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Episode 144: Risk Factors for Pediatric Overweight and Obesity

Future Dr. Lal describes multiple risk factors associated with childhood overweight and obesity. Dr. Arreaza adds comments about caring for pediatric patients with obesity. Practice guidelines are mentioned throughout this episode.

Written by Krustina Lal, MSIII, Western University College of Osteopathic of the Pacific. Comments by Hector Arreaza, MD.

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Introduction:

• Obesity is one of the most common pediatric chronic diseases affecting 14.4 million children and adolescents (about twice the population of New Jersey).
• A recent simulation study from the US found that by 2030, a staggering 55–60% of today’s children will be obese.
• 1 in 4 children in California have obesity.
• Research shows that the ages between 0 and 5 years is a critical period in the development of overweight and obesity. Obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. Pediatricians and other primary care physicians need to be aware of the risk factors for pediatric obesity to provide early anticipatory guidance for prevention, close monitoring, and early intervention when the weight trajectory increases.

We will discuss the risk factors for children and adolescents to develop overweight and obesity, we will be diving deep into general, environmental, and familial factors. This is based off the AAP (American Academy of Pediatrics) “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.” This guideline was published in February 2023, it is available online for free, and this is the first edition.

A. General Factors
- Socioeconomic Status

• A longitudinal analysis of predominantly non-Hispanic white children in the United States found that low socioeconomic status before 2 years of age was associated with higher obesity risk by adolescence in both boys and girls.
• Poverty is associated with toxic stress, limited access to healthy foods, and low physical activity.

-Children in Families That Have Immigrated to the US

• Recently arrived immigrants tend to be healthier than their US-born counterparts. However, as immigrants try to adjust to a new culture, they may adopt Americanized foodways, which are high in fat, sugar, and salt.
  Second-generation Hispanic immigrants are 55% more likely to have obesity than nonimmigrant white children, whereas first-generation Asian immigrants had a 63% lower risk of having obesity.
• Larger body sizes may be an indication of health and wealth in some cultures. This cultural factor may make it more difficult for parents to understand the gravity of their children’s obesity.
• Comment: This is a common concern among Hispanic families that bring their children to the clinic to get “vitamins” to gain weight because they look “sick,” but their BMIs are normal. PCPs should be prepared to address that concern in the clinic.

B. Neighborhood and Community Environments

-School Environment

• The presence of fast foods, vending machines, and/or sweetened beverages in schools may negatively influence children’s food choices, this effect is larger in younger grades.
• One day I went to have lunch with Devin, I liked that they had to go through the salad bar before they went to get other foods. They had the choice between vegetables or fruits.

-Lack of Fresh Food Access

• Neighborhood food environment has been shown to have a mixed association with children’s BMI.
• Children and families in these settings may be unable to access fresh fruits and vegetables and safe physical activity spaces. There may be limitations in transportation, cost, affordability, and availability.

-Fast food proximity

• Low-priced, calorie-rich fast foods with elevated levels of saturated fat, simple carbs, sugar, and sodium are commonly sold in fast food restaurants. Because they are easily available, they taste good, and they are strategically marketed, fast foods tend to be popular among children and adolescents.
• Some studies, not all, have shown an association between fast food locations near schools and obesity in children; a stronger association is seen in populations with lower socioeconomic status.

-Access to safe physical activity

• Greater exposure to green space has been shown to be associated with higher levels of physical activity and a lower risk of obesity.
• That is something we have to recommend during our well-child visits. We are seeing a lot of aversion to going outside among the new generations. Going out seems to be torture when they find so much fun inside their houses (countless amounts of videos, video games, air conditioning/heater, etc...). A strategy for parents can be recommended 1 hour of playing outside before allowing screen time.

-Environmental Health  

• Exposure to environmental hazards during the prenatal period, infancy, and childhood can have impacts on the health and well-being of children.
• Exposure to endocrine-disrupting chemicals may occur through breastfeeding, inhalation, ingestion, or absorption through the skin. We are basically surrounded by hazardous chemicals used in cleaning agents, food packaging, pesticides, fabrics, upholstery, etc. Exposure during early childhood can affect the programming of several systems, including endocrine and metabolic systems, which may affect BMI, cardiovascular, and metabolic outcomes later in life.

C. Family and home environment factors
-Parenting feeding style

• Four types of parent feeding styles have been described:

1. Authoritative
2. Authoritarian
3. Permissive or indulgent
4. Negligent

• Authoritative feeding is considered protective against excessive weight gain. Children tend to eat more healthy foods, be more physically active, and have healthier BMI compared with children raised in homes with authoritarian, permissive or indulgent, or negligent parenting styles.

-Sugar-sweetened beverages within the home

• A systematic review of 20 prospective cohort studies and randomized controlled trials from 2013 to 2015 found that sugar-sweetened beverages (SSBs) were positively associated with obesity in children in all but 1 study.
• Comment: Sugary drinks are an easy way to get calories in your body. People tend to think that drinks don’t count, but they can be loaded with carbs. Orange juice can have up to 25 grams of sugar in a cup, some sodas may have double, and both are high in sugar.

-Portion sizes and snacking behavior 

• Positive association but need long-term studies

-Dining out and family meals

• Eating outside of the home—irrespective of the type of restaurant establishment visited—is associated with a higher risk of weight or BMI gain.
• Conversely, 2 meta-analyses found that an increased frequency of eating family meals was associated with a lower risk of childhood obesity.

-Screen time – This is one of the major struggles we have as parents. It’s a daily fight.

• A recent meta-analysis reported a 42% greater risk of being overweight or obese with more than 2 hours per day of television (TV) compared with 2 or fewer hours.
• Meta-analysis showed that even short exposure to unhealthy food and beverage marketing targeted at children resulted in increased dietary intake and behavior during and after the exposure.
• Marketing occurs via television, websites, online games, supermarkets, and outside schools.
• Male children and adolescents tend to spend more time on media screen devices and other Internet technology than female children and adolescents do.
• There is no conclusive guideline about it, but in general, we can recommend sleep hygiene to avoid insomnia or abnormal sleep patterns, such as avoiding “screens” 1 hour before bed.

-Sedentary behavior

• No association. However, many confounding factors include physical activity, screen time, and unhealthy food intake.

-Sleep duration

• Children 13 years and younger with short sleep duration (∼10 hours) had a 76% increased risk of being overweight or obese compared with their counterparts with longer sleep duration (12.2 hours).
• Sleep restriction may be associated with increased calorie consumption, fatigue, and decreased physical activity.

-Environmental smoke exposure

• Children under 8 years old exposed to environmental tobacco smoke (ETS) have been found to have higher BMI compared with their nonexposed counterparts.
• I wonder If this is a direct or indirect effect of smoke.

-Psychosocial stress

• A meta-analysis showed that prenatal psychological stress was associated with a higher risk of childhood and adolescent obesity.
• Psychosocial and emotional issues may lead to weight gain through maladaptive coping mechanisms, including eating in the absence of hunger to suppress negative emotions, appetite up-regulation, low-grade inflammation, decrease in physical activity, increase in sedentary behavior, and sleep disturbance. Depression has been shown to be a risk factor in both pediatric and adult obesity.

-Adverse childhood experiences

• ACEs include a history of physical, emotional, or sexual abuse; exposure to domestic violence; household dysfunction from parental divorce or substance abuse; economic insecurity; mental illness; and/or loss of a parent because of death or incarceration.
• A study found that having many ACEs increased two times the risk of children having overweight or obese compared with children with no history of ACEs. Stress may result in abnormal coping strategies—such as binge eating, eating in the absence of hunger, impulsive eating, and poor sleep hygiene—which may result in further weight gain.

Summary: The consequences of childhood obesity are far-reaching and extend beyond physical health issues. Children with obesity are more likely to experience a range of health complications, including type 2 diabetes, high blood pressure, sleep apnea, joint problems, and psychological issues such as low self-esteem and depression. Moreover, children with obesity are at a higher risk of carrying their weight-related problems into adulthood, increasing their susceptibility to chronic conditions such as cardiovascular disease, certain types of cancer, and premature mortality. 

As medical providers, we all need to keep general, environmental, and familial factors in mind when discussing weight changes among our pediatric patients. Having knowledge of such influences will help us intervene and prevent further progression. 

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Conclusion: Now we conclude episode number 144, “Risk Factors for Pediatric Overweight and Obesity.” Future Dr. LaL reminded us that childhood obesity is a disease linked to multiple risk factors, including but not limited to: low socioeconomic status, lack of access to safe spaces for exercise, parenting feeding styles, sleep disturbances, and adverse childhood events. Dr. Arreaza emphasized the importance of providing obesity care with kindness and empathy, especially when caring for pediatric patients.

This week we thank Hector Arreaza and Krustina Lal. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

1. Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics February 2023; 151 (2): e2022060640. 10.1542/peds.2022-060640. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and?autologincheck=redirected.
2. Weihrauch-Blüher, S., Wiegand, S. Risk Factors and Implications of Childhood Obesity. Curr Obes Rep 7, 254–259 (2018).
3. Hemmingsson, E. Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication. Curr Obes Rep 7, 204–209 (2018).
4. Royalty-free music used for this episode: "Latina Havana Boulevard." Downloaded on October 13, 2022, from https://www.videvo.net/