Obesity in Children and Adolescents

Obesity means an excess amount of body fat. No general agreement exists on the lowest definition of obesity in children and adolescents, unlike standards for adults. Nevertheless, most professionals accept published guidelines based on the body mass index (BMI) -- modified for age, pubertal stage, and gender -- to measure obesity in children and adolescents. Others define pediatric obesity as body weight at least 20% higher than the healthy weight range for a child or adolescent of that height, or as a body fat percentage above 25% in boys or above 32% in girls.

Although rare in the past, obesity is now among the most widespread medical problems affecting children and adolescents living in the United States and other developed countries. About 17% of adolescents (12-19 years of age) and children (6-11 years of age) are obese in the United States according to the Centers for Disease Control and Prevention. These numbers have continued to increase since at least the early 1990s. Pediatric obesity represents one of our greatest health challenges.

Obesity has a profound effect on a patient's life. Obesity increases the patient's risk of numerous health problems, and it also can create emotional and social problems. Obese children are also more likely to be obese as adults, thereby increasing their lifelong risk of serious health problems such as heart disease and stroke.

If your child or teenager is overweight, further weight gain can be prevented. Parents can help their children keep their weight in the healthy range.

• In infancy, breastfeeding and delaying introduction of solid foods may help prevent obesity.
• In early childhood, children should be given healthy, low-fat snacks and take part in moderate-vigorous physical activity every day. Their television viewing should be limited to no more than seven hours per week (this includes sedentary entertainment like video games and internet surfing).
• Older children can be taught to select healthy, nutritious foods and to develop good exercise habits. Their time spent watching television and playing with computer or video games should be limited to no more than seven hours each week. Avoid snacking or eating meals while watching TV, movies, and videos. Avoid consumption of sugary products, especially those high in corn syrup or fructose derivatives, such as regular soda, pop, or cola (which some regions call "phosphate" drinks). Also, avoid offering a lot of juice.

Any patient who regularly consumes more calories than needed will gain weight. If this is not reversed, the patient will become obese over time. Consumption of just 100 kilocalories (the equivalent of 8 ounces of soft drink) above daily requirements will typically result in a 10-pound weight gain over one year. Many different factors contribute to this imbalance between calorie intake and consumption.

• Genetic factors
  • Obesity tends to run in families.
  • A child with an obese parent, brother, or sister is more likely to become obese.
  • Genetics alone does not cause obesity. Obesity will occur when a child eats more calories than he or she uses.
• Dietary habits
  • The dietary habits of children and teenagers have shifted away from healthy foods (such as fruits, vegetables, and whole grains) to a much greater reliance on fast food, processed snack foods, and sugary drinks.
  • These foods tend to be high in fat and/or calories and low in many other nutrients.
  • Several patterns are associated with obesity. Unhealthy habits include eating when not hungry, eating while watching TV or doing homework, or drinking sodas during sedentary activities (like at the movies or watching TV).
• Socioeconomic status
  • Families with low incomes or nonworking parents are more likely to eat excessive calories for activity level.
• Physical inactivity
  • The popularity of television, computers, and video games has translated into an increasingly sedentary (inactive) lifestyle for many children and teenagers in developed countries like the U.S.
  • Children and teenagers in the United States spend, on average, over three hours daily watching television. Not only does this form of recreation use little energy (calories), it also encourages snacking and sipping.
  • Fewer than half of children in the United States have a parent who engages in regular physical exercise.
  • Only one-third of children in the United States have daily physical education at school.
  • Parents' busy schedules and even fears about public safety prevent many children and teenagers from taking part in sports, dance, or other activity programs after school. Moreover, some schools close their campuses to students and their families after hours due to potential liability risks.
• Although specific medical conditions can cause pediatric obesity, these are very rare. They include hormone or other chemical imbalances and inherited disorders of metabolism. Children who exhibit normal linear growth typically do not have these conditions associated with pediatric obesity.
• Certain medications can cause weight gain by altering how the body processes food or stores fat.

• If you or the school personnel think your child is overweight
• If your child or teenager has expressed concerns about his or her weight
• If your child or teenager has problems keeping up with peers in physical fitness or sports

Weight-to-height tables

These tables give general ranges of healthy weight and define being overweight based on the height of the child or teenager. Many health care professionals define obesity in a child as weighing 20% or more over the healthy range. The tables, however, do not take into account other individual characteristics of each child or teenager. The health care professional must consider the patient's age, gender, pubertal stage, and growth pattern when interpreting the weight-to-height chart. For example, some children gain weight before a growth spurt. This does not necessarily mean they are becoming obese.

Body fat percentage

The percentage of body weight that is fat is a good marker of obesity. Boys with over 25% fat and girls with over 32% fat are considered obese.

Body fat percentage is difficult to measure accurately. The most accurate methods use special equipment not found at most medical offices. The method that measures skin-fold thickness is unreliable unless performed correctly by a trained and experienced technician.

Body mass index (BMI)

This measure assesses weight relative to height. It is the same as the body mass index used to identify adult obesity. BMI is defined as weight (in kilograms) divided by height (in meters) squared (kg/m²). Less commonly, BMI can be calculated in pounds and inches. BMI is closely related to body fat percentage but much easier to measure.

BMI is the standard for defining obesity in adults, but its use in children is not universal. The Centers for Disease Control and Prevention (CDC) suggests two levels of concern for children based on the BMI-for-age charts.

1. At the 85th percentile and above, children are "at risk for overweight."
2. At the 95th percentile or above, they are "overweight."

The American Obesity Association defines those children and adolescents above the 95th percentile as "obese," which corresponds to a BMI of 30 kg/m² (considered obesity in adults).

To calculate a child's BMI, follow these steps:

1. Multiply the child's weight in pounds by 705.
2. Then divide by the child's height (in inches).
3. Divide this again by the height (in inches) again.

To calculate BMI via the Internet, enter the child's height and weight at the web site of the Department of Health and Human Services, Obesity Education Initiative.

Waist circumference (WC)

This measurement in a child or adolescent correlates closely with the future risk of developing type 2 diabetes mellitus and related complications of the metabolic syndrome (high blood pressure, abnormal cholesterol or other fat levels, heart attack, stroke, and damage to eyes, heart, and kidneys). The assessment is made with a tape measure stretched across the widest abdominal girth (usually at or just below the level of the belly button, called the umbilicus). Any value over the 90% percentile for age and gender carries the highest risk.

When the goal is to help a child or teenager reach and maintain a healthy weight, parents must take the lead. Health care professionals and nutrition consultants are there to help. However, parents exert the most control over their child's activities and habits and thus are in the prime position to make and support healthy lifestyle changes.

• The most important thing parents can do for an obese child is to be supportive. Your child's feelings about himself or herself are at least partly determined by your feelings. Let your child know that you love and accept him or her -- at any weight.
• Encourage
• Do not criticize.
• Be aware of your child's concerns about appearance and social relationships.

Weight loss itself is rarely a goal in an obese child or teenager. Rather, the goal is to slow weight gain or simply to maintain a weight over time. The idea is to allow the child to grow into his or her body weight gradually, over time. This may take a year or two, or even longer, depending on the child's age, weight, and growth pattern. Remember, an obese child does not have to become an obese adult. When weight loss is set as a goal, the safest and most practical objective is 2 pounds per month.

For such a plan to succeed, it must involve long-term changes in the habits of the entire family. The obese child should not be singled out. Parents, brothers and sisters, and other family members living in the home all will benefit from a shift toward a healthier lifestyle. Remember that children learn best by example -- set a good one.

The cornerstones of a weight-control plan are physical activity and diet management. Old habits and attitudes -- your own and your child's -- must change. The sooner a plan is put in place, the better, because it is much easier to change habits in children or even teenagers than in adults.

Physical activity

• The single best thing you can do is restrict the amount of time your child spends watching TV, sitting at the computer, or playing video games. These activities burn few calories and encourage snacking and drinking. The U.S. Surgeon General recommends moderate to vigorous physical activity for children and adolescents every day for at least 60 minutes.
• Encourage children and teenagers to enjoy physical activities that burn calories and use different muscle groups. These include games which involve running, swimming, skating, or riding a bicycle. The most effective activities raise the heart rate moderately and cause mild sweating. The child should not become exhausted, overheated, or severely short of breath.
• Allow each child or teenager to try different activities in order to find those that he or she enjoys.
• The goal is to participate in continuous, moderately strenuous activity for at least 30 minutes every day (with total activity for at least one hour daily).
• Be a role model for your children. If they see you being active and having fun, they are more likely to be active and stay active into adulthood.
• Plan family activities so that everyone can get some exercise and have fun. Walk, dance, or bike together.
• Encourage your children to get involved in sports at school or in the community.
• Don't force children to take part in activities they find uncomfortable or embarrassing.
• Whatever activities your children become involved in should be appropriate for their ages and development. Make sure children understand basic safety rules. Make sure they have plenty of water to drink to replace fluid lost by sweating.

Diet management

• First, educate yourself about your child's nutritional needs. Use what you learn to help your children learn a healthy attitude about eating.
• If you are unsure about selecting and preparing foods for a healthy diet, tell your health care professional. He or she can make recommendations or refer you to a nutritionist.
• Involve your children in food shopping and meal preparation.
• Don't dictate exactly what your children eat. Children should help choose what they eat and how much.
• Offer your children a variety of foods, including natural sweets and snacks (such as fresh fruit). All foods have a place in a healthy diet, even foods high in fat and calories -- as long as they are eaten occasionally and in moderation. Familiarize yourself with appropriate serving sizes. A dietician can help with this training.
• Encourage your children to eat slowly. This helps them recognize the feeling of fullness and stop eating when they are full.
• The family should eat together whenever possible. Make meals a pleasant time for conversation and sharing the events of the day.
• Don't forbid snacks. While continuous snacking contributes to weight gain, planned snacks are part of a healthy diet for children. A nutritious and tasty snack after school will give children the energy they need for homework, sports, and play until supper.
• Identify high-risk situations such as having too many high-calorie foods in the house or watching television during meal times. With the distraction of television, many people overeat.
• Don't deprive your child of occasional treats (like chips, cake, and ice cream), especially at parties and other social events.

Meal and snack suggestions

• Most of your diet should be whole grains, fruits, and vegetables. Serve a variety of vegetables (green, red, yellow, brown, and orange), fresh fruits, and whole-grain breads, pasta, and rice.
• Eat two or three servings of low-fat (1% milk) or nonfat (skim) dairy products every day. A dietician can help identify healthy portions based on individual physical factors and age.
• A healthy diet also includes two to three servings of foods from the meat and beans group. This group includes lean meat, poultry, fish, cooked dry beans, eggs, and nuts.
• Limit fats to no more than 25%-30% of total calories.
  • If you now use whole-fat dairy foods, do switch to low-fat (1% milk) or nonfat (skim) dairy products.
  • Trim all fat off meat and remove skin from poultry.
  • Choose low-fat or fat-free breads and cereals.
  • Avoid fried foods.
  • Choose low-fat and tasty snack foods.
    • Fruit, fresh or dried
    • Low-fat or nonfat yogurt or cheese
    • Nuts, sunflower, or pumpkin seeds
    • Whole-grain breads, crackers, or rice cakes spread with a fruit spread or peanut butter
    • Frozen desserts such as frozen yogurt, fruit sorbet, popsicles, and fruit juice bars
  • Do not limit fat intake for children younger than two years of age. However, avoid deep-fried foods at these young ages.
  • Select snacks for young children carefully to avoid choking hazards. For example, cut whole grapes into at least four or five smaller portions.

Parents need to develop good habits of their own to help their children maintain a healthy weight.

• Don't make your child eat when he or she isn't hungry.
• Don't insist that your child finish a meal.
• Don't rush meal time. In general, you eat more when you eat quickly.
• Don't use food to comfort or reward.
• Don't offer dessert as a reward for finishing a meal.
• Offer your child a healthy, balanced diet that includes a variety of foods. No more than 30% of calories should come from fats. The American Heart Association guidelines (see below) are appropriate for most children.
• Switch your child from whole milk to 2% milk at age two years. If she or he is overweight, switch to 1% milk. In early childhood, skim milk should only be substituted following a doctor's recommendation.
• Don't eat at fast-food restaurants more than once a week.
• Make sure meals eaten outside the home, such as school lunches, are balanced.
• Offer your child water to quench thirst. Avoid soda, "power" or energy drinks, sports drinks, cola, and other sugary or caffeinated drinks and teas.
• Limit your child's time spent watching television or playing computer and video games.
• Encourage your child to do something active, like riding a bicycle, jumping rope, or playing ball. Better yet, bicycle or play ball with your child.
• Teach your child good eating and exercise habits now.

American Heart Association Dietary Guidelines for Healthy Children and Families

• Achieve adequate nutrition by eating a wide variety of foods.
• Eat adequate energy (calories) to support growth and development and reach a healthy body weight.
• Recommended average daily fat intake
  • Saturated fat: 7%-10% of total calories
  • Total fat: limited to 25%-30% of total calories
  • Cholesterol: less than 300 mg per day

These guidelines apply to adults and children older than 2 years of age.

These measures should be applied to everyone in the family, not just children who are already overweight or obese.

Parents should focus on building self-esteem and coping with emotional distress.

Some health problems are much more likely to affect obese children than nonobese children.

• Asthma, especially severe asthma
• Diabetes mellitus
• High blood pressure
• High cholesterol
• Heart failure
• Liver problems ("fatty liver")
• Bone and joint problems in the lower body
• Growth abnormalities
• Emotional and social problems
• Breathing problems such as sleep apnea
• Rashes or fungal infections of the skin, acne

Obese children also are much more likely to have these and other obesity-related health problems in adulthood:

• Heart disease
• Stroke
• Certain types of cancer
• Osteoarthritis
• Gout
• Gallbladder disease