, a child who has enlarged tonsils might have a tonsillectomy that can improve the quality of sleep.8 “The close interaction between genetic factors, central neuromotor and ventilatory control, and upper airway narrowing may culminate into clinical presentation of [sleep-related disordered breathing (SDB)] in children. Thus, obesity would predispose children to SDB through the mass loading of upper airway and respiratory muscles as well as impairment in ventilatory control.” 32

The severity of respiratory disturbances in children is increased if they are obese. Obese children also have a higher obstructive apnea index, respiratory disturbance index, oxygen desaturation index, obstructive sleep apnea, and hypopnea.32 The occurrence of respiratory disturbances in children affects their quality of sleep as well as their ability to do every day activities.

Apart from respiratory disturbances that occur specifically during sleep, obesity in children can cause respiratory problems in day-to-day activities. Obesity is a risk factor for children developing asthma.17 Development of asthma or exercise intolerance in an obese child can limit physical activity, which can further increase weight gain.15

Dental Problems
Many dental problems can arise from obesity. Snacking on foods that are high in sugar and carbohydrates leads to carious lesions. Excessive consumption of soft drinks, for example, can lead to increased risk of dental caries due to the high sugar content and increased incidence of enamel erosion from the relatively high levels of acidity in soft drinks.11 Because the presence of dental caries in primary teeth predicts future tooth decay in permanent teeth, it is an important health concern. Obese children also may have gingivitis and periodontal disease.

Obese children often do not eat adequate amounts of fruits and vegetables that contain vitamin C. Vitamin C is important in the formation of collagen, a key component of the periodontal ligament that holds teeth in place. 16 With inadequate vitamin C intake, the formation of the periodontal ligament is compromised and leads to gingivitis, gum inflammation, and/or periodontal disease.16 Therefore, the excess food consumption of obese children can lead to permanent dental problems.

Psychological and Emotional Consequences
Obese children are at risk for psychological and emotional problems in addition to the physical problems obesity causes. Psychological issues include depression, poor self-esteem, impaired relationships with peers and an overall poor quality of life compared to children of normal weight.16 One study found that severely obese youth have a quality of life score similar to children with cancer.19 Children who are at risk for being overweight or who are overweight have an increased risk for depression, anxiety, and poor social interactions that also can contribute to difficulty in school, specifically in math and science.12 Children who are overweight can develop a negative self image as young as five years old.

Adolescents who are obese show a decrease in self-esteem that is associated with sadness, loneliness, nervousness, and high-risk behaviors. 15 Another psychological disorder that obese children can develop is eating disorders. Children who feel like they can’t control eating patterns and behaviors might elicit the use of laxatives or vomiting to attempt to control their weight. 8

Environmental Causes
The rapid rise of obesity in the United States cannot be explained by human genetics and biology. Environmental factors that influence individual behaviors are thought to be the most likely cause of the rapid rise of obesity in the United States.20 Physical inactivity and poor nutrition are widely accepted causes of the expanding American waistline.31 However, less obvious environmental factors cause or contribute to the onset of childhood obesity. These factors range from maternal health during pregnancy to socio-economic conditions. Tracing these in order of most likely occurrence in childhood demonstrates that the potential to experience one or more causes of obesity is significant.

Maternal Pregnancy Factors
Over-nutrition as well as under-nutrition during prenatal development resulting in high birth weight and low birth weight, respectively, can contribute to childhood obesity. Research has shown that maternal obesity in the first trimester of pregnancy more than doubles the risk of the child becoming obese at ages two to four.21 One hypothesis states that maternal obesity increases nutrients transferred across the placenta to the fetus, inducing permanent changes in appetite, neuroendocrine function, and energy metabolism. A decrease in the amount of nutrients to the fetus also has been linked to these same changes.15

Other studies have shown that low birth weight contributes to a greater risk of obesity. Associations between low birth weight and the risk of obesity, insulin resistance, and the metabolic syndrome can be mediated through the hypothalamic pituitary axis, insulin regulation, and vascular responses. 17 One of the most widely accepted causes of low birth weight results from mothers who smoke during pregnancy.

One study looked specifically at the effects of maternal smoking among American Indians. In this study, children of mothers who smoked during pregnancy had lower birth weights and significantly greater rates of weight gain than children of mothers who did not smoke. Due to their low birth weight, these children have a much greater risk for diseases later in life as they display “catch-up” growth between the ages of one and two years old.1 The first year of life is a critical period of adipose development and catch-up growth during this time can have long term effects.

Early Child Development and Infancy
Early child development and infancy have lifelong impacts, including obesity. The intrauterine period may play a role in the development of later obesity due to the fact that a child’s food intake and body fat regulatory systems may be permanently shaped during this time period. 21, 17 Furthermore, children who are bottle-fed have a greater risk for becoming obese than children who are breast-fed.15

One theory exists that an environmental stimulus occurring at a critical period can lead to the development of obesity due to changes that occur in regulatory processes such as alterations in fat cell number, structure and function of the appetite regulation centers of the brain, and pancreatic structure.17 These changes also involve alterations in endocrine functions, resulting in hormonal imbalances as well as obesity.

A cohort study that followed children from 12 weeks of gestation through adolescence showed that “processes occurring during fetal life … have a lasting effect on adrenocortical responses to stress in boys, and on basal adrenocortical activity in girls.” 22 This data demonstrates that the prenatal environment has a far reaching impact on children beyond birth.

Race, Ethnicity, and Socioeconomic Position (SEP)
Although all racial and ethnic groups are experiencing a rise in obesity, obesity rates are higher in certain populations and geographic areas than in others. 4 Minority groups tend to have higher obesity rates than the general population. Higher obesity rates also have been found in geographic areas with lower socioeconomic position and limited access to healthy foods.20 Many studies have examined these factors and have found that minority groups are more socioeconomically disadvantaged overall.

A longitudinal cohort study over a 34-year period studied the association between SEP, race, and obesity.7 This study showed that obesity is more common in black Americans than in white Americans. It also showed that black Americans are more likely to experience low SEP, suggesting that many of the racial differences in obesity and weight gain can be explained by lower SEP. 7 The greater increase of obesity in the lower SEP populations may be a result of other factors, such as education level.

Education
Children living in high-income neighborhoods with parents who have higher levels of education are at less risk to become overweight compared to their peers in low-income neighborhoods.31, 14 There is a higher prevalence of obesity in families in which parents have lower levels of education.14, 23 The lower level of education seems directly related to lower SEP, also linked with obesity and weight gain. Lower educational levels among parents frequently means parents may have inadequate knowledge to make healthy choices, but less available money for healthy food.

Cost of Healthy Foods
The National Institutes of Health (NIH) strategic plan for obesity research observed that one cause of the increase in obesity is frequent consumption of foods that are inexpensive, high in calories, and convenient. Foods that are sweet and high in fat provide dietary energy at the lowest cost and are readily available in all income areas. Fresh fruits and vegetables are a better dietary choice and less likely to cause or contribute to obesity. However, these foods are more expensive than sweets and fats and less likely to be available in low-income neighborhoods.

Consumers with limited resources may select energy-dense diets that are high in refined grains, added sugars, and added fats as an effective way to save money. For this reason, it has been proven that low-cost items, i.e., potatoes (fresh, frozen, and potato chips), canned tomatoes, and iceberg lettuce make up 48 percent of all vegetable servings consumed. Foods that are higher in cost, but contain more nutrients, such as leafy green vegetables, only make up 17 percent of servings consumed. An editorial in the Lancelot stated that “as long as a meal of grilled chicken, broccoli, and fresh fruits cost more and is less convenient than are the less healthy options, the battle for obesity will be lost.” 15 Obese children need to learn to eat more nutritious foods, as well as the proper amount of food to eat.

Improper Portion Sizes and Food Choices
Childhood obesity can be caused by consumption of too great in amount of the wrong types of foods. The constant advertising of calorically-dense foods promotes snacking on or eating too much of the wrong types of foods. According to the AHA, over the past few years caloric intake has increased by 9 percent in adolescent boys and 7 percent in adolescent girls.4 One reason for the increase in unhealthy food consumption is the busy lifestyles of parents. Parents are relying on fast food or home deliveries for meals as opposed to home-cooked meals.16 “Generally, foods prepared away from home are higher in fat, sugar, and salt than are home-prepared foods.”14 Furthermore, a study in West Virginia stated that limited grocery selections lead to smaller amounts of fruits and vegetables consumed. 12

Excessive consumption of “junk foods” leads to a corresponding decrease in consumption of preferred healthy foods. Despite the fact that portion sizes have increased tremendously, children are not eating enough fruits, vegetables, whole grain foods, or drinking enough milk. Skipping meals also has been shown to contribute to the childhood obesity epidemic.

A study of fifth-grade students showed that 3.7 percent did not eat breakfast and these students were 50 percent more likely to be overweight than students who ate breakfast.31 These studies demonstrate the importance of good food choices eaten in the proper amounts throughout the day for adequate nutrition.

Fast Food
Fast food consumption has been shown to be a major contributing factor in the childhood obesity epidemic. In the late 1970’s, fast food consumption made up 2 percent of children’s total energy. By the mid-1990s, fast food consumption by children had increased to 10 percent of total energy.

A study utilizing a household survey found that children who ate fast food consumed an average of 187kcal/day more than those who did not eat fast food. These children also consumed more total fat and saturated fat, more total carbohydrates and added sugars, less dietary fiber, and more energy per gram of solid food than the children who did not eat fast food on a typical day. It also was found that children ate 126kcal/day more on days that they consumed fast food than days they did not eat fast food. Overall, the study showed a “high level of confidence that associations between fast food and dietary factors are causally related. 9”

The decreasing consumption of fruits, vegetables and milk by children also may be related to fast food consumption. In the same study, “children who ate fast food compared to those who did not, consumed more sugar-sweetened beverages, less milk, and fewer fruits and nonstarchy vegetables.” Fruits and nonstarchy vegetables are important in a child’s diet because the low energy density, high fiber content, and low glycemic index in these foods may protect against excessive weight gain.9 Overall, children that eat at fast food restaurants consume more calories (energy intake), tend to have less activity (energy output) and will therefore gain weight.

School Food
Many children eat 5 to 10 of their total weekly meals at school. Most schools provide less nutritional food for lunches and provide more unhealthy snacks. Many schools now have vending machines with potato chips, cookies and soft drinks as opposed to crackers and 100 percent fruit drinks.16 Children who buy their lunch at school are 47 percent more likely to be overweight.12 This statistic could be due to the increased fast food availability in school cafeterias.9 Overall, children that eat outside of the home eat less nutritious meals and are more likely to have excess body fat.

Soft Drinks
Another factor that has been linked to childhood obesity is the consumption of soft drinks. The amount of soft drinks consumed has increased tremendously over the past 20 years, rising 300 percent. While consumption of soft drinks has increased by 137 percent in children, milk consumption has decreased 39 percent. “Between 56 percent and 85 percent of children in school consume at least one soft drink daily.“ Children who consume soft drinks have a higher daily energy intake than children who do not consume soft drinks. Each 12 ounce sugar drink that is consumed daily causes a child’s BMI to increase by 0.18 and causes a 60 percent increased risk of obesity. The link between soft drink consumption and childhood obesity could be due to overconsumption of calories because it is much easier to ingest energy in liquid form. It also could be because soft drinks represent energy added to a meal or snack as opposed to displacing dietary intake.11 The easily consumed soft drinks are calorically dense with low-nutritional value, thus, allowing quick consumption of excess calories and hence leading to excess pounds.

Inadequate Physical Activity
Inadequate physical activity is widely acknowledged as contributing to childhood obesity. Children who do not get enough exercise at school and home are at risk for becoming overweight and obese. Many schools have eliminated or reduced physical education programs. The American Heart Association recommends 150 minutes of physical activity per week for younger children and 225 minutes per week for older children and teens.4 However, reports show that only 8 percent of elementary schools, 6.4 percent of middle schools, and 5.8 percent of senior high schools provide the suggested amount of physical activity.4 The lack of physical activity in schools could be due to limited availability of gymnasiums.12 Additionally, only 40 percent of children ages 9 to 13 participate in an organized sport or physical activity.16 Close to one-fourth of children do not participate in any type of free-time physical activity.16 For children of lower-income households, this may be due to lack of access to parks or safe places to play.16 Also, some parents require their children to remain inside doing homework until they come home from work.16

Television
A sedentary lifestyle is a primary cause of childhood obesity. This is often associated with excessive amounts of television viewing and the rise in childhood obesity appears to be associated with the evolvement of video and computer games. One study found that sedentary activity of more than one hour per day was associated with a significant increase in the risk of becoming obese.31 According to the American Academy of Pediatrics, more than a quarter of all children in the United States watch four or more hours of television daily and have a significantly greater BMI than children who watch two hours or less. Research shows that the risk for obesity increases by 6 percent for every hour of television that a child watches each day.16

Part II

Genetic Influences
In recent decades, there have been no measurable changes in the genetic composition of the population that explain the significant increases in childhood obesity.21, 17 Genetics alone does not cause obesity. However, genetics can underlie a predisposition to obesity, creating genetically susceptible individuals.17 Individuals who are susceptible do not express obesity unless there is a mismatch between food intake (energy intake) and physical activity (energy output) leading to a positive energy balance.21, 17 While obesity is not inherited, some individuals may be more genetically at risk for becoming obese.25

Inheritance
Obesity is a complex disease because it is influenced by many genetic, developmental and environmental factors and is not inherited by way of single-gene dominant or single-gene recessive Mendelian laws.21, 25 Obesity is a multifactorial oligogenic disorder and cases due to defects from a single gene are rare.21, 17 Genetic inheritance can contribute to obesity, insulin resistance, components of the metabolic syndrome and low birth weight.17

At different times of life the relative influence of genes, development and environment may vary. Genes that mediate susceptibility to obesity during development may affect energy intake, energy expenditure, and portioning of energy to fat and lean tissues during development. Genes, either influenced by the environment or inheritance, may influence differences in preadipocyte proliferative activity, lipolysis, and lipogenesis.17

Heritability
Heritability is “the relative proportion of total phenotypic variance in a complex trait that is attributable to the additive effects of genes” while phenotypic variance is composed of environmental and genetic components.17 The most common environmental variations are nutritional and climatic factors. Other common environmental variations are due to maternal prenatal and postnatal effects. Observations of twins, siblings, nuclear families, and extended pedigrees have repeatedly shown that an individual has a significantly greater risk for becoming obese if they have relatives who are obese.17 “When both parents are obese, 80 percent of their children also will become obese; when both parents are not overweight, only 15 percent of their children will eventually become obese.” 25

Heritability of BMI ranges from 20 percent to 60 percent.21, 17 The most constant and highest heritability estimates for BMI come from twin studies during late childhood and adolescent periods. A study between monozygotic and dizygotic twins showed that 75 percent to 80 percent of phenotypic variation in body fat was due to genes and 86 percent of BMI variation also was due to genes.17 This finding also correlates with reports of heritability. This study also stated that the non-shared environment of twins explained the remaining variation on BMI and showed a substantially greater level of variance than the shared environment. Assortative mating also might lead to a greater level of obesity in childhood if a child is born to two obese parents. This shows a greater amount of genetic loading.17

Environment
The familial nature of obesity could result from genes that influence body weight or from environmental factors because family members usually have similar diets and exercise habits.25 Several genes have been identified as influencing BMI and fat mass. Family and twin studies indicate that genes contribute substantially to body fat accumulation and distribution.17

The Minnesota Twin Registry was used as an approach to test the influences of fetal environment on obesity later in life, independent of genetic and postnatal environmental factors. Analysis of monozygotic twin concordance rates showed that the intrauterine environment is critical for encoding adiposity later in life. There was no evidence for the prediction of future measures of BMI independent of genetic factors. It is important to note that most discordance in birth weight in monozygotic twins occurs in the third trimester. These results do not rule out long-term effects of environmental influences on later adiposity during the first two trimesters.17

Gene Disorders
To date, only six single gene disorders that lead to early onset obesity have been identified.17, 21 These disorders are congenital leptin deficiency, a leptin receptor mutation, a POMC mutation, defective pro-hormone convertase (PC1), a Melanocortin 4 Receptor mutation (MC4R), and Single-Minded Homologue (SIM1). All six of these disorders are rare and all involve genes in the lepti-melanocortin pathway.

Congenital leptin deficiency is a gene disorder resulting from a deletion in guanine that causes a frameshift mutation in leptin.17 In these cases, leptin treatment causes dramatic weight loss in obese individuals. A mutation in the leptin receptor results in a truncated receptor that lacks intracellular signaling capabilities.17 POMC gene defects result in a deficiency of some or all of its peptides derivatives including ACTH.17 PC1 cleaves POMC into alpha-MSH and ACTH; therefore, a defect in PC1 also results in peptide derivative deficiencies.17 MC4R mutations are the most common form of monogenic obesity that result in signaling abnormalities of leptin.17 MC4R pharmacological agonists can be used to treat this disorder. SIM1 results from a translocation between chromosomes 1 and 6 that interrupts MC4R expression.17 These six genetic disorders, however, are rare and do not account for the majority cases or the dramatic rise of obesity.

Medical Conditions
Obesity is often associated with other medical conditions. However, identifiable medical conditions that cause obesity in children are rare and do not contribute to principal factors underlying the childhood obesity epidemic.21, 8 Various genetically caused syndromes, for example, have been shown to contribute to obesity, including: Down syndrome, Prader-Willi syndrome, Angelman syndrome, Duchenne muscular dystrophy, Albright hereditary osteodystrophy, Fragile X syndrome, Bardet-Biedl syndrome, Cohen syndrome, Alström syndrome, Borjeson-Forssman-Lehmann syndrome, and Simpson-Golabi-Behmel syndrome type 1.

Several other genes are currently being studied that might contribute to obesity. Furthermore, obesity can result from endocrine disorders such as hypothyroidism, Cushing’s syndrome, hyperadrenocorticism, hypophosphatemic rickets and growth hormone resistance.17

Prevention and Treatment of Childhood Obesity
Prevention and treatment strategies for addressing childhood obesity are similar in some aspects, but distinctive in others. Prevention, in the case of childhood obesity, is defined as taking anticipatory action to thwart the occurrence of obesity. The desired outcome of preventive approaches is to prohibit weight gain in children.21 Treatment of childhood obesity is taking action to reverse obesity and involves a variety of approaches with different goals. While some treatment programs focus on managing and controlling a child’s current weight by implementing behavioral changes, other treatment programs are based on weight loss.8 Childhood obesity prevention and treatment methodologies sometimes use different strategies to promote changes that lead to a common goal: distinctive desired weight and wellness. Preventive strategies dictate long-term continuation, whereas strategies for treatment may only promote short-term changes. For this reason, treatment measures often involve strategies used in prevention in order to induce long-term changes.21

Similarities between prevention and treatment strategies are especially evident among children who are at high risk of becoming obese.21 Most importantly, parental involvement is integral to prevention and treatment of childhood obesity.23 Prevention and treatment both involve evaluation of a child’s health through screenings, as well as individualized intervention that can be carried out in a clinical setting. The primary similarity between prevention and treatment is the focus to correct inequalities in the energy balance equation. These imbalances are affected by personal factors such as age, gender, and genetic profile. However, the majority of the deviations are affected by social, cultural, and environmental factors such as family, school and community. Both prevention and treatment of childhood obesity are directed towards addressing energy imbalance and making the necessary changes in order to correct disproportions in the equation.21

Preventing childhood obesity from occurring in the first place is more effective than treating an obese child. However, changing the lifestyle and behaviors of a child and the child’s family can prove to be a daunting and difficult task. Lifestyle changes are more difficult as a child ages and as the child might become more resistant to these changes. If basic methods to maintain a child’s energy balance are put into practice at an early age, treatment of childhood obesity could be avoided. Because prevention of childhood obesity eliminates the necessity for treatment, the goal of this scientific literature review is to first provide information on prevention of childhood obesity and then to discuss potential methods of treatment if preventive measures are not successful.

Prevention
Method of Prevention
Prevention of childhood obesity can be accomplished by a variety of methods.

Currently, the definition of a child’s optimal BMI does not exist. However, CDC guidelines based on age and gender specific charts suggest a healthy weight range for children is between the 5th and 85th BMI percentiles. Utilizing the CDC charts allows BMI measures to be utilized in assessing both individual and population changes in children over time. CDC charts also allow BMI measures to be applied in order to invoke interventions. Consequently, in populations where children exceed a certain BMI threshold (for example, 75th, 85th, 95th percentiles) a goal can be established to decrease the proportion of children exceeding the threshold.21

There are many different approaches to prevention of childhood obesity. One approach involves categorizing prevention by three different levels of progression.21 Primary prevention aims to avoid the initial occurrence of childhood obesity in a population.21 This is accomplished by helping children who are at a healthy weight maintain their healthy status and not become obese. Secondary prevention is focused on early detection of obesity to limit its occurrence.21 In this case, routine screening of children, especially children at high risk for obesity, will allow obesity to be identified more readily and at an earlier age. Lastly, tertiary prevention seeks to limit the consequences of the disease.21 This is achieved by medical intervention to reduce or eliminate secondary health complications.

More recently, a spectrum of prevention has been put into practice that concentrates on the source of different preventive actions, specifically focusing on the importance of education. The spectrum consists of: education provided by the community, promotion of coalitions and networks, institutional practices undergoing changes, and manipulation of previously determined policies. All of these methods seek to educate individuals (parents, children, and health care providers) in order to strengthen their knowledge and skills to provide a healthy lifestyle for children.21

Goal of Prevention
The goal in preventing childhood obesity is to use basic knowledge and skills in order to maintain energy balance in children.

Ebbeling, et al. published an article on prevention of childhood obesity with the title suggesting a “common sense cure.” 15 In fact, prevention of childhood obesity is common sense; it merely involves making healthy dietary choices and pursuing regular exercise. Many people do not see or understand the importance of these “obvious” prevention keys due to a lack of education. This is what makes prevention a more complex task. Nonetheless, childhood obesity can be prevented with proper knowledge about the nutritional and physical activity needs of children.

The goal of childhood obesity prevention is to focus on maintaining energy balance (calories consumed and calories expended) at a healthy weight while protecting overall health, growth and develop­ment, and nutritional status.21, 24 This goal is accomplished by healthy eating and regular exercise.5, 21, 24 However, the Institute of Medicine states that “changing the social, physical, and economic environments that contribute to the incidence and prevalence of childhood obesity—especially in populations in which the problem is longstanding and highly prevalent—may take many years to achieve.” 21 This means that the ultimate goal to prevent childhood obesity involves directed social change to combine environmental and behavioral processes in order to promote positive outcomes at both the population and individual levels.21 According to the American Obesity Association (AOA), the two most critical links in prevention of childhood obesity are through families and schools. 5

Many school-based intervention studies have been conducted to demonstrate that additions made to school curriculums that educate children on proper diet and physical exercise can be successful at slowing the rates of weight gain in children. These studies include: Cardiovascular Health in Children (CHIC), Child and Adolescent Trial for Cardiovascular Health (CATCH), Girls Health Enrichment Multi-site Studies (GEMS), Middle-School Physical Activity and Nutrition (M-SPAN), Pathways, Planet Health, Sports, Play and Active Recreation for Kids (SPARK), Stanford Adolescent Heart Health Program, Stanford S.M.A.R.T. (Student Media Awareness to Reduce Television).17, 21 Overall, these studies showed inconclusive evidence regarding the effects of school-based interventions. While some studies concluded that children can be educated on factors related to a healthy lifestyle and that behavioral modifications can be made to maintain energy balance, other studies showed no evidence that school-based curriculums have any effect on obesity in children.

Education through school-based or community programs can be effective methods for preventing childhood obesity; however, the most important environment for children to learn healthy lifestyle choices is their home. Educating children alone through school-based curriculums is not sufficient to prevent childhood obesity.15 Teaching parents about proper nutrition and activity for children is necessary for prevention methods to succeed.12

While the home is the most influential environment, it is also the least accessible place to promote health. Educators such as health-care professionals and teachers only have brief opportunities to interact with parents to share information and resources. Due to the major influences that parents have on their children, parents must gain the knowledge and support they need in order to serve as a positive role model for their child’s eating habits and physical activity. 21 Therefore, resources through schools and the community can be used to inform and support parents and caregivers.21 Education allows a parent to utilize basic healthy lifestyle practices in order to act as a role model for their child.

Parents as Role Models
Parents must act as role models to their children by practicing healthy lifestyle behaviors.

Parents have a more profound impact on their children than any other source.24 Parental influence involves promoting certain values and attitudes, rewarding or reinforcing specific behaviors, and serving as role models. Because of the significant impact parents have on their children, parents are a major source of preventing childhood obesity.5, 21 In order for childhood obesity prevention methods to be effective, parents must act as a positive role model to their children.5, 21, 24

In a survey conducted by the AOA, 61 percent of parents said it would not be difficult to change their own eating and physical activity behaviors if it would help prevent any of their children from becoming obese.5 Parents who eat a well-balanced diet and who participate in physical activity cultivate the development of healthy life-style choices for their children.21, 24 These parental influences play a critical role in preventing childhood obesity.21

Unfortunately, negative parental influences can be detrimental to a child’s health and wellbeing. These negative influences have been noted through observed clustering of chronic disease risk factors in families such as obesity and sedentary behaviors.21 Many parents do not recognize an unhealthy weight in their children23 or themselves and they do not know what constitutes a well balanced diet or the amount of physical activity that their children require.21 These parents are not likely to model positive lifestyle behaviors and their children are less likely to partake in a healthy lifestyle. In order for a parent to act as a positive role model, parents must be educated on diet and exercise.

Educating Parents
Because parental influence is so significant, it is essential that parents be educated about a child’s overall health and wellness, including nutritional and activity needs.
Parents who are educated about children’s dietary and activity needs are more likely to provide a healthier environment that includes preventive measures for childhood obesity. “Higher education may increase awareness of the benefits of healthy eating and exercise habits and improve one’s ability to follow health education messages.” 23

The importance of educating parents was shown in the CARDIAC-Kinder Project. At the beginning of the study, parents and children were given information regarding proper nutrition and physical activity for the children. While a number of parents dropped out of the study, some of the remaining parents made modifications to their children’s diet and physical activity. Additionally, during the time of the child’s appointment with a physician, parents discussed information provided to them with the physician. This study supported the idea that informing both parents and children can be effective in achieving a healthier lifestyle for children. These findings also suggested that it would be effective for family health physicians and pediatricians to provide to parents and children information regarding obesity and healthy lifestyles.12

It is extremely important that physicians and other health professionals, educators, psychologists, and nutritionists be aware of parental perceptions about their child’s health, particularly for families of at risk ethnic and cultural groups, as well as families with a lower socioeconomic position. Parents often view “healthy” as an absence of illness. In a study carried out by the Women, Infants, and Children (WIC) program in Dallas, Texas, parents claimed that their child was healthy even though the child’s BMI was greater than the 95th percentile.26 Results from the CARDIAC-Kinder Project also showed that parental perceptions about their child’s health were not accurate. In this study, many parents believed their child was getting enough physical activity despite the fact that 12.6 percent of the children screened were overweight and 3.8 percent were obese.12 Therefore, it is important that parents are educated about childhood.

Despite the fact that more than 31 percent of American children are overweight, only 12 percent of parents polled considered their child to be overweight. 5 Furthermore, in the WIC study just mentioned, parents with children who were classified as being overweight did not believe that their child was overweight.26 Parents might overlook a child’s weight problem due to perceptions of what a healthy child “looks like” that differs among generations, cultures, and individuals. In this case, it is important to educate parents that obesity is never a norm for children because it leads to serious health risks during childhood that can continue into adulthood.21

It also is crucial that parents are educated on the many health consequences and risks related to obesity in children. Parents in the Dallas WIC study were unaware of health risks related to childhood obesity. Educating parents about health risks and consequences is very important because this provides motivation for the parent to change risky behaviors.26

Pregnancy and Breastfeeding
Once a parent gains knowledge about children’s health, he/she can practice basic preventive methods. Some processes involved in prevention of childhood obesity begin during pregnancy and during the time a child is breastfeeding.

It is critical that prevention of childhood obesity begin early, occurring at or before the time a child is a toddler or preschool age. Early prevention is extremely important because lifestyle patterns involving diet and physical activity begin to imprint in the child throughout these time periods and will be reinforced into childhood and adolescence.26 Remarkably, parental influences aimed to prevent childhood obesity can begin before birth. It is well recognized that good nutrition and a healthy lifestyle during pregnancy are important for producing healthy babies. Healthy decisions during pregnancy also can act to prevent childhood obesity. Research shows that many physiological functions of a child can be affected during the intrauterine period.1, 15, 17, 21, 22 If a pregnant mother pursues healthy dietary and physical activity habits, she is helping to decrease the chances that her child could become obese in the future.21

Parental influences also begin before a child has a conscious awareness of the behaviors that the parent is promoting. Research has shown that breastfeeding allows a significant amount of protection from childhood obesity,3 even if it is not the only nutrition for infants.21 The American Academy of Pediatrics recommends that breastfeeding be the exclusive method of feeding for infants during the first six months of life.3 Breastfeeding is thought to encourage an infant’s ability to regulate energy intake. This regulation allows the child to eat in response to hunger and satiety cues that eventually allows the child to have greater control in determining meal and portion sizes. Furthermore, research shows that flavors from a mother’s diet are transmitted to her child during breastfeeding. If a mother has a well-balanced diet with a variety of foods, her child is more likely to accept a greater number of foods later in life.21

Satiety Cues
Healthy practices implemented while a mother is pregnant and breastfeeding build a foundation for many crucial components of a child’s nutritional demands, including the ability to recognize satiety and to determine correct portion sizes.

Another way to help prevent childhood obesity is by parental recognition of their child’s satiety cues. Even by 6 weeks of age, an infant holds the ability to recognize the energy density of breast milk and formula. By recognizing various energy densities, the infant is then able to adjust the volume of breast milk or formula consumed in order for their total energy intake to remain relatively constant. Toddlers and young children are also able to recognize physiological fullness. Despite the portion size put in front of them, a toddler or young child will only eat until their satiety cues to turn on. However, research has shown that by the time a child is five years old, they eat what they are served. At this point, environmental cues can dominate the child’s eating behavior instead of paying attention to their own physiological satiety cues.21

The ability of a child to recognize satiety provides an important intuition that the child must continue to be aware of throughout life. In order for a child to learn to eat correct portion sizes, they must learn to recognize their own cues for physiological fullness. In order for infants, toddlers and children to recognize when they have consumed enough food, it is important that a parent does not coax the child to eat beyond his/her satiety cues. The “clean your plate” method of eating can support unhealthy eating behaviors and parents are strongly discouraged from using this technique.21 Rushing meals is another factor that discourages children from recognizing fullness. For this reason, parents must avoid rushing their child at mealtime.5 Using food as a reward is another unhealthy trap parents should avoid because it also encourages overriding satiety cues.5, 21

In order to demonstrate the importance of correct portion sizes to their children, parents should show control over how much they eat by paying attention to their own portion sizes.21 Furthermore, parents must be aware of the correct proportions for toddlers and younger children to eat so they do not provide more excessive portion sizes to their child.5, 21 Letting a child decide when he/she has had enough to eat can be hard for parents because parents often worry about their child receiving enough nutrients, food and milk. The bottom line for parents is to remember that if a child is continually able to recognize satiety cues throughout childhood, they have a decreased risk for consuming extravagant portion sizes later in life.21

Healthy Foods
A critical component in preventing childhood obesity is a child’s consumption of a variety of healthy foods.

Children consume food and beverages for many reasons. The most important reason for consumption is to provide the body with energy and nutrients for physical necessities. However, eating can surpass the need for energy and involve aspects related to social, cultural, and emotional lifestyles. Food and drink are integral in family life, celebrations, and recreational and social activities.

Food and drink consumption also provide psychosocial wellbeing because eating and drinking are pleasurable and are often used in the emotional expression and coping responses of many children. Therefore, as a parent is working to prevent their child from becoming overweight, careful consideration of these matters must be taken into account.21

Children consume foods based on palatable flavor. Innately, children prefer foods that are sweet and salty. During early childhood, toddlers begin to decide what foods they like. Food preferences decided during this time period play an important role in the types of foods a child will eat later in life.21 Parents can promote healthy eating habits to their children by presenting children with a variety of nutritious, low-energy-dense foods, such as fruits and vegetables.5, 21 A child’s rejection of a certain food is normal and expected; therefore, encouraging young children to try a variety of foods often involves offering a food multiple times. In fact, as many as 5 to 10 exposures of a certain food might be needed in order for the child to accept the food. It is not only important that children be presented with various foods, but parents need to eat a variety of healthy foods to model the importance of a well-rounded diet to their children. Research has shown that promoting healthy foods to children also occurs at school by school-based availability and accessibility of fruits and vegetables.21

As children grow older, they become more independent in making decisions about what foods to eat and how much food to eat. This is due to the child spending less time at home and more time at school and activities. For this reason it is important that parents promote healthy food choices by making them available in the home and consuming these foods themselves. If a parent eats fruits and vegetables and drinks milk, those items are available for the child to eat also.5, 21 Research has shown that a child’s consumption of fruits and vegetables is positively influenced by the availability of these foods in their home. Along with providing healthy food in the home, parents also must provide foods that make up a well-balanced diet. A balanced diet for children consists of an overall dietary pattern that provides all the essential nutrients in the appropriate amounts to meet a child’s nutritional needs, while supporting life processes such as growth without promoting excess weight gain.21

Conversely, parents can limit the availability of foods that are high in calories and sugar, especially soft drinks. However, it is important to recognize that limiting unhealthy foods is different than restricting these foods. Research has shown that when a child is restricted from eating palatable foods, they are more likely to develop a preference for these foods. With a strong preferential driving force, children are likely to eat these foods when they are away from the home, and especially in large proportions. Therefore, when a parent provides healthy food choices to their child, without restricting palatable foods, the child is more likely to make healthy decisions based on diet and portion size.21

In order for a child to receive the proper combinations and amounts of foods, parents must be educated about correct nutrition and portion sizes for their children.19 Providing a variety of healthy foods, a well balanced diet, and encouraging reasonable portion sizes are important factors of the Dietary Guidelines for Americans provided by the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (DHHS) in 2000. These dietary guidelines consist of 3 principles that provide insight into daily behaviors and activities in order to promote a healthy lifestyle.

The first principle is to aim for fitness, seeking a healthy weight and pursuing daily physical activity. The second rule establishes ways to build a healthy base for everyday eating. This includes utilizing the Food Guide Pyramid to guide daily food choices, choosing a variety of grains (especially whole grains), and choosing a variety of fruits and vegetables. The third principle of dietary guidelines builds off of the second principle in that food and drink must be chosen in a reasonable manner. A diet must consist of foods that are low in saturated fat and cholesterol, with moderate intake of total fat. Food and drink also must be chosen that moderate sugar and salt intake.29

Recently the USDA released Dietary Guidelines for 2005. The 2005 guidelines differ from the 2000 guidelines in that the Food Guide Pyramid has been replaced by “My Pyramid”. My Pyramid utilizes the same principles as the Food Guide Pyramid, but instead of generalizing recommendations it allows individuals to calculate their personal nutritional needs based on age, gender, and physical activity level.30

Physical Activity
Another crucial component in the prevention of childhood obesity is a child’s regular participation in exercise.

Preventing childhood obesity not only consists of making healthy dietary choices. Physical activity is another crucial component in maintaining energy balance in children. The IOM reports that physical activity is defined as any body movement produced by skeletal muscles and resulting in expended energy. Not only is physical activity important to maintain energy balance, it also is critical for developmental processes. Unstructured gross motor play is important in young children for optimal brain development as well as social, cognitive, and emotional development in young children.21

In order for a child’s physical activity needs to be met, a minimum of 60 minutes of moderate to vigorous physical activity is required daily for children.21, 24, 30 According to a study conducted by Veugelers, et al., participation in physical activity more than seven times per week is associated with a decreased risk of becoming overweight. Involvement in physical education classes at school two or more times per week shows a decreased risk of obesity.31

While there is a positive relationship between physical activity in parents and children,26 research has been inconclusive as to whether or not parental physical activity correlates with their child’s physical activity.21 However, data have shown that children with physically active parents are more likely to be physically active themselves. Therefore, parental support for a child’s activity level is critical and can be accomplished many ways.5, 21

Physical activity in children is often a natural, fun part of interacting with family and friends as a part of a child’s everyday routines, and is not necessarily driven by a conscious desire to exercise. One of the strongest associations of physical activity in children is the amount of time a child spends outside.21, 26 Children who play outside are generally more physically active and expend a greater amount of energy than children who do not play outside. One way parents can support their child’s physical activity is to encourage and monitor outdoor play. Monitoring outdoor play provides the safety needed for a child to participate in vigorous, necessary types of needed physical activity. In this case, the parent determines safe places for the child to play in the community (parks, sports fields, pools, gyms, etc); and should be educated on ways to identify safe places for children to play.21, 26

Participation in organized activities through school and sports is another way children are involved in physical activity. One way a parent can support their child’s involvement in an organized sport or activity is by purchasing the necessary equipment for various types of activities. Parents also can support their child by providing transportation to and from the activity.21 Additionally parents can promote physical activity through organized sports by joining a team themselves.5 However, this method of involvement can be limited by financial resources of the parent(s).

Other methods to promote physical activity are to encourage the child to try a new activity and to continue participating in an existing activity. Family outings and vacations centered around physical activity are another way for parents to promote activity.5, 21 Parents can give rewards or give gifts to their children that encourage activity, like balls, jump ropes, and sports equipment.21

Most studies involving the relationship between a parent’s education and socioeconomic position with his/her child’s physical activity have found that the child’s physical activity is positively correlated with parental education and socioeconomic position. Parents who understand the necessity of physical activity in children and who have the financial resources to enroll their children in activities, have children who participate in a greater amount of physical activity. Therefore, it is crucial that parents be educated about the need for physical activity in children.21, 26 Even if a parent lacks the financial ability to enroll his/her child in activities, education concerning different types of activities a child can participate in that do not cost money (such as unstructured outdoor play) will still allow the parent to promote physical activity to the child.21

Several programs that promote and educate families about physical activity have been studied. Some programs involved activities that the parent and child completed at home. Other programs through school and community-based centers provided education to parents and children on nutrition and physical activity. Yet another program used parent training and family participation to increase physical activity in children with low fitness levels. While all types of programs were successful at increasing physical activity levels, the programs involving education for both parents and children were slightly more effective.21

Limiting Television
By limiting the amount of television a child watches each day, parents are helping to ensure that a child receives a sufficient amount of physical activity and that healthy eating habits are being carried out.

In order to increase physical activity levels in children, time spent in sedentary activities must be decreased. This change mainly means adjusting the amount of television a child should watch per day5 Parents must be educated on the amount of television their child should watch and they should understand the relationship between the amount of television watched and the degree to which a child is overweight.26 Long periods of inactivity, ranging from two or more hours each day, is discouraged in children between the ages of five and 12 years old.21 The American Academy of Pediatrics recommends that daily television viewing, including video and computer games, be less than two hours per day for children. It also urges that children less than two years of age should not view the television at all. Additionally, the American Academy of Pediatrics advises that televisions not be placed in children’s bedrooms.2

Limiting the amount of time a child watches television or plays video and computer games not only decreases the amount of sedentary activity the child participates in, but also decreases the amount of unhealthy foods a child consumes. Snacking is common during television viewing and can lead to consumption of high caloric foods and large portion sizes. Therefore, decreasing time in front of the TV will also decrease unhealthy food consumption.21

Family Meals
Another way that parents can support healthy lifestyle choices is by insisting that families eat meals together.

Studies have shown that a child’s consumption of fruits, vegetables, grains, and foods high in calcium are associated with the frequency that a family eats meals together. Additionally, parents must reduce the amount of times that meals are eaten in front of the television as these meal-times lead to an increased amount of unhealthy foods consumed.21 Increasing the frequency that a family eats dinner together and decreasing the frequency that meals are eaten in front of the television leads to a decreased risk of obesity in children.5, 31

Monitoring Growth and Weight
While a parent’s constant observation and support are essential to prevent a child from becoming obese, monitoring a child’s growth and weight status by a health care professional guarantees good health and wellbeing.

Routine monitoring of a child’s health ensures the success of healthy lifestyle behaviors and activities engaged in by parent and child. It is not unusual for parents of an infant to be aware of their child’s height and weight, and for them to know where the child’s measurements on a standard growth curve. However, when a child becomes older, parents can be oblivious to an increasing weight problem because of the many, sporadic growth spurts.

In order to reduce the chances that a parent may overlook a child’s weight problem, regular open communication between parents and health-care providers regarding the child’s BMI trends is crucial to provide the parent with knowledge about his/her child’s growth and weight status. Because some families may not have health insurance or be able to afford a routine exam with a health-care provider, programs at schools can be used to conduct periodic assessments of a student’s BMI status in order to provide this information to the parent.21

Part III

Evidence demonstrates that one of the greatest preventive measures in addressing childhood obesity is the development of constructive parenting skills and positive role modeling.8 Therefore, the main source of childhood obesity prevention is the home. Children discover life skills and behaviors in an environment where parents participate in activities and behaviors that promote healthy living.

The key factor in prevention of childhood obesity is parental promotion of early initiation of healthy eating and exercise. Parents who eat fruits and vegetables have children who also eat fruits and vegetables. Parents who drink milk usually have children who drink milk. When parents display the ability to control portion sizes, their children also will be more likely to possess that same capability. Parents who are supportive of physical activity have children who are more physically active. Lastly, parents who watch less television have children who watch less television.

Hypothesis and Specific Aims
The specific aim of this protocol is to test the hypothesis that monthly meetings lasting 45 minutes between parents, caregivers, overweight children and a physician can lower BMI and skinfold thickness of overweight children. The general purpose is to prevent obesity in at-risk children 14 years of age or younger.

Study Design and Procedures
Participants of the study will include children 14 years of age and younger as well as the parent(s), family, and caregivers of the child. Other caregivers of the child also will be included in the study and for simplification purposes will be represented as “parents” in the study design due to their active role in the child’s lifestyle behaviors. The child’s BMI must be less than the 95th percentile and a skinfold thickness less than the 95th percentile. The child must have a consecutive history or increasing BMI’s within the last 12 months. More specific procedures are outlined below.

Following consent, the parent(s) will be asked to fill out two questionnaires. The first questionnaire will concern the family and include: health history of both the parent(s), eating history of family, and exercise history of both the parent(s). The second questionnaire will concern the child and includes: age, weight, symptoms, medications, the total number of caregivers, health history, and exercise history. The child’s BMI and skinfold will be measured by a trained professional. The parents will be asked to record daily food consumption and physical activity of the family and child. Subjects will then be scheduled for an initial visit and follow-up visits approximately every 4 weeks.

During the initial visit with the physician the child’s BMI and skinfold thickness will be assessed (if applicable) and information will be provided to the parent(s) about the health of the child. Physicians will provide educational information (in verbal and print form) to the child’s parent(s) about important dietary and physical activity needs of children. The session will include a 15 minute period for addressing parents’ questions. The parent(s) will then carry out recommended lifestyle behaviors.

Daily food consumption and physical activity will be recorded by the parent(s). In addition, all parents will be provided information about the importance of positive parental influence and role modeling. This information will include the importance of parent(s) healthy eating and exercise as well as parenting skills that promote recognizing satiety and choosing healthy foods.

Physicians will direct parents to information provided by organizations concerning nutrition and physical activity for children. Information can be accessed through the internet or by requesting information in writing.

In between visits the parent(s) will record daily food and drink intake as well as daily physical activity of both the parent(s) and the child. After the initial visit, follow up visits will consist of taking measurements of the child’s BMI and skinfold thickness and plotting measurements on growth charts. Physicians also will evaluate and discuss dietary intake and exercise of the parent(s) and child. If the physician notices unhealthy lifestyle habits of either the parent(s) or child, or if the child has a change in BMI that presents a concern, the physician can help the parent(s) re-evaluate the importance of preventing childhood obesity. Follow up visits will take 30-45 minutes to complete depending on the number of questions the family asks.

Duration of subjects’ participation will last for a total of 5 years without exceeding 14 years of age for each child. Data gathered will be assessed by looking at each individual child’s BMI trends, skinfold thicknesses, daily caloric intake, and physical activity over the five-year period. Obesity will be said to be prevented if the child’s BMI remains below the 95th percentile over the duration of the study.

Risks and Benefits Involved in the Study
There are limited risks associated with the procedures used in this study. The child could develop psy­chological conditions if the parent(s) and/or the physician focus on body image and weight as opposed to healthy lifestyle behaviors.

In order to minimize risks, necessary precautions consist of BMI and skinfold measurements per­formed by professional health care providers and physician discussion with parents. Routine physical exams between visits also can decrease risks involved in the study.

The benefits of the study are decreasing body fat and symptoms of being an overweight child.

Significance of the Study
This study is designed to answer the recurrent question of the impact of family education in preventing childhood obesity. It includes healthy nutritional and physical activity education from a physician to the family. The parent is then responsible for influencing and encouraging their child. The study’s long-term purpose and significance is that it should prevent obesity in children.

Treatment
In 1998 a landmark Pediatrics article published by Barlow and Dietz, titled “Obesity Evaluation and Treatment: Expert Committee Recommendations” stated recommendations for the screening and treatment of obese children. These same recommendations are currently used by many organizations including the CDC and AOA, with only a few, minor changes. All organizations and publications agree on five main principles for weight-management treatment of obese children in order to elicit behavioral changes to promote long-term success: early intervention, healthy eating, daily physical activity, parents and families acting as positive influences, and all changes consisting of small steps.6, 8, 10

Goal of Treatment
The goals of a weight-management program must be established.

Because obesity represents a chronic disease, frequent visits, continuous monitoring, and reinforcement is required for success.“ When treatment for childhood obesity focuses on behavior changes and is family-based, sustained weight loss can be achieved.8

The primary goal of a program to manage uncomplicated obesity is establishing healthy eating and activity, and not trying to achieve ideal body weight.”8 An appropriate secondary goal for obese children is a weight goal that consists of obtaining a BMI below the 85th percentile. With this in mind, the key to a successful weight-management program is to stress important skills necessary to change behavior and to maintain those changes.8

When a child has secondary complications of obesity an important medical goal is to improve or resolve the complication. Decreasing or eliminating these complications will not only improve the child’s health, but it also will “remind the family that weight control leads to overall well-being even if the child does not approach ideal body weight.“ Furthermore, these improvements will reinforce behavioral changes made by the family. 8

Assessment and Evaluation of Candidates
Assessment and evaluation of candidates to participate in a weight-management program must occur in order to ensure that medical risks are not being taken.

Children with a BMI greater than the 85th percentile should undergo evaluation to determine potential participation in a weight-control program. Particular attention should be given to children with a BMI greater than the 95th percentile or a child with a BMI between the 85th and 95th percentiles who has secondary complications. A child who has a recent, large change in BMI should also undergo evaluation.8, 10 Any underlying syndromes such as rare genetic syndromes and secondary complications, should be evaluated.8

Children whose parents and relatives have a history of hypertension and dyslipidaemia are at risk for severe cardiovascular conditions. These children should be evaluated carefully and those who present with hypertension and/or dyslipidaemia should participate in a weight-control program.8 Weight-control programs for children in these cases not only decrease the effects of adiposity, but they also improve the consequences of hypertension and dyslipidaemia.8, 10

Children with certain complications of obesity require a rapid weight loss program as opposed to a traditional weight-control program and should be referred to a pediatric obesity specialist or treatment center. The complications that require rapid weight loss include slipped capital femoral epiphysis, Blount’s disease, sleep apnea or obesity hypoventilation syndrome. In addition, a child who is massively obese, even if he/she does not present complications, also should be considered for care by a specialist. This diagnosis is based on physician judgment because a definition of massive obesity does not currently exist for children. Children with these complications should immediately undergo a weight-loss program implemented by a pediatric obesity specialist, as these diseases can be potentially fatal and lead to serious morbidity. In rare cases, weight loss surgery should be considered.6, 8, 10

A child with an eating disorder or depression should not participate in a weight-control program unless there is concurrence with a therapist or he/she has been treated with success for the psychological disorder.8, 10 Without successful treatment or dual therapy with a therapist, weight-control treatment may be ineffective and also could increase the adverse effects of the psychological disorder.8

Evaluation for Weight-Control or Weight-Loss Program
Specific evaluations of the child’s BMI must occur to determine whether the child should participate in a weight-control or weight-loss program.

Children less than two years of age should not participate in a weight-loss program unless specific circumstances apply, such as delayed motor development due to excess body weight.10 All children age two and older who are at risk for being overweight with no identified complications should participate in a weight-management program consisting of appropriate changes in diet and exercise. Children ages two to seven who have secondary complications and whose BMI is at the 95th percentile or greater will benefit from weight loss rather than weight maintenance. Children who are older than seven years of age and whose BMI falls between the 85th and 95th percentiles and who have non-acute secondary complications of obesity, or whose BMI is greater than the 95th percentile, should also undergo weight loss.8, 10 Weight loss for children older than age seven should consist of additional changes in eating and activity made by a clinician and should equal about one to two pounds per week10. These changes must only be made after the family has first demonstrated that they can maintain the child’s weight.8

Family Involvement
Involvement of the entire family and all caregivers is imperative for the success of the child participating in the program.

Involvement of all family members is essential to the long-term success of the weight-management program.10, 15 When the entire family and all caregivers are involved, new family behaviors are created consistent with the child’s new eating and activity goals.6, 8 If the child is the only family member who changes eating habits and activity, relapse is more likely. As the only member in a weight-control program a child might feel deprived which, builds resentment towards the program, leading to failure and decreased chances of success in the future. If caregivers do not participate in the changes being applied, but the parents do, the child receives opposing viewpoints and the program will likely fail. Clinicians also should be aware of and respect an adolescent’s increasingly independent eating and activity behaviors.8 Therefore, success requires a team effort involving the child, the entire family, and the physician.

Readiness of a Family
The readiness of the family must be evaluated in order for success of the program to occur.

In the case of childhood obesity, most of the responsibility for learning and implementing healthy lifestyle changes rests on the parents’ shoulders. Thus, family involvement is the key to successful weight-management.8, 10 However, older children who see the need to be involved in a weight-management program and who possess the means to carry out such a program, such as the ability to drive and buy groceries, carry the responsibility for themselves. It also is important to note that other caregivers such as babysitters and grandparents must be responsible for applying weight-management principles. Parents who are ready to modify diet and activity can do so successfully with young children, who may or may not be ready for change themselves.8

Families who are not ready for change often demonstrate the following rationale: they believe obesity is inevitable and cannot be changed, they are not interested in modifying diet and activity, or they express an overall lack of concern for the obese child. For families in these cases there are several ways to improve their readiness, depending on the severity of the obesity. Counseling can improve motivation of the family to begin a weight-management program. “A practical way to address readiness is to ask all members of the family how concerned they are about the patient’s weight, whether they believe weight loss is possible, and what practices need to be changed.”8 Motivational interviewing is a technique that can be used that prepares the family to change addictive behavior.8

A weight-management program applied by parents who are not ready to make changes in their children’s lifestyle can produce adverse effects, and will most likely be unsuccessful. In this case the program can not only be futile, but can be harmful to the child. A child’s self esteem may deteriorate even further and future efforts to improve the child’s weight will be unsuccessful. Parents with histories of eating disorders might find it especially difficult to manage their child’s diet and activity and should undergo evaluation by a therapist before any weight-management efforts are begun by the family.8

Involvement of Health Care Professionals
A variety of experienced professionals can carry out many characteristics of a weight-management program.

While most of the responsibility for a child to succeed in a weight-management program is up to the parents, clinicians play an important role in treatment programs. Trained nurses, nurse practitioners, nutritionists and physicians can help a family change and monitor behaviors. Counselors, such as psychologists and social workers, help a family to create successful changes in diet and activity. A team approach involving clinicians with various areas of expertise working together can provide a solid support for a family participating in a weight-control program.8

Clinician Communication With Families
Clinicians must pay careful attention to the language and the manner used in communicating with the families.

An important factor in treatment of childhood obesity is for health care professionals to be sensitive to the child and to focus on positive aspects of the child’s health and lifestyle.6 Clinicians who care for families with an obese child must treat them with sensitivity and compassion, and the conviction that obesity is an important and chronic, but treatable medical problem. Families respond best to clinicians who show understanding of the struggles that the family experiences. Clinicians who stress successful behavioral changes, rather than weight changes, influence the families in a much more positive way. When a clinician talks with the family about diet and activity, questions must be structured in an objective and non-accusatory way, with focus being given to the family’s behaviors, not characteristics of the family or child. Clinicians who are not critical about failures the family might encounter, but who are sensitive in these matters also show a more positive impact on the families participating in a weight-management program. Furthermore, clinicians should educate families about medical complications of obesity, such as hypertension, high cholesterol, heart disease, and diabetes.8

Maintenance of Baseline Weight
Maintenance of baseline weight leads to prolonged weight management.

The first step in weight control for all overweight children two years of age or older is to maintain baseline weight. This can be achieved by modest changes in diet and activity. Maintenance of baseline weight leads to prolonged weight maintenance allowing a gradual decline in the child’s BMI as they grow in height. For children who do not have any secondary complications of obesity, prolonged weight maintenance is an appropriate goal.8 The step helps the child achieve the primary goal through healthy eating and physical activity.

Gradual Changes
Small, gradual changes allow the family to adapt to and apply these changes as part of a permanent, every day routine.

Methodic, gradual, long-term changes will be more successful than multiple, frequent changes.8 Changes should not be focused on short-term diets or exercise plans that are aimed at rapid weight loss. Clinicians should recommend two or three specific changes in diet or activity at a time.8 Furthermore, these small changes must be achievable in order to avoid discouragement and to allow for normal growth processes.6 Additional changes should only be recommended after the family has shown mastery of the initial changes. The family should visit with the clinician every two weeks to allow an evaluation of the progress made and to recommend further, gradual changes.8

Caloric Intake
Reducing calorie intake is essential in a weight-management program.

The first step in reducing caloric intake is to assess the family’s typical eating habits. Asking families to describe daily eating patterns can provide insight into excessive caloric intake. Families should describe meals and snacks in a typical day and estimate daily and weekly consumption of foods high in calories and fats. Meals eaten or prepared outside the home also should be evaluated. These meals would include: food at school, meals at restaurants and fast food establishments, and meals prepared by a caregiver or grandparent. A detailed examination should be given to time periods when a child could partake in unsupervised eating such as after school, at a friend’s house, and during school activities. These unsupervised eating periods often result in a high amount of calories consumed.8

Once a family’s typical eating habits have been evaluated, changes can be made in order to produce a well-balanced and healthy advance towards eating. Counting calories is not a worthwhile approach to reducing caloric intake. Counting calories is tedious, difficult, and inaccurate,8 therefore, other strategies that are easier and more likely to succeed are used. Decreasing or eliminating specific foods that are high in calories provides a way to lower calorie intake without making the child feel hungry or deprived.8

Another approach called the “stoplight diet” puts emphasis on a balance of high-, medium-, and low-calorie foods by respectively assigning red, yellow, and green color designations to foods, without prohibiting specific foods. Green, yellow, and red light foods are determined by the amount of calories per average serving of the standard food in that food group. With this method, green light foods can be eaten more frequently than red light foods.8 Barlow and Dietz, et al. do not recommend commercial programs for reducing calorie intake in children.8 However, the AOA states that some structured weight loss programs such as Weight Watchers and Jenny Craig can be used as long as permission is granted by parents and medical professionals.6

Physical Activity
Increasing physical activity is another crucial component of a weight-control program.

A careful evaluation of daily activities provides insight into ways to increase daily energy expenditure. The most obvious ways that children participate in physical activity is involvement in organized sports and school-based physical education. However, children also expend energy through daily activities such as walking to school, walking to a bus stop, unorganized play, and chores. The reasons for daily, sedentary activities in which a child participates must be evaluated. These include the amount of time watching television, playing video games, playing on the computer. The lack of safe areas to play and lack of adult supervision are issues that also can affect a child’s sedentary lifestyle, and should be taken into consideration.8

After a child’s daily activities have been assessed, simple and obvious changes can be made to increase their energy expenditure. Defined exercise like exercise classes and videos, stationary bikes, and treadmills are usually boring to children, so activities should be focused on fun and intriguing ways to involve children in exercise.8

The most obvious way to increase activity in children is to limit the amount of TV watched, and video and computer games played, to one or two hours per day. Decreasing time in front of the television increases the amount of time a child has for active opportunities.8 Another way to increase energy expenditure is to incorporate activity into usual, daily routines. These could include walking or riding a bike to school, and playing with a friend after school instead of talking on the phone. If a parent walks a child to school, then both the child and the parent profit from the exercise.8 Vigorous activities for children include organized sports, unstructured play, and school-based physical education. Vigorous physical activity is important for a child’s wellbeing as well as involvement in a weight-control program.8

Parenting Skills
Parents must display basic parenting skills for the program to be successful.

In order for a weight-management program implemented by a family to be effective, parents must abide by basic parenting skills.10 In treatment of childhood obesity, it is important for parents to be sensitive to their child’s needs and focus attention on positive reinforcement.6 Children are always good, but their behaviors can be good or bad. Therefore, parents need to find reasons to praise the child’s behavior making sure that these praises are directed towards the behavior of the child, not the child him/herself. Children should be rewarded for their good behaviors, but these rewards should never involve food. Positive rewards for children should include activities with the parents and family.8

Most importantly, parents must act as a role model for their children by improving upon their own dietary consumption and activity level. In order to create a positive model for their children, parents can ask for rewards from their children in exchange for changes in their own behavior such as increasing time with the child or modifying diet and activity. A reward that children can provide to parents in exchange for playing catch with them might be an extra hour of sleep.8 Another important parenting skill is consistency. If a parent does not display consistency, a child’s undesirable behaviors are reinforced. Furthermore, inconsistency on the parent’s behalf will negatively affect the child’s view of the parent as a role model.8

Other parenting skills that should be put into practice are to make time each day for the family members to be together. Because success of a weight-management program depends upon family togetherness, the family members as a whole should motivate each other’s eating behaviors. Parents should insist that the family eat dinner together daily. Families also should substantially decrease the frequency of eating at restaurants because parents might have less control over food choices when they are not at home. Time for snacks should also be set aside for the family to share in together. When parents provide meal and snack ideas for the family, only healthy options should be given and all temptations should be removed. When children choose for themselves they are less likely to view their choice as distasteful. Even though the child should have some say in deciding what foods they eat, the ultimate responsibility of choosing these foods and determining a time to eat them is up to the parent. Once the parents provide the food to their children, the child should decide whether or not to eat.8

Early Intervention
Intervention should begin early, as earlier intervention promotes a higher level of success.

Intervention for weight-control should occur preferably before a child is three years of age. Earlier intervention allows for crucial changes to prevent the development of obesity during the critical first year of life17. BMI begins to increase again after four years of age. Therefore, it is important to attempt to positively impact weight control during the third year of life17. Changes are more difficult to facilitate and maintain in older children, especially adolescents8. The second critical time period for changes in adiposity occurs during puberty17. The older the child is, the higher the risk of lifelong obesity8. Intervention prior to the fourth year of life or by the latest before puberty is vital to the success of learning long-term weight control17.

Monitoring Eating and Activity
The family must learn to monitor eating and activity to allow permanent changes to be maintained.

Monitoring eating and activity guarantees that behavioral changes have occurred and that these changes are being maintained. This practice involves an active role by all members of the family and care­givers. Regular meetings of families with a clinician not only provide times to review and reinforce goals of healthy diet and activity, but also offer an opportunity for family support.8

Oversight of the program helps identify and solve problems that interfere with the program such as: people who impede changes, food consumption outside the home, lack of time for physical activity, lack of time for food preparation, and the absence of safe places for physical activity.8

If weight measurements are taken periodically at home the child may become more aware of treatment goals that can strengthen success. However, taking weight measure­ments at home can be harmful to the child if the focus of the family is aimed at body image and not on healthy eating and activity.8

Complications of Weight-Management Programs
There are a few harmful effects that can occur during a weight-control program. If rapid weight loss occurs, then a child could lose lean body mass or could develop gall bladder disease. If well-balanced eating behaviors do not occur then a child might suffer from inadequate nutrition.8 If the focus is on body image and weight loss and not on the child’s behavior, then psychological and emotional problems can arise. A child might become preoccupied with his/her weight, leading to self-esteem issues and possible eating disorders. When a parent becomes focused on the child’s weight rather than the child’s behaviors, conflict can develop between the parent and the child, leading to emotional issues.8

Treatment Available for Kansas and Missouri Children
On June 20, 2006 a news release announced that the University of Kansas and Children’s Mercy Hospitals and Clinics are uniting to form an obesity research, treatment, and community outreach center within 18 months.28 Because 24.3 percent of Kansas children and 32 percent of Missouri children are obese, the center will have a special focus on childhood and adolescent obesity. The center has a goal to serve 30,000 children in its first five years by promoting healthy eating and physical activity and will include state of the art equipment in order to accomplish these tasks.28

Discussion and Conclusions
The prevalence of childhood obesity has climbed tremendously and now includes more than 16 percent of American children who are obese. The seriousness of the childhood obesity epidemic encompasses a vast range of both physical and psychological complications and consequences. Childhood obesity can result in T2DM, cardiovascular disease, respiratory disturbances, and other disorders. Obese children also can be faced with devastating emotional consequences, such as poor self-esteem, depression, and a poor quality of life.

The primary causes of childhood obesity include an unhealthy diet and lack of proper exercise, which disrupt proper energy balance in children. These imbalances often result from lack of physical activity due to sedentary activities like television viewing and poor nutrition arising from fast food and soft drink consumption. Genes alone do not cause obesity, but genetics can underlie a predisposition to obesity if a child does not receive enough physical activity and unhealthy food choices are made.

While schools can provide some means of preventing obesity in children, the most important place for preventive measures to be implemented is the home. Prevention of childhood obesity consists of three basic rules: healthy eating, adequate physical activity, and supportive parenting. While these principles might seem obvious to some, not all parents have the knowledge necessary to prevent children from becoming obese. Therefore, it is important to educate parents about children’s health.

If preventive measures for childhood obesity are not followed or are unsuccessful, treatment intervention should occur. In order to determine whether a child should participate in a weight-loss or weight-management program, specific evaluations and assessments must occur. Treatment of a child with obesity is accomplished by a weight-control program that includes family and physician support with gradual but permanent behavioral changes addressing healthy eating and physical activity. 

Rebecca Fahlgren is currently a second year medical student at Kansas City University of Medicine and Biosciences (KCUMB) in Missouri. She received her Masters of Science in Biomedical Sciences at KCUMB in July 2006 where this article was originally written as her Masters thesis with contribution from her advisory committee: Linda E. May, PhD; V. James Guillory, DO, MPH; and Douglas R. Rushing, PhD.

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