Pediatric Annals

from the guest editor 

Obesity

Katherine Kaufer Christoffel, MD, MPH

Abstract

It is not news to anyone reading this that too many children are overweight. You know it because of the children you see in your offices and from those you see in your neighborhood. You may also know it because you have a child, grandchild, sibling, niece, or nephew who is overweight. The issue of obesity is reported in the news and journals often. Yet many of us are ineffective in dealing with this problem at home and at work.

It is not news to the families that we treat that it is unhealthy to be overweight, to eat junk food, and to be inactive. Yet many families are ineffective in keeping overweight at bay, and our communities keep getting heavier. For the past 20 years or so, my clinical practice has focused on nutritional problems. Overweight patients are the most challenging, although we do as well with them as anyone.1 We and the families usually work very hard for modest results.

We know the scope and difficulty posed by epidemic overweight, but there is much we don't know. We do not routinely track patterns of childhood overweight in local areas. We need more information about preventing childhood overweight, its natural history in the current era, and what cutting-edge science may offer in the future. Two recent journal articles printed elsewhere have given us a taste of the fascinating new knowledge that will come.2,3

While research continues, millions of young children are passing through their formative years. The window of opportunity for prevention is not long. Because our current methods have been ineffective, we have to do things differently. Clinically, this means emphasizing prevention and very early intervention, understanding and addressing overweight as a family problem, and linking clinical efforts to manage overweight with efforts at the community and society levels.

As pediatricians, we are well aware of the power we have to lead the nation towards healthy changes on behalf of children. We have seen it with immunizations, child safety seats, poison prevention, and tobacco-use prevention. The epidemic of childhood overweight calls on us to rise to the challenge again. This has been recognized by a recent statement from the American Academy of Pediatrics, which is a good step forward for prevention efforts.4

It is my hope that this issue of Pediatric Annals will also be a good step forward. Its intent is to help you, as a primary care practitioner, use current knowledge to help families and their children avoid the worst this epidemic has to offer. In putting the issue together, I did not seek to provide a reference on diagnosing and treating the morbidities that are associated with overweight, such as hyperlipidemia, type 2 diabetes, and obstructive sleep apnea; recent specialist reviews are available on these conditions and others.5-7 Instead, I want this issue to be useful for morbidity prevention.

I do not think we know how to treat established overweight effectively, in the sense that we can make it go away and stay away. Of course, it is true that some children outgrow their overweight and do not become overweight as adults. I am not convinced, however, that pediatricians can consistently intervene clinically to increase the odds of this. Therefore, I prefer to talk about managing overweight rather than treating it.

I do not fully agree with those who say childhood obesity is a disease. Certainly it is "an alteration of the state of the body or some of its organs," but it does not routinely "interrupt or disturb the performance of the vital functions, cause or threaten pain and weakness" by itself.8 Some overweight-associated…

It is not news to anyone reading this that too many children are overweight. You know it because of the children you see in your offices and from those you see in your neighborhood. You may also know it because you have a child, grandchild, sibling, niece, or nephew who is overweight. The issue of obesity is reported in the news and journals often. Yet many of us are ineffective in dealing with this problem at home and at work.

It is not news to the families that we treat that it is unhealthy to be overweight, to eat junk food, and to be inactive. Yet many families are ineffective in keeping overweight at bay, and our communities keep getting heavier. For the past 20 years or so, my clinical practice has focused on nutritional problems. Overweight patients are the most challenging, although we do as well with them as anyone.1 We and the families usually work very hard for modest results.

We know the scope and difficulty posed by epidemic overweight, but there is much we don't know. We do not routinely track patterns of childhood overweight in local areas. We need more information about preventing childhood overweight, its natural history in the current era, and what cutting-edge science may offer in the future. Two recent journal articles printed elsewhere have given us a taste of the fascinating new knowledge that will come.2,3

While research continues, millions of young children are passing through their formative years. The window of opportunity for prevention is not long. Because our current methods have been ineffective, we have to do things differently. Clinically, this means emphasizing prevention and very early intervention, understanding and addressing overweight as a family problem, and linking clinical efforts to manage overweight with efforts at the community and society levels.

As pediatricians, we are well aware of the power we have to lead the nation towards healthy changes on behalf of children. We have seen it with immunizations, child safety seats, poison prevention, and tobacco-use prevention. The epidemic of childhood overweight calls on us to rise to the challenge again. This has been recognized by a recent statement from the American Academy of Pediatrics, which is a good step forward for prevention efforts.4

It is my hope that this issue of Pediatric Annals will also be a good step forward. Its intent is to help you, as a primary care practitioner, use current knowledge to help families and their children avoid the worst this epidemic has to offer. In putting the issue together, I did not seek to provide a reference on diagnosing and treating the morbidities that are associated with overweight, such as hyperlipidemia, type 2 diabetes, and obstructive sleep apnea; recent specialist reviews are available on these conditions and others.5-7 Instead, I want this issue to be useful for morbidity prevention.

I do not think we know how to treat established overweight effectively, in the sense that we can make it go away and stay away. Of course, it is true that some children outgrow their overweight and do not become overweight as adults. I am not convinced, however, that pediatricians can consistently intervene clinically to increase the odds of this. Therefore, I prefer to talk about managing overweight rather than treating it.

I do not fully agree with those who say childhood obesity is a disease. Certainly it is "an alteration of the state of the body or some of its organs," but it does not routinely "interrupt or disturb the performance of the vital functions, cause or threaten pain and weakness" by itself.8 Some overweight-associated morbidities are diseases in the latter sense, but overweight itself usually is not. I find it more helpful to think of obesity as a chronic condition, similar to atopy, that is associated with some diseases (as atopy is associated with asthma).

I am worried that in our zeal to help our children, we risk harming them instead. Low self-esteem is among the most prevalent and disabling consequences of overweight in our youth.9,10 The media convey a body ideal that is thinner than ever at a time when our young people are heavier than ever. Thus the proportion of young people - especially girls and women - who are miserable because of their body images is at an all-time high. The view from within that despair is well communicated in popular books.11,12 As pediatricians work with families, we must be careful that we do not become another source of unrealistic expectations and condemnation. These considerations emphasize the importance of prevention, universal approaches that speak to children of all shapes, and at least as much attention to self-esteem as to body mass index (BMI).

It is important to bring a healthy skepticism to the common view that overweight must be reversed to effectively manage its associated morbidities. Although overweight often contributes to obstructive sleep apnea (OSA) via increased posterior pharyngeal tissue, the OSA generally can be reversed by surgery or managed with Continuous Postive Airway Pressure (CPAP) devices. Conditions such as hypertension, hyperlipidemia, and insulin resistance may also be manageable using lifestyle and medical approaches. Research is needed to clarify when and to what degree BMI-lowering is essential. It seems unwise to assume that substantial weight loss is always required.

I believe there has not yet been enough focus on the development of the adipose organ during early childhood and the opportunity it poses for prevention of enduring overweight of early onset. Clinicians and scholars have focused mainly on adolescents because of rates of their overweight, unhappiness with weight, morbidities, and increased odds for a lifelong weight problem. This has kept attention away from the period referred to as the adipose, or BMI, rebound, which is when all children add adipose cells that then forever demand to be fed. Pediatricians, most of whom spend more time with young children than with teens, should understand the dynamics of the adipose/BMI rebound and what these may mean for the prevention of overweight in children of all ages. This will bring an end to the era when it was okay to tell families that a child just has "baby fat" well into the school years.

I am sure that clinicians cannot be effective in preventing or managing overweight unless what happens in the office is tied to what happens in schools and other community settings. Just as we have had to facilitate child passenger safety via public education, legal measures, and child safety-seat distribution, so we must expect to have to facilitate families' access to healthy foods, non-motorized transportation, and safe settings for recreational activity using such multi-disciplinary, multi-sector approaches.

This issue of Pediatric Annals incorporates these views. The authors who contributed echo and complement one another, but focus on different aspects of the problem and different health care settings for addressing it.

Because the field of overweight prevention and management is evolving rapidly, this is a time of flux in terminology and methodology. You will note that most papers avoid the term "obesity" because it is not currently recommended for use in childhood. Similarly, the papers emphasize the use of BMI, rather than other indices of weight for height. This makes for some regrettable clumsiness in places (eg, referring to overweight in a sentence that cites papers on obesity).

REFERENCES

1. Davis K, Christoffel KK. Obesity in preschol and school-age children: treatment early and often may be best. Arch Pediatr Adolesc Med 1994; 148(12):12571261.

2. Arch Pediatr Adolesc Med. 2003;157(8): 709-832.

3. Am J Public Health. 2003 ;93(9): 13691608.

4. American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112(2):424-430.

5. Kanani PM, Sperling MA. Hyperlipidemia in adolescents. Adolesc Med. 2002;13(1):37-52.

6. Aye T, Levitsky LL. Type 2 diabetes: an epidemic disease in childhood. Curr Opin Pediatr. 2003; 15(4):411-415.

7. Sterni LM, Tunkel DE. Obstructive sleep apnea in children: an update. Pediatr Clin North Am. 2003;50(2):427-443.

8. CancerWeb Project Main Page. CancerWeb Dictionary. Available at: http://cancerweb.ncl.ac.uk/omd. Accessed November 14, 2003.

9. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):1813-1819.

10. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weight-based teasing and emotional well-being among adolescents. Arch Pediatr Adolesc Med 2003;157(8):733-738.

11. Pipher M. Reviving Ophelia: Saving the Selves of Adolescent Girls. [CITY, STATE]: Ballantine Books; 2002.

12. Maine M. Body Wars. Carlsbad, Calif: Gurze Books; 1999.

10.3928/0090-4481-20040101-04

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