Promotion of physical activity in primary care for obesity treatment/prevention in children

PURPOSE OF REVIEW: Physical activity has been highlighted internationally as a beneficial intervention for weight control and the improvement of physical and mental health. This review highlights findings from recent literature to guide office-based promotion of physical activity for obesity treatment and prevention. RECENT FINDINGS: Children worldwide participate in far less than the current physical activity recommendations. Family-based activity provides children with positive role modeling as well as motivational support for maintaining an active lifestyle. The integration of physical activity into daily life can be an effective alternative to sports and structured exercise programs. Decreasing sedentary behaviors is also a positive contribution, although its link to physical activity levels is still unclear. Some families may see neighborhood safety and access to recreational facilities as barriers to keeping their children physically active. SUMMARY: Research in the field of pediatric obesity and overweight treatment and prevention continues to find challenges and solutions. Promotion of physical activity by the pediatric provider is demonstrated by current evidence to be a positive intervention against this global problem.     

Adipositastherapie und -prävention im Kindesalter

Obesity is perceived as the consequence of individual behavior, a given genetic background, and a lack of adaptation to an “obesigenic” environment. Social health insurance law in Germany deems obesity to be a disease if either complications of overweight are present in addition to a deviation of the body mass index (BMI) from normal values or if this deviation fulfills the definition of extreme obesity (BMI > 99.5. percentile). Long-term effectiveness of treatment programs for obese children and adolescents, however, has not yet been reliably demonstrated. Prevention strategies should therefore not try to transfer models of obesity therapy to larger parts of the population. They should rather build on experiences with substance abuse prevention, smoking cessation and HIV/AIDS prevention. Prevention of overweight and obesity is a task of public health promotion and needs concerted efforts of actors on all levels of the causal web of obesity.     

Viewpoint article: Childhood obesity – looking back over 50 years to begin to look forward

The last 50 years have seen the emergence of childhood obesity as a major public health concern and a condition now regularly encountered in routine general paediatric practice. Causes are extremely complex, bringing together multifactorial environmental factors and individual genetics, and we still do not have a clear understanding of why some children appear predisposed to exaggerated and sometimes extreme weight gain. Overweight and obese children of today face an uncertain future. They are likely to experience higher rates of type 2 diabetes and heart disease, as well as many other health problems. However, while the prevalence of childhood obesity has progressively increased over the last few decades, so has research into its underlying causes. This has led to large‐scale trials aimed at improving prevention or treatment. As data have emerged from such studies, we have begun to accept that the heterogeneity of obesity means that broad ‘common sense’ strategies to address diet and activity will not lead to success on their own. Now is the time to begin to build on this information, dispelling myths and beliefs, in order to focus research efforts and take first steps towards more sophisticated strategies that go beyond the surface behaviours that simply potentiate obesity. Through carefully designed studies, aimed at tackling fundamental questions missed in the hasty development of ‘common sense’ approaches, will come answers that can lead to the development of more effective community‐ and health‐care‐orientated prevention and treatment programmes.     

Obesity in childhood--diagnosis and therapy

Obesity during childhood represents one of the most common nutritional disorders in industrialized countries. The duration of obesity in childhood correlates well with the probability to become an obese adult. Diagnosis of obesity requires reference weight for height tables and the measurement of skinfolds with the caliper technique. Using this method a differentiation between overweight and overnutrition can easily be performed also in an outpatient clinic. For therapeutic purpose a longterm dietary regime with a hypocaloric nutrition has to be reached. Some other dietary regimes ("Protein-modified fast" and "very low calorie diets") are presented and their clinical practicability discussed. The earlier treatment starts for obese children and adolescents the higher is the likelihood for longterm-success. It is emphasized that even pediatricians should focus their interest on prevention of obesity by means of prudent diet education.     

Integrative approach to obesity

Integrative medicine blends conventional medicine with carefully evaluated complementary therapies and considers all elements of a patient's lifestyle (physical, mental, spiritual). Integrative medicine therapies and philosophies have characteristics similar to those of successful treatment programs for pediatric obesity. This article defines pediatric obesity and explores those similarities in more detail. It also updates the practitioner on selected integrative approaches as they relate to prevention and treatment of pediatric obesity.     

Physical activity and cardiovascular health in children

The rapid growth in the prevalence of obesity in children and the tracking of obesity from childhood to adulthood can predispose children to type 2 diabetes and CVD at an early age. Strategies to prevent obesity and its complications are of urgent importance. In view of the enormous cardio-protective role of physical activity, pediatricians should implement more intensely preventive strategies based on physical activity, diet, and behavior. This approach is crucial as an effective form of prevention of development of diabetes and CVD, as well as a therapy for children with risk factors for CVD. However, this is a complex task and requires a unified approach that involves environmental, behavioral, cultural, economic, legislative, and physiological factors, as well as a favorable environment that promotes physical activity along with healthy dietary habits.     

Prävention der kindlichen Adipositas während der Schwangerschaft

Currently, epidemiological and experimental data are being intensively discussed which indicate that exposures during prenatal life have lifelong consequences for the risk of developing obesity and subsequent metabolic and cardiovascular diseases. In this context, observations in offspring of mothers with diabetes during pregnancy as well as studies in children with low birth weight were most influential. This paper illustrates the current knowledge on perinatal programming of obesity and associated diseases and discusses possible aetiopathogenic mechanisms, focussing on epidemiological and animal studies on the consequences of exposure to maternal obesity/diabetes and prenatal undernutrition. The resultant far-reaching potential for primary prevention of chronic diseases as well as the paradigmatic character of these hypotheses and observations for the general understanding of health and disease are highlighted.     

Aetiology of overweight and obesity in children and adolescents

The epidemic diffusion of obesity in industrialised countries has promoted research on the aetiopathogenesis of this disorder. The purpose of this review is to focus mainly on the contribution that European research has made to this field. Available evidence suggests that obesity results from multiple interactions between genes and environment. Parents obesity is the most important risk factor for childhood obesity. Twin, adoption, and family studies indicated that inheritance is able to account for 25% to 40% of inter-individual difference in adiposity. Single gene defects leading to obesity have been discovered in animals and, in some cases, confirmed in humans as congenital leptin deficiency or congenital leptin receptor deficiency. However, in most cases, genes involved in weight gain do not directly cause obesity but they increase the susceptibility to fat gain in subjects exposed to a specific environment. Both genetic and environmental factors promote a positive energy balance which cause obesity. The relative inefficiency of self-adapting energy intake to energy requirements is responsible for fat gain in predisposed individuals. The role of the environment in the development of obesity is suggested by the rapid increase of the prevalence of obesity accompanying the rapid changes in the lifestyle of the population in the second half of this century. Early experiences with food, feeding practices and family food choices affect children's nutritional habits. In particular, the parents are responsible for food availability and accessibility in the home and they affect food preferences of their children. Diet composition, in particular fat intake, influences the development of obesity. The high energy density and palatability of fatty foods as well as their less satiating properties promotes food consumption. TV viewing, an inactivity and food intake promoter, was identified as a relevant risk factor for obesity in children. Sedentarity, i.e. a low physical activity level, is accompanied by a low fat oxidation rate in muscle and a low fat oxidation rate is a risk factor of fat gain or fat re-gain after weight loss. Conclusion Further research is needed to identify new risk factors of childhood obesity, both in the genetic and environmental areas, which may help to develop more effective strategies for the prevention and treatment of obesity.     

Childhood obesity

Several conclusions can be drawn on the basis of the research reviewed: Obese children are more likely to become obese adults than are their thinner peers. Parent weight may interact with child weight status in the etiology of adult obesity. Obese children with obese parents are more likely to become obese adults than are obese children with thin parents. The prediction of adult obesity from childhood obesity improves with the age of the child. As the obese child gets older, he or she is more likely to become an obese adult. The inclusion of parents in the treatment process is important for the success of childhood weight control. It may be best to see the parent and child separately in treatment meetings rather than together. Children with thin parents may do better in weight control than children of obese parents. Adherence to exercise is likely to be a problem with obese children, and the choice or design of an exercise program should take these adherence problems into account. Nutritional adequacy of the child's diet should be evaluated both in terms of what the child is eating as well as in terms of the prescribed diet. Likewise, growth of the obese child during dieting should be monitored and should be related to expected height, which can be based on parent height. In summary, childhood obesity is a problem that places a child at great risk for becoming an obese adult. However, a growing body of research has emerged that has identified important risk factors for the development of obesity in children. Likewise, treatment methods have been developed that produce significant and long-lasting effects on childhood weight status. Continued development of treatment methods would be of great potential importance in the prevention and treatment of this prevalent problem.     

Building capacity for childhood obesity prevention and treatment in the medical community: call to action

Large gaps exist in the capacity of the US medical system to participate meaningfully in childhood obesity-prevention efforts and to meet the treatment needs of obese children. Current primary care practice for the prevention and treatment of childhood obesity often varies from evidence-based recommendations. Childhood obesity specialists have partnered successfully with schools of medicine, professional societies, and other organizations to collaboratively engage with primary care providers in quality improvement for obesity prevention and treatment. This review and commentary targets 2 audiences. For childhood obesity experts and their organizational partners, methods to support change in primary practice and the evidence supporting their use are outlined. For primary care providers and non-obesity specialists, effective strategies for changing practice and the potential benefits of addressing childhood obesity systematically are discussed.     

Treatment of childhood obesity

This article provides current guidelines on the treatment and prevention of childhood obesity. Since factors involved in obesity change with age, the therapeutic approach in pre-school children will be different from pupils and adolescents. The treatment will also be modulated on the basis of weight excess, weight gain velocity and complications. The main goal of the treatment should be to encourage the child and his family to have healthy lifestyle. Families who are not ready for change might benefit from counselling to improve motivation before starting treatment. A detailed alimentary and behavioural history is the start point of the treatment. The strategy of the intervention is to induce changes at three levels: 1) attitudes of parents; 2) physical activity; 3) energy intake. The treatment of the adolescents should take into account the pubertal changes and the psychological aspects of this peculiar period of life. Obesity is a chronic disease and its treatment needs long-life follow-up. The long-term results of the obesity treatment are often disappointing and we have to consider consistent prevention programs for better results.     

The development of obesity in childhood

Multiple factors appear to influence and promote the development of obesity: The importance of genetic factors has been demonstrated in some studies, however, it is very difficult to distinguish between environmental and genetic influences. Independently, increased birthweight, massive weight gain in the first months after birth and overweight of the mother or of both parents seem to be risk factors, which are able to promote the development of childhood obesity. In the past few years more attention has been paid to psychological factors and their influence on appetite, physical activity and energy balance. Whether metabolic changes on cellular and microcellular basis can cause obesity is not sufficiently known until now. Nutrition in early childhood and fat cell hyperplasia and hypertrophia induced by nutritional factors probably do not imply persistence of obesity but may promote obesity and worsen the prognosis of therapy. Due to the fact that a high percentage of obese adolescents remain obese in adulthood, and due to the poor results in the treatment of obesity as well as the association of overweight with an increased risk for morbidity and mortality an effective therapy and prevention of obesity even during childhood seem to be of great importance.     

儿童肥胖症与肠道菌群相关性的研究进展

近年越来越多的研究发现肠道菌群与肥胖症的发生发展密切相关。肠道菌群可能通过增加能量摄取、影响肠道激素分泌、引起慢性系统炎症、产生胰岛素抵抗等对儿童肥胖症产生作用。该文对儿童肥胖症与肠道菌群相关性和可能的机制进行综述,以期为儿童肥胖症的病因和防治提供参考依据。     

The prevalence of obesity in children with autism: a secondary data analysis using nationally representative data from the National Survey of Children's Health

Background  

The prevalence of childhood obesity has increased dramatically in the last two decades and numerous efforts to understand, intervene on, and prevent this significant threat to children's health are underway for many segments of the pediatric population. Understanding the prevalence of obesity in populations of children with developmental disorders is an important undertaking, as the factors that give rise to obesity may not be the same as for typically developing children, and because prevention and treatment efforts may need to be tailored to meet their needs and the needs of their families. The goal of the current study was to estimate the prevalence of obesity in children and adolescents with autism.     

Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report

To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child's obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient's age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.     

An update in prevention and treatment of pediatric obesity

Background  Obesity prevalence is growing as well as its severity with increasing morbidity and mortality. This “globesity” also affects developing countries where under nutrition and stunting frequently coexist with overweight and obesity. One third of obese adults began to be so in the pediatric ages. There are two main types of prevention: general one representing greater actions from health authorities and the individual one carried out by the pediatrician and the patient at risk. Once the state of obesity is reached (relative body mass index, rBMI >121%) the longer lasting care becomes more complex and frequently unsuccessful. The treatment of obesity is aimed to care for the present and silent disorders and for preventing its further tracking to adulthood. Data sources  Identification of pediatric population at risk which is the one with an rBMI of 111%–120% plus other risk factors. Specific individual actions include reduction of food intake, increase of energy expenditure, involvement of parents, and the child-adolescent himself in the prevention. Therapy is based on some principles plus the important medical and emotional approach. Results  A Cochrane study based on only 10 appropriate studies showed a predominant poor efficacy of the undergone preventive action. Treatment guides are presented after our own experience with a group of 400 kids with an average follow-up of 7 years and other individual prevention studies. Conclusions  Involving motivated pediatricians with a minimum of time for visits and better follow-up in the frame of a general national preventive programme could be a rational outcome. Treatment of obesity should never be postponed whatever the clinical care is.     

Family therapy treatment: working with obese children and their families with small steps and realistic goals

Childhood obesity treatment can be discussed from several points of view, and there are many forms of treatment. Solution-focused brief therapy (SFBT) and systemic family therapy can be useful in a wide range of contexts and settings such as social care, education and healthcare. They can also be used wherever practitioners sometimes feel that they have very little impact on the patient and where the patient seems to be resistant to acknowledging his/her problem. Health professionals need to assist by starting to explain main goals and medical information in terms of a single, small, concrete and important goal, described as the beginning of a new behaviour, not as the end of something. This report focuses on some useful tools and methods taken from casework examples from multidisciplinary obesity team meetings with more than 300 families during a 3-y project approximately between 2002 and 2003 at the Childhood Obesity Unit at University Hospital, Malm?. Other casework examples are taken from supervision and training professionals who are currently working with or are going to work with childhood obesity using a solution-focused model. The main aim of this report is to discuss and think about the difference between problem-solving and solution-building interview questions when it comes to treatment regarding how best to help children and parents with serious obesity health problems. CONCLUSION: There is a great need for treatment models and the prevention of childhood obesity now and in future, which presents an interesting and urgent challenge for open-minded thinking and new fields of research.     

Effects of breastfeeding on weight changes in family-based pediatric obesity treatment

Research indicates that breastfeeding may provide protective effects against the development of obesity; however, breastfed children may still become obese because of the obesogenic environment. This study is designed to examine the effects of retrospective recall of breastfeeding on weight changes in children participating in a 6-month behavioral treatment program for childhood obesity. The independent variable of breastfeeding was defined as children who were exclusively breastfed for 4 weeks (excluding water or medication) versus those who were never breastfed. Child percent overweight and body mass index changes during 6 and 12 months were evaluated for 94 families based on mother report of breastfeeding status using analysis of covariance, controlling for socioeconomic status and initial child weight status. Data were compiled for secondary analysis from pediatric obesity randomized controlled outcome studies evaluating core components of family-based treatments. Results showed that, compared with nonbreastfed (formula) children (n = 28), breastfed children (n = 66) showed significantly larger reductions in (mean +/- SEM) percent overweight at 6 months (-15.2 +/- 1.1 vs -10.2 +/- 1.7, p <.05) and 1 year (-10.3 +/- 1.3 vs -5.9 +/- 1.8, p <.05). Similarly, breastfed children showed greater reductions in body mass index at 6 months (-2.1 +/- 0.19 vs -1.1 +/- 0.28) and 1 year (-0.8 +/- 0.23 vs +0.1 +/- 0.32). Findings suggest the beneficial effects of breastfeeding may extend beyond obesity prevention to include improved outcome in family-based pediatric obesity treatment. Potential mechanisms relating breastfeeding, obesity prevention, and enhanced outcome in pediatric obesity treatment are discussed.     

Prevention and treatment of overweight and obesity in children and adolescents

Increasing numbers of obese children and adolescents all over the world demand an investment in the primary and secondary prevention of obesity and overweight in this age group. The goal of preventive measures in children is to avoid the negative short- and long-term health problems associated with obesity. Primary prevention aims at establishing a healthy, active lifestyle and keeping children and adolescents within a range of body weight which is considered to be healthy. Constant availability and affordability of palatable and energy-dense food in the affluent society of the western world demands preventive strategies. Universal or public health prevention seems to be the most suitable form because several other cofactors of morbidity and mortality of affluent societies can also be prevented. However, in most European countries there is a lack of awareness of the necessity of prevention programmes, not only among the general population but also among the medical society. More awareness and consciousness to the problem of obesity must be generated in order to lead to effective therapeutic programmes. For those children and adolescents who are already obese, secondary prevention is mandatory. Therapeutic intervention programmes for the obese aim at long-term weight maintenance and normalisation of body weight and body fat. They have to modify eating and exercise behaviour of the obese child and establish new, healthier behaviour and lifestyle. Treatments programmes must include behavioural components in order to permanently change nutrition and physical exercise of the obese children and adolescents. However, long-term results of treatment programmes in European countries are scarce and the reported results, even of multidisciplinary regimens, are not impressive. Conclusion In most European countries there is an urgent need not only for a growing awareness of the problem of obesity in children and adolescents but also for development of new comprehensive approaches in treating this group.