Overweight Children
Prevalence, Problems, and Solutions (?)
David L. Gee, PhD
FCSN 547 – Nutrition Update
Summer 2004
Assessment of Overweight in
Children

1997 Expert Panel




The Maternal and Child Health Bureau, Health Resources
and Services Administration, the Department of Health
and Human Services
PEDIATRICS Vol. 102 No. 3 September 1998, p. e29
Recommends that BMI be routinely used to screen
children for overweight
Defined


Overweight as a BMI for age over the 95th percentile
Risk for overweight as a BMI for age between the 85th
and 95th percentile
Is a child’s BMI useful in predicting adult obesity?
Note: in 1999-2000, 26% of 20-39 yo were obese.
Prevalence of Overweight Children in the US
Prevalence of Overweight and
Obesity Among US Children,
Adolescents, and Adults,
1999-2002
1999-2004
A. Hedley et al.
JAMA 2004; 291: 2847-2850
C. Ogden et al.
JAMA 2006; 295: 1549-1555
Prevalence of Overweight and Obesity Among US
Children, Adolescents, and Adults, 1999-2002
(2003-2004)

NHANES

1999-2000



2001-2002



N=4115 adults
N=4018 children
N=4390 adults
N=4258 children
Adult prevalence



65.1% overweight or obese (66.3%)
30.4% obese (32.2%)
5.1% extreme obese (BMI>40) (4.8%)
Prevalence of Overweight and Obesity Among
US Children, Adolescents, and Adults, 1999-2002
2003-2004

Children 6-19 yrs

31% at risk for overweight or overweight



6-11: 37.2%
12-19: 34.3%
16% overweight
At risk for overweight or overweight




by age
2-5 = 22.6% (26.2%)
6-11 = 31.2% (37.2%)
12-19 = 30.9% (34.3%)
Prevalence of Overweight and Obesity Among US
Children, Adolescents, and Adults, 1999-2002
2003-2004

At risk for overweight or overweight




by gender
Boys = 31.8% (34.8%)
Girls = 30.3% (32.4%)
At risk for overweight or overweight


By ethnicity
White = 28.2% (29.2%b, 27%g)


Black = 35.4% (31%b, 40%g)


33.5%, 35.4%b, 31.5%g
35.1%, 30.4%b, 40.0%g
Mexican-American = 39.9% (42.8%b, 36.6%g)

37.0%, 41.4%b, 32.2%g
Type 2 Diabetes in the Young
The evolving epidemic
(review article)
Z. Bloomgarden
Diabetes Care 2004 (Apr);
27:998-1010
Type 2 Diabetes in the Young
The evolving epidemic
Prevalence

NHANES III (1988-1994)






~3000 subjects, 12-19 yo
IFG: 17.6 per 1000
HbA1c>6%: 3.9 per 1000
Diabetes (all types): 4.1 per 1000
Extrapolate: ~600,000 US adolescents with
some degree of glycemic abnormality
How many with Type 2 diabetes?
Type 2 Diabetes in the Young
The evolving epidemic
Prevalence

Sinha et al., NEJM 346:802-810, 2002


167 obese adolescents and children
4% prevalence of Type 2 DM


IGT




All in Hispanic and black adolescents
16% obese white
27% obese black
26% obese Hispanic
(UK study found risk of Type 2 DM 13.5 times
greater in Asian than white children)
Prevalence of T2 diabetes has increased significantly (2-3X)
among Indian children in the past 30 years.
Type 2 Diabetes in the Young
The evolving epidemic
Prevalence Trends

10 fold increase from 1982-1994 in Cincinnati


% of diabetic children w/ T2 increased from
9.4% (1994) to 20% (1998) (Florida)


J. Ped. 128:608-615, 1996
Pub. Health Rep. 117:373-379, 2002
~1/3rd of children w/ diabetes have T2 in
OH, AR, CA(Hispanics)

Diabetes Care 22:345-354, 1999
Type 2 Diabetes in the Young
The evolving epidemic
Prevalence


Other factors:
Gender

Girls 1.7 times more likely than boys


Diabetes Care 22:345-354, 1999
Family History

2/3rd of children w/ T2DM with at least one
parent with T2DM

Diabetes Care 23:381-389, 2000
Type 2 Diabetes in the Young
The evolving epidemic
Prevalence

Other factors (1998 study from India)


Low birthweight
High prepubertal weight
Type 2 Diabetes in the Young
The evolving epidemic
Screening



Prevalence of T2DM in young low but growing
Prevalence of overweight growing rapidly
Screening of all children not cost effective


~$10,000 per case found (Japan/Taiwan study)
ADA/AAP Consensus Position


Diabetes Care 2000
Testing >10yr if BMI > 85th pct with 1o or 2o
relative with DM, at risk ethnic group, or signs of
insulin resistance (metabolic syndrome)
Obesity and the Metabolic
Syndrome in Children and
Adolescents
R. Weiss et al.
NEJM 350:2362-74,2004
Obesity and the Metabolic Syndrome
in Children and Adolescents

Metabolic Syndrome


Cluster of metabolic abnormalities associated with
insulin resistance
Diagnosis of Metabolic Syndrome in Adults

Three or more of the following:

Abdominal Obesity




Hypertriglyceridemia (>150 mg/dl)
Low HDL




men > 40” waist circumference
women > 35” waist circumference
men < 40 mg/dl
women < 50 mg/dl
Pre-hypertension (>130/>85 mmHg)
Pre-diabetes (> 110 mg/dl)
Obesity and the Metabolic Syndrome in
Children and Adolescents
Methods






439 obese children/adolescents
31 overweight siblings
20 non-obese siblings
41% white, 31% black, 27% Hispanic
Administered oral GTT
Measured BP, plasma lipids, C-reactive
protein
Obesity and the Metabolic Syndrome in Children
and Adolescents
Criteria for Metabolic Syndrome in Children

Obesity (instead of waist circumference)

Obese = z-score >2.0 for BMI



Moderate Obese = z-score 2.0-2.5
Severe Obese = z-score > 2.5
Metabolic values




TG: > 95th pct
HDL-C: < 5th pct
Glucose intolerance following OGTT
Insulin resistance = [fasting glu]x[fasting plasma
insulin]/22.5
Obesity and the Metabolic Syndrome in Children
and Adolescents
Anthropometric & Metabolic Characteristics
Non-obese
Overweight
Moderate
Obese
Severe
Obese
BMI
18.4
24.5
33.4
40.6
Glucose
87.4
86.8
90.5
90.2
Insulin
uU/ml,<.001
10.3
14.6
31.3
38.6
Insulin
resistance
<.001
2.2
3.12
7.05
8.69
Triglycerides
Mg/dl, <.001
48.4
83.1
104.6
96.5
(mg/dl,<0.05)
Obesity and the Metabolic Syndrome in Children
and Adolescents
Anthropometric & Metabolic Characteristics
Non-obese
Overweight
Moderate
Obese
Severe
Obese
58.5
46.7
41.1
39.9
92.2
95.5
98.1
97.3
106
116
121
124
IGT
%, .01
0
3.23
14.4
19.9
CRP
.01
.05
.13
.33
HDL-C
Mg/dl,<.001
LDL-C
Mg/dl, p=.41
Systolic BP
mmHg,<.001
Mg/dl, .001
Obesity and the Metabolic Syndrome in Children
and Adolescents
Prevalence

Overall


38.7% in moderately obese
49.7% in severely obese


39% in severely obese blacks
“…metabolic syndrome is far more common
among children and adolescents than
previously reported…prevalence increases
directly with the degree of obesity.”

Prevalence of
metabolic
syndrome
increases with
degree of insulin
resistance
Health-Related Quality of Life
of Severely Obese Children
and Adolescents
J. Schwimmer et al
JAMA 289:1813-1819 (Apr 9,
2003)
Health-Related Quality of Life of Severely
Obese Children and Adolescents

Health-related QOL





Physical functioning
Emotional functioning
Social functioning
School functioning
106 children & adolescents



mean age = 12 yrs (+3)
Mean BMI = 34.9 (+9.3) (z-score=2.6)
Compared with 401 healthy and 106 cancer
pediatric patients
Obese children and adolescents reported
significantly lower health-related QOL in all
domains compared with healthy controls.
Obese children were more likely to have impaired
health-related QOL than healthy controls and were
similar to children and adolescents with cancer.
Health-Related Quality of Life of Severely
Obese Children and Adolescents
Conclusions:

Obese children and adolescents reported
impairment of total and all domains of QOL


Likelihood of impaired QOL was 5.5 times greater
in obese than healthy
Obese children and adolescents reported
similar impairment of QOL as in cancer
patients undergoing chemotherapy

Lower than children with rheumatoid arthritis,
type 1 diabetes, congenital heart disease.
Children’s Food Consumption Patterns
Have Changed over Two Decades (19731994): The Bogalusa Heart Study
T. Nicklas et al., JADA 104:1127-1140 (2004)
Children’s Food Consumption Patterns
Have Changed over Two Decades (19731994): The Bogalusa Heart Study

One 24-hr dietary recall


Seven surveys of 10 yr-olds
1584 children surveyed
Grams of food consumed by source of consumption
2000
1800
1600
1400
Home
1200
School***
1000
Restaurant***
Other***
800
Total**
600
400
200
0
1970
1975
1980
1985
1990
1995
Amount of food consumed at schools and restaurants
Increased, while the amount consumed in ‘other’ decreased.
100
90
80
grams/day
70
60
1974
50
1994
40
30
20
10
0
Desserts****
Candy****
Condiments****
Salty snacks***
Seafood
The amount of dessert and candy consumed decreased,
While the amount of salty snacks increased.
80
70
grams per day
60
50
1974
40
1994
30
20
10
0
Egg***
Pork**
Cheese****
Beef
Poultry****
Egg and pork consumption decreased, while
consumption of cheese, beef and poultry increased.
250
grams per day
200
150
1974
1994
100
50
0
Fats/Oils*
Fruits/Juices**
Veg
Bread/Grains*
Mixed Meats****
Consumption of fats/oils and breads/cereals decreased,
while consumption of fruits/juices and mixed meats
increased.
500
450
400
grams per day
350
300
1974
250
1994
200
150
100
50
0
Milk**
Sw eet Bev**
Milk consumption decreased while consumption of
sweetened beverages increased.
Amount consumed by meal
1800
1600
1400
grams per day
1200
1000
1974
1994
800
600
400
200
0
Breakfast
Lunch****
Dinner****
Snacks****
Total**
Total consumption and consumption at lunch and dinner
Increased, while consumption of snacks decreased.
Children’s Food Consumption Patterns
Have Changed over Two Decades (19731994): The Bogalusa Heart Study








Findings that may contribute to childhood
obesity
More food consumed at restaurants
More fruits and fruit juices
More cheese, mixed meat, beef, and poultry
More salty snacks
More sweetened beverages and less milk
More food consumed at lunch and dinner
More total food consumed
Children’s Food Consumption Patterns
Have Changed over Two Decades (19731994): The Bogalusa Heart Study





Surprising findings
Less food consumed at places other
than home, school, restaurants
Less fats and oils
Less dessert and candy
Less food consumed outside of meals
(snacks)
Parent Weight Change as a Predictor
of Child Weight Change in FamilyBased Behavioral Obesity Treatment
B. Wrotniak et al.
Arch. Pediatr. Adolesc. Med.
158: 342-347 (Apr. 2004)
Parent Weight Change as a Predictor of Child Weight
Change in Family-Based Behavioral Obesity Treatment

Family-based behavioral treatment

Parenting techniques




Reinforcement
Stimulus control
Environmental restructuring
Obese parents make similar behavioral
changes
Parent Weight Change as a Predictor of Child Weight
Change in Family-Based Behavioral Obesity Treatment

Participants


142 obese children (8-12yo) and at least
one parent attended family-based weight
control program
2-year study with measurements at 6, 12,
and 24 months
Parent Weight Change as a Predictor of Child Weight
Change in Family-Based Behavioral Obesity Treatment

Both child and
parents lost
significant
amounts of
weight over 6
and 24 months
Parent Weight Change as a Predictor of Child Weight
Change in Family-Based Behavioral Obesity Treatment

Parents who lost the most weight had
children who lost the most weight.
Parent Weight Change as a Predictor of Child Weight
Change in Family-Based Behavioral Obesity Treatment

Conclusions:



“Parent z-BMI change was a significant
predictor of child z-BMI change over 6 and
24 months.”
“…youth benefit the most from parents
who lose the most weight in family-based
behavioral programs.”
“…support the inclusion of parents into
family-based programs for their children.”
Reducing children’s television
viewing to prevent obesity: A
randomized controlled trial.
T. Robinson
JAMA 282:1561-1567 (1999)
Reducing children’s television viewing to prevent
obesity: A randomized controlled trial.


Many observational studies have found
associations between television viewing and
child/adolescent adiposity.
Reviewed in AAP’s Policy Statement




Pediatrics 112:424-430 (2003)
25% children watch >4hrs TV/day
BMI of children who watch >4hrs per day
significantly greater than those watching < 2hrs
per day
TV in child’s bedroom significant predictor of
overweight
Reducing children’s television viewing to prevent
obesity: A randomized controlled trial.


192 3rd & 4th grade children in two
matched public elementary school
Intervention group


18-lesson, 6-month classroom curriculum
to reduce TV, videotape, and videogame
use
Measures at 0 and 8 months
Reducing children’s television viewing to prevent
obesity: A randomized controlled trial.

Compared to controls, children in intervention
group had statistically significant relative
decreases in BMI, TSF, waist circumference,
and W/H ratio.
Reducing children’s television viewing to prevent
obesity: A randomized controlled trial.

The intervention significantly decrease
children’s television viewing and video
game use.
Reducing children’s television viewing to prevent
obesity: A randomized controlled trial.

However, reducing television viewing did not
significantly reduce:



Or increase



Frequency of snacking in front of TV
Daily servings of high-fat foods
Overall physical activity
Fitness
“Reducing television… may be a promising,
population-based approach to help prevent
childhood obesity.”
Useful references

American Academy of Pediatrics – Policy
Statement


Pediatrics 112:424-430(2003)
Society for Nutrition Education

Guidelines for Childhood Obesity Prevention
Programs: Promoting Healthy Weight in Children


J. Nutr. Ed. Behav. 35:1-3 (2003)
Childhood and Adolescent Overweight: The
Health Professional’s Guide to Identification,
Treatment, and Prevention.


M Mullen & J Shield
ADA 2004