Pediatric GI – Childhood Obesity

Overview

  • What is childhood obesity and how is it measured?

    Obesity is the term used to describe someone’s weight when it is considered unhealthy because it is too high. 17% (12.5 million) of American children are obese. Obesity typically happens over a long period of time when children take in more calories than they use. Some children are obese because they are more genetically prone to weight gain, others are obese because they eat too many high calorie foods, and others are obese because they do not get enough exercise. All of these can be due to a number of factors including decreased access to healthy foods or unsafe parks for getting exercise, among many other causes. Typically, obesity happens because of a combination of these things.

    When discussing weight, we use Body Mass index or BMI, a ratio of weight and height, and plot it on the appropriate growth curve to compare a child to their peers. People can be classified—from lowest to highest—as underweight, normal/ideal weight, overweight, or obese, with subdivisions in obese for “morbidly obese.”

    Your child’s doctor, nurse and/or school nurse may tell you that your child is overweight or obese using growth curves and by calculating the child’s BMI. Schools are becoming more aware of obesity in children and are screening children for these issues. Schools may send home letters informing you that your child is overweight or obese after measuring weights and heights at school. It is important to discuss this with your child’s pediatrician.

    BMI value is calculated using the following equations:
    English (Pounds/Inches): BMI = (Weight in Pounds/(Height in inches x Height in inches)) x 703
    Metric (Kg and meters): BMI = (Weight in Kilograms/(Height in meters x Height in meters))

    The actual value of the normal BMI varies by age in children and teenagers and therefore BMIs must be plotted on a growth curve to determine if they are elevated or not.

    BMI’s from the 85th percentile to 95th percentile for age are considered overweight.

    BMIs higher than the 95th percentile for age are considered obese.

    You can also use this BMI Calculator from the Centers for Disease Control (CDC).

Complications

  • What complications are associated with childhood obesity?

    There are many complications of childhood obesity. In general, obesity can decrease life expectancy by approximately 20%, which is about 15 years.

    Obesity increases children’s risk of many conditions outlined below including (see Figure 1):

    Cardiovascular disease or Heart Disease—Children with obesity are at an increased risk over their lifetime of heart attacks and strokes because obesity leads to increased cholesterol in the bloodstream. This cholesterol can deposit in the arteries and cause heart attacks and strokes when they are older.

    Diabetes—Children with obesity are at high risk of developing problems with Type II Diabetes in childhood and later in life. Children more commonly develop insulin resistance, which can lead to diabetes. Diabetes carries its own risks of complications including blindness from diabetic eye disease known as retinopathy, blood vessel disease leading to poor wound healing and nerve disease that leads to decreased sensation or feeling in the arms or legs.

    Knee and back pain—Increased weight can cause increased stress on joints which leads to pain. This increased weight can also cause degeneration of joints leading to arthritis at earlier ages than people who are not obese or overweight.

    Liver problems and gallstones—Extra body fat can deposit in the liver and cause nonalcoholic fatty liver disease (NAFLD). If left untreated, NAFLD can eventually progress to liver cirrhosis and liver failure. Obesity can also increase the risk of having gallstones, that can cause abdominal pain and inflammation of the pancreas. The gallbladder may need to be removed by surgery if this were to occur.

    Gastroesophageal reflux and/or Heartburn—Increased fat in children’s abdomen can increase the pressure in their abdomen and make it more likely that stomach acid, food and liquid can go back up into the esophagus. This causes irritation of the esophagus, bad breath, and even vomiting.

    High blood pressure—Obesity increases the risk of high blood pressure, which can lead to strokes later in life. High blood pressure can also increase the risk of kidney disease.

    Metabolic syndrome—Obesity increases the risk of a group of symptoms together that we call the metabolic syndrome. These symptoms include high blood sugar levels, high blood pressure, high blood cholesterol levels, and increased abdominal measurements. Having this group of symptoms together increases the risk of heart disease and diabetes.

    Sleep apnea—Increased weight around the neck can cause decreased breathing during sleep. This can lead to decreased energy levels during the day, fatigue and problems with concentration during the day. For the same reasons, obesity also contributes to snoring, which can also disrupt sleep too and cause decreased energy during the day.

    Cancer in adulthood—Obesity increases the risk of many different types of cancer in adulthood. These include cancers of the esophagus (food tube), colon, pancreas, and liver.

    Depression and low self-esteem—Children can be subject to bullying, teasing,and mistreatment by other children because of their weight. Often, this can lead to low self-esteem, school avoidance, and depression. Additionally, children may eat to feel better about these thoughts, further worsening their obesity.

    Figure 1. Complications of childhood obesity include many problems that can affect children both in childhood and later in life. These include non-alcoholic fatty liver disease, gastroesophageal reflux disease (GERD), depression, headaches, sleep apnea, asthma, cardiovascular disease, hypertension (high blood pressure), kidney disease (nephropathy), metabolic syndrome, Type 2 diabetes, and joint problems.

Risk Factors

  • What are the risk factors for childhood obesity?
    • Sedentary lifestyle/not getting enough exercise—More than 2 hours of screen time or time in front of the TV/Computer/Phone/Video game
    • Poorly balanced diets: low in fiber and fresh foods, high in junk/processed foods and sugary drinks.
    • Certain ethnic backgrounds have been shown to have higher rates of obesity such as American Indian and Hispanic children.
    • Obese or overweight family members
    • Children from low-income families are at higher risk of obesity because higher fat foods often cost less than healthier foods

    Underlying medical problems account for less than 1% of cases of obesity, and it is important to discuss this with your pediatrician or family doctor if your child is having additional signs or symptoms that are concerning. However, it is far more common that children are not choosing the best food options and are not getting enough exercise.

    Some misconceptions about childhood obesity include that children will grow into their excess pounds with their next growth spurt. It is important not to use a growth spurt as a reason for not working on diet and exercise in an overweight or obese child. Many parents may feel that the growth chart does not apply to their children because the entire family has larger body sizes. In reality, it is important that all children are evaluated on the same growth curve. The healthy weight range for a certain height does not change based on the build of the child or their family members.

Treatment

  • What are the treatments for childhood obesity?

    Lifestyle changes
    The first steps in treatment for children who are obese and for children who are overweight are lifestyle changes. Treatment of obesity in children includes changing the child’s energy balance to cause weight loss by expending more energy than the child takes in. This includes consuming a healthy diet and increased activity to help burn more calories. To lead a healthy lifestyle, the American Academy of Pediatrics recommends the following for all children—referred to as the “5-2-1 Almost none Plan:”

    • At least 5 servings of fruits and vegetables each day. A goal should be to have at least one green leafy vegetable and at least one fruit or vegetable rich in vitamin C such as oranges, strawberries, citrus juices, broccoli, or tomatoes each day.
    • Maximum of 2 hours of “screen time” for pleasure each day (not including schoolwork). Screen time includes watching television, playing video games and using computers, tablets and smart phones.
    • A goal of 1 hour of vigorous physical activity including playing outside, sports, dancing, etc.
    • Zero” or No sugary beverages. These include soda/pop, juices, and sports drinks. Children should try to consume only water. Calories from drinks like soda and juice are considered “empty” calories because they provide only calories, but no nutrition.

    Other tips for weight loss include limiting portion sizes, drinking a glass of water before meals and waiting at least 20 minutes before asking for a second helping at a meal. If drinking milk, choosing skim milk over whole milk is best. A few tips for increased exercise include getting 1 hour of sweaty exercise each day or purchasing a pedometer (something that measures the number of steps you take) and making a goal of getting in 10,000 steps a day. It may be helpful to start at 5,000 and slowly work up to this goal.

    The best way to achieve success at weight loss and to fight obesity is to live a healthy lifestyle, as described above. Having the entire family participate with these changes is a great way to encourage healthy living in all family members. Weight loss may occur slowly at first, and it is important to be patient and continue dietary interventions and increased activity.

    Medications
    If reduced calories and increased activity are not enough, medications may be used in combination with dietary and lifestyle changes to help promote weight loss. These medications are not indicated when obesity starts, and are limited in the ages when they can be used. These medications include Sibutramine, which helps to decrease appetite and is approved by the FDA for teenagers over 16 years of age. Orlistat, known by the brand names Xenical or Alli (over the counter medicines) helps to decrease fat absorption in the intestine and is approved by the FDA for teenage patients between 12–16 years of age.

    Surgery
    If medication is not successful, surgical options-called bariatric surgery- can be used to decrease the size of the stomach. However, surgical options should be considered a last resort after all other avenues for weight loss have been attempted. Gastric bypass procedures (Figure 2) are the only form of bariatric surgery currently approved by the FDA for use in teenagers, because they are the most extensively studied. Sleeve gastrectomy (Figure 3) is increasingly used as a type of weight loss surgery in teenagers. Bariatric surgery is reserved for the patients who meet the following criteria:

    1. BMI ≥35 kg/m2 and severe complications from obesity such as severe obstructive sleep apnea, type 2 diabetes mellitus, or severe and progressive nonalcoholic fatty liver disease
    2. BMI ≥40 kg/m2 with more minor complications from obesity.
    3. Physical maturity, or mature bones
    4. History of sustained efforts to lose weight through changes in diet and physical activity.
    Figure 3. Sleeve Gastrectomy. Surgical removal of part of the stomach to create a smaller stomach pouch or “sleeve.” Figure 2. Roux-en-y Gastric Bypass. A small portion of the stomach is kept in place to create a new stomach pouch. The remainder of the stomach and first part of the small intestine stay intact so that the digestive juices can be released for digestion (green arrow).

Helpful Hints

  • Helpful Hints for Families to be successful at weight loss:
    • Eat meals as a family
    • Remove TV’s from bedrooms
    • Start with daily exercise and work up to a goal of at least 1 hour each day
    • Purchase a pedometer (that measures steps) and make a goal of 10,000 steps a day
    • Limit fast food to twice a week

Author(s) and Publication Date(s)

Elizabeth Collyer, MD and Naim Alkhouri, MD, Cleveland Clinic, Department of Pediatric Gastroenterology—Published November 2015.

What is Childhood Obesity?

  • What is childhood obesity and how is it measured?

    Obesity is the term used to describe someone’s weight when it is considered unhealthy because it is too high. 17% (12.5 million) of American children are obese. Obesity typically happens over a long period of time when children take in more calories than they use. Some children are obese because they are more genetically prone to weight gain, others are obese because they eat too many high calorie foods, and others are obese because they do not get enough exercise. All of these can be due to a number of factors including decreased access to healthy foods or unsafe parks for getting exercise, among many other causes. Typically, obesity happens because of a combination of these things.

    When discussing weight, we use Body Mass index or BMI, a ratio of weight and height, and plot it on the appropriate growth curve to compare a child to their peers. People can be classified—from lowest to highest—as underweight, normal/ideal weight, overweight, or obese, with subdivisions in obese for “morbidly obese.”

    Your child’s doctor, nurse and/or school nurse may tell you that your child is overweight or obese using growth curves and by calculating the child’s BMI. Schools are becoming more aware of obesity in children and are screening children for these issues. Schools may send home letters informing you that your child is overweight or obese after measuring weights and heights at school. It is important to discuss this with your child’s pediatrician.

    BMI value is calculated using the following equations:
    English (Pounds/Inches): BMI = (Weight in Pounds/(Height in inches x Height in inches)) x 703
    Metric (Kg and meters): BMI = (Weight in Kilograms/(Height in meters x Height in meters))

    The actual value of the normal BMI varies by age in children and teenagers and therefore BMIs must be plotted on a growth curve to determine if they are elevated or not.

    BMI’s from the 85th percentile to 95th percentile for age are considered overweight.

    BMIs higher than the 95th percentile for age are considered obese.

    You can also use this BMI Calculator from the Centers for Disease Control (CDC).

Complications

  • What complications are associated with childhood obesity?

    There are many complications of childhood obesity. In general, obesity can decrease life expectancy by approximately 20%, which is about 15 years.

    Obesity increases children’s risk of many conditions outlined below including (see Figure 1):

    Cardiovascular disease or Heart Disease—Children with obesity are at an increased risk over their lifetime of heart attacks and strokes because obesity leads to increased cholesterol in the bloodstream. This cholesterol can deposit in the arteries and cause heart attacks and strokes when they are older.

    Diabetes—Children with obesity are at high risk of developing problems with Type II Diabetes in childhood and later in life. Children more commonly develop insulin resistance, which can lead to diabetes. Diabetes carries its own risks of complications including blindness from diabetic eye disease known as retinopathy, blood vessel disease leading to poor wound healing and nerve disease that leads to decreased sensation or feeling in the arms or legs.

    Knee and back pain—Increased weight can cause increased stress on joints which leads to pain. This increased weight can also cause degeneration of joints leading to arthritis at earlier ages than people who are not obese or overweight.

    Liver problems and gallstones—Extra body fat can deposit in the liver and cause nonalcoholic fatty liver disease (NAFLD). If left untreated, NAFLD can eventually progress to liver cirrhosis and liver failure. Obesity can also increase the risk of having gallstones, that can cause abdominal pain and inflammation of the pancreas. The gallbladder may need to be removed by surgery if this were to occur.

    Gastroesophageal reflux and/or Heartburn—Increased fat in children’s abdomen can increase the pressure in their abdomen and make it more likely that stomach acid, food and liquid can go back up into the esophagus. This causes irritation of the esophagus, bad breath, and even vomiting.

    High blood pressure—Obesity increases the risk of high blood pressure, which can lead to strokes later in life. High blood pressure can also increase the risk of kidney disease.

    Metabolic syndrome—Obesity increases the risk of a group of symptoms together that we call the metabolic syndrome. These symptoms include high blood sugar levels, high blood pressure, high blood cholesterol levels, and increased abdominal measurements. Having this group of symptoms together increases the risk of heart disease and diabetes.

    Sleep apnea—Increased weight around the neck can cause decreased breathing during sleep. This can lead to decreased energy levels during the day, fatigue and problems with concentration during the day. For the same reasons, obesity also contributes to snoring, which can also disrupt sleep too and cause decreased energy during the day.

    Cancer in adulthood—Obesity increases the risk of many different types of cancer in adulthood. These include cancers of the esophagus (food tube), colon, pancreas, and liver.

    Depression and low self-esteem—Children can be subject to bullying, teasing,and mistreatment by other children because of their weight. Often, this can lead to low self-esteem, school avoidance, and depression. Additionally, children may eat to feel better about these thoughts, further worsening their obesity.

    Figure 1. Complications of childhood obesity include many problems that can affect children both in childhood and later in life. These include non-alcoholic fatty liver disease, gastroesophageal reflux disease (GERD), depression, headaches, sleep apnea, asthma, cardiovascular disease, hypertension (high blood pressure), kidney disease (nephropathy), metabolic syndrome, Type 2 diabetes, and joint problems.

Risk Factors

  • What are the risk factors for childhood obesity?
    • Sedentary lifestyle/not getting enough exercise—More than 2 hours of screen time or time in front of the TV/Computer/Phone/Video game
    • Poorly balanced diets: low in fiber and fresh foods, high in junk/processed foods and sugary drinks.
    • Certain ethnic backgrounds have been shown to have higher rates of obesity such as American Indian and Hispanic children.
    • Obese or overweight family members
    • Children from low-income families are at higher risk of obesity because higher fat foods often cost less than healthier foods

    Underlying medical problems account for less than 1% of cases of obesity, and it is important to discuss this with your pediatrician or family doctor if your child is having additional signs or symptoms that are concerning. However, it is far more common that children are not choosing the best food options and are not getting enough exercise.

    Some misconceptions about childhood obesity include that children will grow into their excess pounds with their next growth spurt. It is important not to use a growth spurt as a reason for not working on diet and exercise in an overweight or obese child. Many parents may feel that the growth chart does not apply to their children because the entire family has larger body sizes. In reality, it is important that all children are evaluated on the same growth curve. The healthy weight range for a certain height does not change based on the build of the child or their family members.

Treatment

  • What are the treatments for childhood obesity?

    Lifestyle changes
    The first steps in treatment for children who are obese and for children who are overweight are lifestyle changes. Treatment of obesity in children includes changing the child’s energy balance to cause weight loss by expending more energy than the child takes in. This includes consuming a healthy diet and increased activity to help burn more calories. To lead a healthy lifestyle, the American Academy of Pediatrics recommends the following for all children—referred to as the “5-2-1 Almost none Plan:”

    • At least 5 servings of fruits and vegetables each day. A goal should be to have at least one green leafy vegetable and at least one fruit or vegetable rich in vitamin C such as oranges, strawberries, citrus juices, broccoli, or tomatoes each day.
    • Maximum of 2 hours of “screen time” for pleasure each day (not including schoolwork). Screen time includes watching television, playing video games and using computers, tablets and smart phones.
    • A goal of 1 hour of vigorous physical activity including playing outside, sports, dancing, etc.
    • Zero” or No sugary beverages. These include soda/pop, juices, and sports drinks. Children should try to consume only water. Calories from drinks like soda and juice are considered “empty” calories because they provide only calories, but no nutrition.

    Other tips for weight loss include limiting portion sizes, drinking a glass of water before meals and waiting at least 20 minutes before asking for a second helping at a meal. If drinking milk, choosing skim milk over whole milk is best. A few tips for increased exercise include getting 1 hour of sweaty exercise each day or purchasing a pedometer (something that measures the number of steps you take) and making a goal of getting in 10,000 steps a day. It may be helpful to start at 5,000 and slowly work up to this goal.

    The best way to achieve success at weight loss and to fight obesity is to live a healthy lifestyle, as described above. Having the entire family participate with these changes is a great way to encourage healthy living in all family members. Weight loss may occur slowly at first, and it is important to be patient and continue dietary interventions and increased activity.

    Medications
    If reduced calories and increased activity are not enough, medications may be used in combination with dietary and lifestyle changes to help promote weight loss. These medications are not indicated when obesity starts, and are limited in the ages when they can be used. These medications include Sibutramine, which helps to decrease appetite and is approved by the FDA for teenagers over 16 years of age. Orlistat, known by the brand names Xenical or Alli (over the counter medicines) helps to decrease fat absorption in the intestine and is approved by the FDA for teenage patients between 12–16 years of age.

    Surgery
    If medication is not successful, surgical options-called bariatric surgery- can be used to decrease the size of the stomach. However, surgical options should be considered a last resort after all other avenues for weight loss have been attempted. Gastric bypass procedures (Figure 2) are the only form of bariatric surgery currently approved by the FDA for use in teenagers, because they are the most extensively studied. Sleeve gastrectomy (Figure 3) is increasingly used as a type of weight loss surgery in teenagers. Bariatric surgery is reserved for the patients who meet the following criteria:

    1. BMI ≥35 kg/m2 and severe complications from obesity such as severe obstructive sleep apnea, type 2 diabetes mellitus, or severe and progressive nonalcoholic fatty liver disease
    2. BMI ≥40 kg/m2 with more minor complications from obesity.
    3. Physical maturity, or mature bones
    4. History of sustained efforts to lose weight through changes in diet and physical activity.
    Figure 3. Sleeve Gastrectomy. Surgical removal of part of the stomach to create a smaller stomach pouch or “sleeve.” Figure 2. Roux-en-y Gastric Bypass. A small portion of the stomach is kept in place to create a new stomach pouch. The remainder of the stomach and first part of the small intestine stay intact so that the digestive juices can be released for digestion (green arrow).