Obesity is a contributor to or a cause of chronic medical and/or surgical conditions including diabetes, hypertension, hyperlipidemia, heart disease, stroke, certain cancers, recurrent trauma and arthritis. Here are the ponderous facts:The apparent rise in the incidence of hypertension and diabetes worldwide is concerning.  Certain populations, non-Hispanic blacks, for instance are at higher risk.

The more severe the obesity, the greater the chances of morbidity or mortality from these conditions.  Trends in such outcomes, however, do not always correlate well with the incidence of obesity. For example, over the past few decades, obesity is identified more often, while mortality rates, especially from coronary heart disease and stroke seem to be decreasing, perhaps through improvements in medical care and public health.

The prevention and treatment of obesity and overweight—Population-based Strategies

• Primary and Secondary Prevention: Those that focus on the bio-psycho-social model and the environment.
• Tertiary Prevention: for those who are already obese, there are clinical preventive maintenance medicine strategies and treatment regimes—e.g., increasing fruit and vegetable consumption, labels of caloric density in fast food restaurants, etc.

"In 2007-2008, 9.5% of infants and toddlers (95% confidence interval [CI], 7.3%-11.7%) were at or above the 95th percentile of the weight-for-recumbent-length growth charts. Among children and adolescents aged 2 through 19 years, 11.9% (95% CI, 9.8%-13.9%) were at or above the 97th percentile of the BMI-for-age growth charts; 16.9% (95% CI, 14.1%-19.6%) were at or above the 95th percentile; and 31.7% (95% CI, 29.2%-34.1%) were at or above the 85th percentile of BMI for age. Prevalence estimates differed by age and by race/ethnic group. Trend analyses indicate no significant trend between 1999-2000 and 2007-2008 except at the highest BMI cut point (BMI for age 97th percentile) among all 6- through 19-year-old boys (odds ratio [OR], 1.52; 95% CI, 1.17-2.01) and among non-Hispanic white boys of the same age (OR, 1.87; 95% CI, 1.22-2.94)."

Cynthia L. Ogden, Margaret D. Carroll, Lester R. Curtin, Molly M. Lamb, and Katherine M. Flegal "Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008." JAMA. 2010;303(3):242-249.

"The prevalence of obesity in the United States continues to be high, exceeding 30% in most sex and age groups. Comparisons between Canada and the United States show that obesity prevalence was higher in the United States in 1999-2002 than in Canada in 2004, with the difference largely due to higher obesity prevalence among women.10 Comparisons of obesity prevalence between Canada and the United States that are limited to white adults show no significant differences for men.10 A review of prevalence estimates in European countries found that the prevalence of obesity based on measured weights and heights varies widely from country to country, with higher prevalences in Central, Eastern, and Southern Europe.11 In most cases, the prevalence of obesity appeared lower in European countries than in the United States. However, estimates from other countries are not precisely comparable with US estimates because of differences in study methods, years of measurement and the age ranges, and methods of age adjustment or age categorization.

The prevalence of obesity shows significant variation by racial and ethnic groups. Racial and ethnic differences in the prevalence of obesity as defined by BMI should be interpreted cautiously because they do not necessarily correspond to differences in fat mass or percentage of body fat.

In the United States, a study of data from military recruits, veterans, and national surveys suggests mean BMI has increased over a long period since the Civil War up to recent times, with increases in the last several decades perhaps less steep than those observed earlier.

In 2007-2008, the prevalence of obesity was 32.2% among adult men and 35.5% among adult women. The increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate over the past 10 years, particularly for women and possibly for men.

Katherine M. Flegal, Margaret D. Carroll, Cynthia L. Ogden, and Lester R. Curtin  "Prevalence and Trends in Obesity Among US Adults, 1999-2008." JAMA. 2010;303(3):235-241.

"Despite the many advances in preventive medicine and treatment that reduced cardiovascular disease, the new stage of the epidemiologic transition, the age of obesity and inactivity, emerged to threaten the progress made in postponing illness and death to later in adult life spans. The steady gains made in both quality of life and longevity by addressing risk factors such as smoking, hypertension, and dyslipidemia are threatened by the obesity epidemic."

Gaziano, JM   "Fifth Phase of the Epidemiologic Transition; The Age of Obesity and Inactivity" JAMA. 2010;303(3):275-276. Published online January 13, 2010 (doi:10.1001/jama.2009.2025).

The US Preventive Services Task Force (USPSTF) recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to intensive counseling and behavioral interventions to promote improvements in weight status (grade B recommendation).

Recommendation Statement in Pediatrics, Feb 2010; 125: 361 - 367.

Positive Association between Comprehensiveness, Intensity of Treatment and Outcome

"The obesity epidemic has been part of the pediatric landscape since the 1980s and is now one of the most common issues that pediatricians confront in their day-to-day practice. From the first National Health and Nutrition Examination Survey (NHANES) (1971–1974) to NHANES 2003–2006, obesity (BMI > 95th percentile for age and gender) increased from 5.0% to 12.4% in children aged 2 to 5 years, from 4.0% to 17.0% in children aged 6 to 11 years, and from 6.1% to 17.6% in adolescents (aged 12–19 years).1–4 Although there is evidence that these rates have begun to stabilize,4 this leaves us with 16.3% of 2- to 19-year-olds with BMI values above the 95th percentile and 31.9% above the 85th percentile.5"

Obesity treatment can be effective and extend beyond the immediate intervention.

Comprehensive treatment, defined as treatment includes: (a) counseling for healthy diet or even weight loss, (b) counseling for physical activity, and (c) instruction in and support for use of behavioral management techniques to make durable lifestyle (diet and physical activity) changes.

The level of intensity of intervention matters, i.e., twice-weekly hour-long meetings for 6 months and once-weekly hour-long meetings for the following 6 months with a combination of group and individual sessions with a group of multidisciplinary personnel including dieticians, psychologists, trainers, and practitioners in the context of a medical home.

Lower-intensity interventions can used in structured, weight-management efforts in primary care. However, "Payment for multidisciplinary personnel and financial support of group treatment models, telephone and Internet care and mechanisms to support parent-only care interactions, would be critical to allow interventions such as these to be implemented in practice."

It is surprising that the final USPSTF recommendation was limited to screening and treatment only of children older than 6 years of age.  Regardless, pediatricians should continue to screen all children older than 2 years for overweight and obesity by using BMI percentiles and measure weight for length in children younger than 2 years of age.

Hassink SG,  [Wilmington, Delaware] "Treatment: Pediatricians on the Right Track!"  [Commentary] Published online January 18, 2010 Pediatrics Vol. 125 No. 2 February 2010, pp. 387-388 (doi:10.1542/peds.2009-3308)  [Free PDF]

Abstract

Background The effect of childhood risk factors for cardiovascular disease on adult mortality is poorly understood.

Methods In a cohort of 4857 American Indian children without diabetes (mean age, 11.3 years; 12,659 examinations) who were born between 1945 and 1984, we assessed whether body-mass index (BMI), glucose tolerance, and blood pressure and cholesterol levels predicted premature death. Risk factors were standardized according to sex and age. Proportional-hazards models were used to assess whether each risk factor was associated with time to death occurring before 55 years of age. Models were adjusted for baseline age, sex, birth cohort, and Pima or Tohono O'odham Indian heritage.

Results There were 166 deaths from endogenous causes (3.4% of the cohort) during a median follow-up period of 23.9 years. Rates of death from endogenous causes among children in the highest quartile of BMI were more than double those among children in the lowest BMI quartile (incidence-rate ratio, 2.30; 95% confidence interval [CI], 1.46 to 3.62). Rates of death from endogenous causes among children in the highest quartile of glucose intolerance were 73% higher than those among children in the lowest quartile (incidence-rate ratio, 1.73; 95% CI, 1.09 to 2.74). No significant associations were seen between rates of death from endogenous or external causes and childhood cholesterol levels or systolic or diastolic blood-pressure levels on a continuous scale, although childhood hypertension was significantly associated with premature death from endogenous causes (incidence-rate ratio, 1.57; 95% CI, 1.10 to 2.24).

Conclusions Obesity, glucose intolerance, and hypertension in childhood were strongly associated with increased rates of premature death from endogenous causes in this population. In contrast, childhood hypercholesterolemia was not a major predictor of premature death from endogenous causes.

Extracts:

"Although there was no significant association between childhood hypercholesterolemia and death before 55 years of age in this young cohort, an elevated cholesterol level in childhood may emerge as a significant risk factor and other causes of death may predominate if the cohort is followed to older ages. Cholesterol levels, however, are lower in American Indians than they are in most other ethnic groups,³¹ a finding that may partially explain the absence of association for this trait. The relationship between BMI and high-density lipoprotein (HDL) cholesterol is relatively strong in Pima children (r=–0.3 to –0.6), but the relationship between BMI and total cholesterol is weaker (r=0.1).¹⁹ The effect of BMI on premature death might be attributable in part to low HDL-cholesterol concentrations, which were not measured in most of the study participants. Nevertheless, we speculate that low HDL-cholesterol levels are likely to mediate rather than confound this relationship."

"It is possible that the relationship between childhood BMI and mortality is confounded by unmeasured lifestyle factors. Nevertheless, obesity can be both the cause and the consequence of adverse lifestyle factors such as physical inactivity, excessive caloric intake, and specific nutrient preferences. Thus, such factors may be important components of the causal pathway between obesity and death. It is also possible that genetic factors have pleiotropic effects on BMI and mortality."

"Childhood obesity is predictive of excess mortality in several divergent settings,^20,21,22 indicating that obesity itself is causally related to either death or other commonly related factors. Even if preventing childhood obesity does not affect the risk of death, increased physical activity and modification of diet are likely to have long-term benefits. The lack of specific data on such factors is a limitation of this study."

"In summary, obesity in children who do not have diabetes is associated with an increased rate of death from endogenous causes during early adulthood, an association that may be partially mediated by the development of glucose intolerance and hypertension in childhood. In contrast, the cholesterol level in childhood is not a major determinant of premature death in this population. Childhood obesity is becoming increasingly prevalent around the globe. Our observations, combined with those of other investigators, suggest that failure to reverse this trend may have wide-reaching consequences for the quality of life and longevity. Such evidence underscores the importance of preventing obesity starting in the early years of life"

Franks PW, Hanson RL, Knowler WC, et al. "Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death." N Eng J Med Feb. 11, 2010; 362(6):485-493. 

Comment

"In a select population, the presence of some, but not all, adult cardiovascular risk factors in childhood was associated with premature death in adulthood. Because the American Indian population has a unique health profile (e.g., high rates of obesity and diabetes), the applicability of the findings to a heterogeneous population is uncertain. Nonetheless, this study provides a starting point for predicting long-term outcomes and costs associated with childhood obesity, glucose intolerance, and hypertension."

F. Bruder Stapleton, MD. Published in Journal Watch Pediatrics and Adolescent Medicine, February 10, 2010 

See also,

Daniels SR, Arnett DK, Eckel RH, et al.  "Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment." Circulation. 2005 Apr 19;111(15):1999-2012.

Comment in: Circulation. 2005 Apr 19;111(15):1866-8.

Patient leaflet about this condition

• Obesity

See Also "Obesity's Massive Impact"

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A realistic view of what one can accomplish in weight management.

"'As clinicians, we celebrate small changes because they often lead to big changes,'said Dr. David Ludwig, director of the Optimal Weight for Life program at Children’s Hospital Boston.  [Yet, such changes alone would] not produce substantial weight loss."

"Why wouldn’t they? The answer lies in biology. A person’s weight remains stable as long as the number of calories consumed doesn’t exceed the amount of calories the body spends, both on exercise and to maintain basic body functions. As the balance between calories going in and calories going out changes, we gain or lose weight.

But bodies don’t gain or lose weight indefinitely. Eventually, a cascade of biological changes kicks in to help the body maintain a new weight. As the JAMA article explains, a person who eats an extra cookie a day will gain some weight, but over time, an increasing proportion of the cookie’s calories also goes to taking care of the extra body weight. Eventually, the body adjusts and stops gaining weight, even if the person continues to eat the cookie.

Similar factors come into play when we skip the extra cookie. We may lose a little weight at first, but soon the body adjusts to the new weight and requires fewer calories.

Regrettably, however, the body is more resistant to weight loss than weight gain. Hormones and brain chemicals that regulate your unconscious drive to eat and how your body responds to exercise can make it even more difficult to lose the weight. You may skip the cookie but unknowingly compensate by eating a bagel later on or an extra serving of pasta at dinner."

"While small steps are unlikely to solve the nation’s obesity crisis, doctors say losing a little weight, eating more heart-healthy foods and increasing exercise can make a meaningful difference in overall health and risks for heart disease and diabetes."

Parker-Pope T.  "In Obesity Epidemic, What’s One Cookie?" March 1, 2010, 5:08 pm — Updated: 11:43 am

Overweight and obese children who participated in the Mind, Exercise, Nutrition, Do It program, commonly known as MEND— a free, 10-week, after-school weight management course that promotes healthy eating and physical activity among overweight and obese children and their families, experienced significant decreases in waist circumference, reductions in BMI and improvements in blood pressure, recovery heart rate, physical activity level and global self-esteem.

From 2005 to 2007, researchers at the University College London Institute of Child Health conducted a randomized, controlled trial to assess the efficacy of the MEND program.

The MEND intervention involved 18 two-hour sessions during nine weeks. All sessions were conducted by two MEND leaders and one assistant. Eight sessions were devoted to behavior change, eight to nutrition and 16 to physical activity. In addition, a 12-week family swimming pass was issued to all participating families at the end of the program.

The researchers included 116 children aged 8 to 12 years with BMI >98th percentile and randomly assigned them to either participate in intervention or wait six months for intervention. They took measurements at baseline, six and 12 months. Mean attendance was 86%.

At six months, children assigned to the MEND program had a reduced waist circumference z score (–0.37) and a BMI z score that compared with children assigned to wait six months for intervention (–0.24; P<.0001 for both). At 12 months, children in the intervention group had reduced their waist circumference z score by 0.47 and BMI z score by 0.23 (P<.0001 for both).

Data reveal a –4.1-cm difference in waist circumference and a –1.2 difference in BMI between children enrolled in the MEND program and the control group; however, the researchers noted little change in body composition during the study period.

The benefits of the MEND program were sustained for nine months after completion of the program, according to the researchers.

“The MEND program isn’t a miracle pill for obesity, but what this independent study does show is that child weight loss programs that involve the whole family are a scientifically proven and sustainable solution to the child obesity crisis,” Harry MacMillan, chief executive of MEND, said in a press release. “With the recent suspension of obesity drugs, people are starting to wake up to the fact that quick fixes don’t work. These research findings prove that teaching children how to keep fit and eat healthy does work if done in the right way.”

"MEND program deemed effective intervention for childhood obesity." Posted on the Pediatric SuperSite on February 17, 2010

Ref., Sacher PM. Obesity. 2010;18:S1-S7.

Abstract

Objective To determine whether modifying eating behaviour with use of a feedback device facilitates weight loss in obese adolescents.

Design Randomised controlled trial with 12 month intervention.

Setting Hospital based obesity clinic.

Participants 106 newly referred obese young people aged 9-17.

Interventions A computerised device, Mandometer, providing real time feedback to participants during meals to slow down speed of eating and reduce total intake; standard lifestyle modification therapy.

Main outcome measures Change in body mass index (BMI) standard deviation score (SDS) over 12 months with assessment 18 months after the start of the intervention. Secondary outcomes were body fat SDS, metabolic status, quality of life evaluation, change in portion size, and eating speed.

Results Using the last available data on all participants (n=106), those in the Mandometer group had significantly lower mean BMI SDS at 12 months compared with standard care (baseline adjusted mean difference 0.24, 95% confidence interval 0.11 to 0.36). Similar results were obtained when analyses included only the 91 who attended per protocol (baseline adjusted mean difference 0.27, 0.14 to 0.41; P<0.001), with the difference maintained at 18 months (0.27, 0.11 to 0.43; P=0.001) (n=87). The mean meal size in the Mandometer group fell by 45 g (7 to 84 g). Mean body fat SDS adjusted for baseline levels was significantly lower at 12 months (0.24, 0.10 to 0.39; P=0.001). Those in the Mandometer group also had greater improvement in concentration of high density lipoprotein cholesterol (P=0.043).

Conclusions Retraining eating behaviour with a feedback device is a useful adjunct to standard lifestyle modification in treating obesity among adolescents.

Trial registration ClinicalTrials.gov NCT00407420 [ClinicalTrials.gov] . 

RESEARCH:
Ford AL, Bergh C, Södersten P,, et al.. "Treatment of childhood obesity by retraining eating behaviour: randomised controlled trial." BMJ 2009;340:b5388, doi: 10.1136/bmj.b5388 (Published 5 January 2010) [Free full text]

The Household Routine as a Factor in Obesity

OBJECTIVE To determine the association between the prevalence of obesity in preschool-aged children and exposure to 3 household routines: regularly eating the evening meal as a family, obtaining adequate sleep, and limiting screen-viewing time.

METHODS We conducted a cross-sectional analysis of a nationally representative sample of 8550 four-year-old US children who were assessed in 2005 in the Early Childhood Longitudinal Study, Birth Cohort. Height and weight were measured. We assessed the association of childhood obesity (BMI 95th percentile) with 3 household routines: regularly eating the evening meal as a family (>5 nights per week); obtaining adequate nighttime sleep on weekdays (10.5 hours per night); and having limited screen-viewing (television, video, digital video disk) time on weekdays (2 hours/day). Analyses were adjusted for the child's race/ethnicity, maternal obesity, maternal education, household income, and living in a single-parent household.

RESULTS Eighteen percent of children were obese, 14.5% were exposed to all 3 routines, and 12.4% were exposed to none of the routines. The prevalence of obesity was 14.3% (95% confidence interval [CI]: 11.3%–17.2%) among children exposed to all 3 routines and 24.5% (95% CI: 20.1%–28.9%) among those exposed to none of the routines. After adjusting for covariates, the odds of obesity associated with exposure to all 3, any 2, or only 1 routine (compared with none) were 0.63 (95% CI: 0.46–0.87), 0.64 (95% CI: 0.47–0.85), and 0.84 (95% CI: 0.63–1.12), respectively.

CONCLUSIONS US preschool-aged children exposed to the 3 household routines of regularly eating the evening meal as a family, obtaining adequate nighttime sleep, and having limited screen-viewing time had an 40% lower prevalence of obesity than those exposed to none of these routines. These household routines may be promising targets for obesity-prevention efforts in early childhood.

Anderson SE, (Columbus, Ohio), Whitaker RC (Temple) "Household Routines and Obesity in US Preschool-Aged Children." Pediatrics  March 2010; 125 (3):420-428 (doi:10.1542/peds.2009-0417) Published online February 8, 2010