Definition/Introduction

Childhood obesity is a rising health concern in the United States, as its prevalence continues to increase among children of all ages.[1] For instance, the number of obese children between the ages of 6 to 11 years old increased substantially from 4.2 to 15.3 percent in the United States between 1963-1965 and 1999-2000.[2] Studies have noted differences in the prevalence of childhood obesity in different age, racial, ethnic, and geographic groups.[1][2] Between 2015 to 2016, the prevalence of childhood obesity was more significant among Hispanic (26%) and Black (22%) pediatric populations, compared to that among Asian (11%) and white (14%) pediatric populations.[3]

Obesity is a condition characterized by the accumulation of excessive fat in the body. Body Mass Index (BMI) is a measure used to classify overweight and obesity using height and weight (kg/m^2). BMI values may significantly differ in children and adolescents, depending on their age and gender. Thus, once a BMI of a child is calculated, it is often compared with reference values for a particular gender and age group to determine his or her BMI percentile.[4] A child’s BMI value in the 85th to 94th percentile is considered overweight, whereas the value at or above the 95th percentile is defined as obesity.[5]

Issues of Concern

The importance of addressing the issue of pediatric obesity is substantial, for it is often associated with various health complications, including type 2 diabetes and dyslipidemia.[6][7] Obese children have a higher chance of becoming obese adults than non-obese children, and they are predisposed to develop further complications, such as coronary artery disease, hypertension, and cancers, during their adulthood.[8][6]

Thirty-two percent of US children and adolescents aged 2 to 19 are overweight, and 17 percent of them are obese.[9][10] If the ongoing trends of pediatric obesity continue with no intervention, 65 million more adults will be diagnosed with obesity in the United States by 2030. Possible health consequences of these trends include 6 to 8.5 million new cases of diabetes, 5 to 7.3 million new cases of heart disease, and 492,000 to 669,000 new cases of cancer. The estimated combined medical costs for treating these diseases project to be $48 to 66 billion per year in the United States.[11]

Causes of Pediatric Obesity

Genetics play a role in the development of childhood obesity but only accounts for less than 5 percent of its cases. It often has to be combined with environmental or behavior factors to influence weight. Thus it is not considered the major cause that is responsible for the dramatic increase in pediatric obesity.[12][13]

Multiple environmental factors significantly contribute to the rising rates of childhood obesity. Decreased activity level among children and adolescents is significantly associated with obesity. In 2007, only 36 percent of US children and adolescents met the recommended levels of physical activity.[4] Larger portion sizes and increased consumption of unhealthy food choices, such as high caloric snacks, sugary beverages, and fast foods, are some major factors in the development of pediatric obesity.[13] The food choices that parents make also correlate with the increasing number of cases in pediatric obesity. The type of snacks that are available in the house and of foods that parents like to eat can affect the foods that their children consume.[14] When one parent is obese, his or her children will have about a 40% chance of becoming obese. When both parents are overweight, their children have an approximately 80% chance of becoming obese.[15] Because unbalanced and low nutritious diets are highly associated with childhood obesity, health professionals must recommend healthy diets to families using appropriate pediatric nutritional guidelines.[16]

Pediatric Nutritional Guidelines 

An article by Gidding et al.[17] discusses some of the general dietary recommendations by the American Heart Association for children aged two and older, as indicated in the following: 

• Balanced dietary calories with physical activity (60 minutes of moderate to vigorous physical activity every day)
• Daily consumption of vegetables and fruits and limited consumption of juice
• Reduced consumption of sugary drinks and foods
• Increased consumption of whole-grain bread and cereals instead of refined-grain foods
• Increased consumption of oily fish
• Reduced salt intake 

Other dietary recommendations for children include carbohydrate reduced or restricted diet and low calorie and fat foods.[18] Daily recommended servings of fruits, vegetables, grains, and dairy products vary depending on a child’s gender and age. Children aged 2 to 3 are recommended to consume 1 cup of fruits and vegetables each, regardless of their gender. Recommendations for children aged 4 to 8 are to eat 1.5 cups of fruits irrespective of their gender, while females and males are recommended to eat 1 cup and 1.5 cups of vegetables, respectively.[17] Thus, medical practitioners must use pediatric nutritional guidelines to give proper dietary recommendations to parents of pediatric patients.

Clinical Significance

In a study performed by Palhares et al., the clinical markers of overweight and obese subjects (n=161) aged between 5 to 19 years were analyzed.[19] An increase in parameters, including systolic and diastolic blood pressures (in 8.1% and 9.3% of the participants, respectively), glucose (10%), insulin (36.9%), and leptin (95% of obese and 66% of overweight participants), was observed. On the other hand, a decrease in high-density lipoprotein (47.2%) and adiponectin (29.5% of obese and 34% of overweight participants) levels were noted.

Diabetes Mellitus

Twenty years ago, the dominant type of pediatric diabetes cases was immune-mediated type 1 diabetes (T1DM). Due to a rising rate of childhood obesity, the number of type 2 diabetes (T2DM) cases has dramatically increased among children and adolescents. T2DM is responsible for almost 50 percent of all new diabetes cases among children.[20]

Clinical signs and symptoms of children with T2DM may be difficult to distinguish from those of children with other types of DM, such as T1DM. T1DM is predominantly present in the White population, whereas T2DM predominates more in the Black, Hispanic, Asian, and Native American populations. B-cell autoantibodies are more commonly observed in T1DM than in T2DM pediatric populations. Ketoacidosis is more frequent in T1DM patients. Some of the associated disorders of T1DM are autoimmune diseases related to thyroid and adrenal glands. T1DM patients have low levels of insulin and C-peptide, whereas T2DM patients have high levels of insulin and C-peptide.[21] As the number of children and adolescents with T2DM continues to rise, it has become increasingly substantial for medical practitioners to diagnose pediatric patients with correct diabetes mellitus to provide appropriate treatment as early as possible. Obesity is observable in both T1DM and T2DM pediatric patients. 

Hypertension and dyslipidemia are associated with insulin resistance and obesity, and thus commonly observed in pediatric patients with T2DM. Children who are obese often present with increased LDL cholesterol and triglycerides levels and decreased HDL cholesterol levels. Elevated LDL cholesterol may lead to atherosclerosis and trigger chronic inflammation. Abnormal lipid levels are present in 12 to 17% of children and adolescents who are overweight.[22] Acanthosis nigricans and polycystic ovarian syndrome (PCOS), which are also associated with insulin resistance and obesity, are common disorders among children and adolescents with T2DM.[23]

Acanthosis Nigricans

Patients with Acanthosis nigricans present with velvety hyperpigmented patches that are poorly demarcated on the skin. These dark patches, which may be itchy and odorous, can be commonly found in body folds of the neck, groin, and armpits. This condition occurs in up to 90 percent of children with T2DM.[21] Acanthosis nigricans is more frequent in Native Americans, Pacific Islanders, Hispanics, and African Americans.[24] These ethnic groups also have a higher chance of developing T2DM.[25]

Polycystic Ovarian Syndrome (PCOS) 

PCOS is an endocrine disorder that presents with chronic anovulation and hyperandrogenism and may lead to infertility in women at their reproductive age. It is prevalent in 5 to 13% of women at reproductive age, and 70 to 80 % of women with PCOS are infertile.[26] Patients with PCOS often have abnormal glucose metabolism and lipid levels. The onset of glucose intolerance in PCOS patients occurs earlier (in their 30s and 40s) than healthy female patients.[27] Common signs and symptoms of PCOS include cystic ovaries, pelvic pain, hirsutism, alopecia, acne, and Acanthosis nigricans.[28] 

Children and adolescents with T2DM are more likely to develop progressive complications at earlier ages than those diagnosed with the disease later in their adulthood. Some of these complications include stroke, myocardial infarction, renal insufficiency and chronic renal failure, neuropathy, and retinopathy that leads to blindness.[20]

Diabetic Retinopathy

With the rising number of pediatric T1DM and T2DM cases, more children and adolescents have been at risk of developing diabetic retinopathy (DR) and experiencing visual impairment. Because DR may progress without any symptoms, conducting an annual retinal examination on diabetic children and adolescents and initiating appropriate ophthalmic therapy are crucial to prevent irreversible visual loss. Children and adolescents should get their first DR screening test when they are 10 to 12 years old or when it has been 2 to 5 years since being diagnosed with diabetes. Patients with prolonged DR may present with “hard exudates,” which are lipid deposits that look like dots on the fundus of the eye, in their retina. These deposits in the macula may lead to the development of diabetic maculopathy.[29] A study performed by Minuto et al. shows a significant association between DR and elevated serum triglycerides levels (> 65 mg/dL).[30] In a pilot study performed by Mayer-Davis et al., DR subjects showed significantly higher LDL cholesterol levels than the subjects without DR.[31] 

Nursing, Allied Health, and Interprofessional Team Interventions

Managing pediatric obesity requires multidisciplinary efforts from health professionals at different levels, including physicians, school nurses, and diabetes educators. 

Primary Care

Family medicine physicians and pediatricians should educate pediatric patients and their parents regarding the importance of maintaining a healthy balance between diet and physical activity. They should help the patients and their family members to gradually reduce the amount of fast food and sweetened beverages they consume and increase nutritious snacks, fruits, and vegetables. Providers should perform appropriate screenings to manage obesity effectively and efficiently. 

Some of the recommendations for pediatric obesity screening appear below:[32]

• Obtain a fasting lipid profile for overweight children and adolescents with BMI 85-95 percentile
• Obtain a hemoglobin A1c or fasting blood glucose panel and AST and ALT blood tests if overweight children are over ten years old and have one or more risk factors (elevated blood pressure or lipid levels, smoker, or have a family member with obesity-related diseases)
• Obtain a fasting lipid panel when children have no risk factors but are with BMI ≥95th percentile, regardless of their age. 
• Obtain a fasting blood glucose or HbA1C test and liver function tests when children aged over ten years have no risk factors but present with BMI ≥95th percentile. 
• If lipids levels are normal, screening should be repeated every two years. If the levels are borderline, repeat in 1 year. If the levels are abnormal, repeat in 2 weeks to 3 months. 

School Nurses 

School nurses may play a crucial role in pediatric obesity management since they work closely with children at school. School nurses who are experts in motivational interviewing and weight management can counsel students about their diet and exercise and encourage them to maintain a healthy lifestyle. They can continue to monitor children as they move from grade to grade, and thus can ensure the children in obesity management programs follow the program regimen for longer durations. School nurses may also have regular telephone consultations or in-person counseling sessions with parents and discuss nutrition and physical activity that are necessary at home.[33]

Diabetes Educators 

Diabetes educators can serve as an essential link between school nurses and pediatric endocrinologists. School nurses often reach out to diabetes educators to discuss suspected pediatric diabetes cases who triage patients before referring them to endocrinologists. They help primary care providers and school nurses select children who need a referral to a pediatric endocrinologist for T2DM treatment or children who require assistance with lifestyle management.[34]