C h a p t e r 1 0
Disorders of Nutritional Status
233
benefit of offering surgery to patients with even lower
levels of obesity (e.g., BMI >30 with comorbid condi-
tions such as diabetes).
34
Childhood Obesity
Obesity is the most prevalent nutritional disorder
affecting the pediatric population in industrialized
countries in the world.
35,36
The definition for obesity in
children is a BMI at or above the sex- and age-specific
95th percentile, while a BMI between the 85th and
95th percentile is defined as being overweight.
34
These
criteria have been selected because they correspond to
adult BMIs of 30 and 25, respectively.
37
The findings
from the National Health and Nutrition Examination
Survey (NHANES), conducted between 2008 and
2010, indicated that 16.9% of children and adoles-
cents were obese.
35
The major concern of childhood obesity is that obese
children will grow up to become obese adults. Health
care providers are now beginning to see hypertension,
dyslipidemia, type 2 diabetes, and psychosocial stigma
in obese children and adolescents. In North America,
type 2 diabetes now accounts for half of all new diagno-
ses of diabetes (type 1 and type 2) in some populations
of adolescents.
38
In addition, there is a growing concern
that childhood and adolescent obesity may be associ-
ated with negative psychosocial consequences such as
low self-esteem and discrimination by adults and peers.
34
Childhood obesity is determined by a combination
of hereditary and environmental factors. It is associated
with obese parents, gestational diabetes and excessive
weight gain during pregnancy, formula feeding, par-
enting style, parental eating habits, energy-dense food
choices, erratic eating patterns, ethnicity, and sedentary
lifestyle.
34–36,38,39
Children with overweight parents are
at highest risk. One of the factors leading to childhood
obesity is the increase in inactivity. Increasing percep-
tions that neighborhoods are unsafe has resulted in less
time spent outside playing and walking and more time
spent indoors engaging in sedentary activities such as
television viewing and computer usage. Television view-
ing is associated with consumption of calorie-dense
snacks and decreased indoor activity. Studies have
shown a 10% decrease in obesity risk for each hour per
day of moderate to vigorous physical activity, while the
risk increased by 12% for each hour per day of televi-
sion viewing.
38
Obese children also may have a deficit in
recognizing hunger sensations, stemming perhaps from
parents who use food as gratification. The impact of
fast food, increased portion size, calorie density, sugar-
sweetened soft drinks and foods (especially fructose),
22
and high-glycemic-index foods are likely contributing to
the increased weights in children and adolescents.
Diagnosis and Treatment.
Given the enormity of the
problem of overweight and obesity in children, the
American Medical Association (AMA), the Department
of Health and Human Services’ Health Resources and
Services Administration (HRSA), and the Centers for
Disease Control and Prevention (CDC) assembled an
expert committee to develop recommendations for the
assessment, prevention, and treatment of this public
health problem.
37
Their recommendations include a
yearly assessment of weight status in all children by mea-
surement of height and weight to determine BMI for age
and comparing it to standard growth charts. Children
who are 2 to 18 years of age with a BMI greater than
or equal to the 95th percentile for age and sex or a BMI
greater than 30 (whichever is smaller) should be classi-
fied as obese. Those children with a BMI greater than
or equal to the 85th percentile but less than the 95th
percentile for age and sex should be placed in the over-
weight category.
Because adolescent obesity is predictive of adult obe-
sity, treatment of childhood obesity is desirable.
36
The
goals of therapy in uncomplicated obesity are directed
toward healthy eating and activity, not achievement of
ideal body weight. Families should be taught awareness
of current eating habits, activity, and parenting behavior
and how to modify them. In children with complica-
tions secondary to the obesity, the medical goal should
be to improve that problem. The weight loss interven-
tions should include all family members and caregiv-
ers; begin early at a point when the family is ready for
change; and assist the family to learn to monitor eating
and activity patterns and to make small and acceptable
changes in these patterns.
Overweight and obese children should be treated
using a staged method based on their age, BMI, and
related comorbidities. Dietary goals should focus on
well-balanced meals with a healthy approach to eating.
Specific strategies can include reduction of specific high-
calorie foods or an appropriate balance of foods that are
low, medium, and high calorie. Commercial diets should
be used with caution. Pharmacologic therapy and bar-
iatric surgery should be reserved for children with com-
plications and for severe obesity, respectively.
SUMMARY CONCEPTS
■■
Obesity, which refers to excess body fat resulting
from consumption of calories in excess of those
expended for exercise and activities, reflects the
influences of heredity; socioeconomic, cultural,
and environmental factors; psychological
influences; and activity levels.
■■
Overweight and obesity are determined by
measurements of body mass index (BMI) and
waist circumference, which is used to determine
the distribution of body fat in terms of upper
or lower body obesity. In upper body or central
(visceral) obesity, the adipocytes release
free fatty acids and adipokines that increase
cardiometabolic risk and produce many of the
adverse effects of obesity.
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