Too Much “Screen Time”
Contributory and causal factors for the epidemic of childhood obesity appear to be changing and continue to be identified and evaluated. Environmental considerations seem particularly significant at this particular point in history. “Screen time,” which takes many forms (computers, televisions, handheld devices), has increased dramatically over the past five years for children and adolescents. Studies have shown that children who watch more than one hour of television per day are more likely to be obese than those who watch less. Unfortunately, the average American child watches more than four hours of television per day, totaling an astonishing two months of non-stop television watching per year. Surveys have revealed that more than 70 percent of American children aged 8-18 years have a television in their bedrooms.
Bad Diets
Dietary habits of young people have also come under increased scrutiny, given the crucial role nutrition plays in weight management and overall health. The benefit of appropriate nutrition tends to start very early on, as infants who are breastfed longer or started on solid food after four months of age are less likely to become obese as adolescents. An alarming trend has been the dramatic three-fold rise in soft drink consumption over the past 20 years. In fact, 56 to 85 percent of children in school consume at least one sugar-sweetened drink per day, including fruit-based juices. Conversely, milk consumption has been halved during this same period of time, with the exception of sugar-sweetened varieties such as chocolate milk. These trends are noteworthy, because for every sugar-sweetened drink a child has the risk of obesity increases by 160 percent. Poor nutritional intakes have also resulted in an increased prevalence and severity of dental problems in children.
In addition to more sugar-sweetened drinks, our children are also having fewer healthy, well-balanced meals. Increasingly hectic lifestyles often crowd out home cooked meals eaten with family members. Low-income and some racial/ethnic minority groups are often exposed to poor food environments, with few grocery stores and an abundance of fast-food and convenience stores. These trends are resulting in Americans consuming almost 34 percent of their meals outside of the home and accounting for 42 percent of their food budget. Past studies have shown that children who report eating fast food consume, on average, 150 more calories per day than children who don’t eat fast food, increasing their risk of gaining weight.
Efforts Underway to Curb the Obesity Epidemic
The cause of rapidly rising childhood obesity is multifactorial. As such, the related treatment modalities must also be multifactorial. Early identification of and intervention in children who are at risk of becoming obese are crucial to stemming the tide of this epidemic. Key organizations, including the American Academy of Pediatrics and the CDC, are increasing their focus on childhood obesity and providing additional treatment guidelines. For example, in overweight or obese children yet to go through their growth phase (younger than 5 years of age), the goal is weight maintenance. For older children, weight loss is recommended, since height gain alone will not correct the obesity. In these children, a weight loss goal of 1 to 2 pounds per month is noted to be appropriate.
Because most children spend a significant amount of time in the school setting, changes also are underway to improve the quality of nutrition offered at various educational sites. The American Beverage Association, with the support of the Clinton Foundation and the American Heart Association, proposed guidelines which would cap the number of calories in beverages in schools to no more than 100 per container. As of the 2009-2010 school year, 98.8 percent of all audited schools were in compliance.
What Can Parents Do?
The strongest predictor of child lifestyle choices is parental lifestyle choices. As such, many groups are now providing dietary and behavioral interventions at the family level. One such group was able to show successful weight control over 10-year periods.
Limited Role of Medication
Medication can play a role in weight management, but only one pharmaceutical is currently approved for use in adolescents. Studies in this age group are marred by significant drop-out rates, a limited number of subjects and very short-term results. Due to the lack of quality, long-term data, medications for adolescent weight management are not often recommended.
When Could Surgery be Considered an Option?
We are finding a similar situation with bariatric (weight loss) surgery. Currently, bariatric surgery is the most definitive and longest-lasting weight loss treatment. There are a small number of studies in adolescents showing significant weight loss and improvement or resolution in related conditions, such as type 2 diabetes, hypertension and obstructive sleep apnea. In adults, patients are considered candidates for bariatric surgery if they have a body mass index (BMI; as kg/m2) of 40 or higher, or a BMI of 35 or higher if one or more weight-related conditions are present. For example, an adult who is 5’ 0” and is 205 pounds has a BMI of 40; someone who is 5’ 4’ and weighs 205 pounds has a BMI of 35.2.
In pediatrics, stricter guidelines should be followed when considering bariatric surgery. The following guidelines are usually followed:
- BMI ≥ 40 with one or more serious weight-related condition(s)
- BMI ≥ 50 with less serious condition(s)
- Failure of non-surgical weight loss
- Greater sexual maturity (Tanner stage IV or higher) and 95 percent of adult height based on estimated bone age
However, because of relative physical and psychological immaturity and limited research, consideration of adolescent bariatric surgery must occur on a very thorough and case-by-case basis.
Conclusion
In summary, obesity in the pediatric population has risen at an alarming pace in the past several decades. Causal factors of this epidemic are multifactorial, including economic, environmental and genetic considerations. Because obesity is a chronic disease, overweight and obese children typically progress to obese and less healthy adults. Prevention and intervention strategies must be developed and utilized to slow the devastating effects pediatric obesity is having on the physical, emotional and financial health of our country.
Dr. Manpreet Mundi is a senior associate consultant in the Department of Medicine and Division of Endocrinology, Diabetes, Metabolism and Nutrition at the Mayo Clinic. He received his internal medicine and endocrinology training at the University of Southern California and Los Angeles County-USC Medical Center. His clinical interests include inpatient and outpatient nutrition health, bariatric surgery and mentoring endocrine fellows. He would also like to thank Paul A. Lorentz, R.N. for his editorial assistance.
Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU, received his M.D. degree from Mount Sinai School of Medicine in 1985. He then completed his residency in Internal Medicine at the Baylor College of Medicine in 1988. After returning to Mount Sinai to complete his fellowship training in Endocrinology, Metabolism and Nutrition in 1990, Dr. Mechanick started his private practice in Manhattan in Endocrinology, Diabetes and Metabolic Support. Since then, he has become the Director of Metabolic Support and Clinical Professor of Medicine in the Division of Endocrinology, Diabetes and Bone Disease at the Mount Sinai Hospital. He continues to care for many patients with endocrine, diabetes and nutritional disorders, as well as train physicians in endocrinology and nutrition. 
