#32014: Childhood Obesity: Impact on Health Care

Obesity and obesity-related complications such as type 2 diabetes disproportionately affect minority populations, specifically black Americans and Hispanic Americans of all ages [38]. Studies have found that 19.5% of non-Hispanic black children and adolescents in the United States (2 to 19 years of age) and 21.9% of Hispanic American children and adolescents (2 to 19 years of age) are overweight [17]. Girls and women, particularly those who are black and Hispanic American, are affected more severely than boys and men.

It is important to understand the impact of cultural perceptions of overweight and obesity. Taking into consideration the impact of overweight and obesity on the Hispanic population in the United States, this is one cultural group that should be examined [16]. There is a widely held belief in many Hispanic cultures that infants and children who are larger or overweight are healthier and stronger. The Hispanic view of overweight is one of health and strength, not of disease or illness [45]. In one study of Hispanic mothers, the women were more likely to consider average-weight children (50th to 75th percentile BMI) too thin or unhealthily thin [45]. When presented with images of children with BMIs in the 95th percentile, the women generally described the children as "slightly overweight" [45].

In many cultures, eating is a social event and is often the center of celebrations. In these contexts, children observe the behaviors and preferences of parents, siblings, other older relatives, and peers, and this can influence future food selections [16].

Genetic changes in human populations occur too slowly to be responsible for the obesity epidemic. Yet variants in several genes may contribute to obesity by increasing hunger and food intake [40]. There is a growing body of evidence that describes obesity as a polygenic disorder, with many genes being linked or associated with a predisposition to adiposity [46]. The pathogenesis of polygenic obesity is multifactorial and due to the interaction among genetic, epigenetic, and environmental factors [47]. Scientists have identified more than 1,100 independent genetic loci associated with obesity traits [47]. These genes impact several body systems and processes, including appetite, which partially explains why some infants are indifferent to food while others eat eagerly [2]. Rarely, a specific variant of a single gene (monogenic obesity) causes a clear pattern of inherited obesity within a family [48]. Some research has supported the presence of a human obesity syndrome thought to be linked to genetic defects [49]. Many of these genetic differences are manifested in the body's regulatory hormone levels.

Leptin is a hormone that is mainly released by adipose tissue when fat molecules accumulate. It is also produced in the stomach, ovaries, and skeletal muscle. In those of normal weight, leptin inhibits appetite in satiated individuals [2]. In some overweight individuals, the leptin pathway is inhibited, which results in the lack of signaling to stop eating [2]. Leptin receptor mutations and pro-opiomelanocortin deficiency are both associated with overeating and subsequent obesity [46,50].

In addition to leptin, the hormone ghrelin may impact an individual's risk of developing obesity [51]. It is the only known appetite-stimulating hormone, and when administered to both lean and obese human volunteers, it has been shown to increase food intake [52]. Ghrelin is involved in both short-term regulation of food intake and long-term regulation of body weight through decreasing fat utilization [53]. Ghrelin is produced primarily in the stomach and acts as a growth hormone secretagogue. Its receptors are located on hypothalamic neurons and in the brainstem [10,51]. The primary function of ghrelin is the regulation of pituitary growth hormone secretion independent of growth-hormone-releasing hormone and somatostatin [11]. It has been hypothesized that ghrelin is an endocrine link between the stomach, hypothalamus, and pituitary and is important for the regulation of energy intake/output [10]. Plasma ghrelin concentrations are negatively correlated with body weight, percentage of body fat, and plasma leptin and insulin, suggesting that plasma ghrelin is down-regulated in obesity [10,51]. Ghrelin antagonists and receptor blockers are a group of molecules that have received interest for development as anti-obesity targets [54].

A negative relationship between socioeconomic status (as measured by income, education, and occupational status) and adult overweight and obesity has been well established, and this connection appears to be established for children as well [44]. In the period 2011–2014, obesity prevalence among children whose adult head of household had completed college was 9.6% compared with 21.6% for children whose adult head of household had completed high school or less [44]. Among non-Hispanic white children, the lowest prevalence of obesity was observed among those whose adult head of household completed college; however, this was not the case for non-Hispanic black children [44]. In 2011, obesity prevalence (based on family income) among children 2 to 4 years of age from low-income households ranged from 14.2% (income-to-poverty ratio ≤50%) to 185% (income-to-poverty ratio 151% to 185%) [44].

Increased understanding of the impact of social determinants of health on the chronicity of obesity has enabled a broader and deeper understanding of the complexity of obesity risk and treatment [55]. In its first edition of guidelines for the evaluation and management of children and adolescents with overweight and obesity, the American Academy of Pediatrics (AAP) defines social determinants of health as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks" [55]. Risk factors for overweight and obesity, many of which are social determinants of health, include broader policies and systems factors; institutional or organizational factors; neighborhood and community; and family, socioeconomic, environmental, ecological, genetic, and biological factors [55].

Children and adolescents with overweight and obesity may experience weight stigma, teasing, and bullying, which contribute to binge eating, social isolation, and decreased physical activity. Internalized weight bias negatively impacts mental health [55]. As a potential source of weight bias/stigma, healthcare providers should identify and address their own weight bias and learn how to reduce it in the clinical setting. Actions to reduce weight stigma include using appropriate capacity medical equipment, displaying inclusive educational materials, and utilizing person-first language (e.g., using the term "child with obesity" rather than "obese child"). This practice is consistent with recommendations from the AAP and other national organizations [55].

Adverse childhood experiences (ACEs) are negative experiences caused by situations or events in the lives of children and adolescents that can pose threats to their current and future physical and mental health. ACEs may include loss of a parent, divorce, abuse, financial hardship, and parental mental illness [55]. ACEs have been associated with obesity in childhood [56,57]. Children and adolescents who live in poverty have a higher likelihood of experiencing ACEs, but risk for ACEs occurs at every income level. The greater the number of ACEs a child experiences, the greater the risk for obesity [55].

Although childhood obesity may be related to specific cultural and national circumstances, universal themes have emerged, including social factors, exercise, advertising, public policy, and the importance of partnership in policy [58]. The obesogenic environment is characterized by increased accessibility and affordability of energy-dense foods in conjunction with declining levels of physical activity [46]. Although community efforts and public policy have been shown to improve childhood obesity rates, studies have indicated that most Americans feel that individuals are responsible for their own obesity and that of their children [38]. However, it is important to recognize that society has created an environment by means of an economic structure that makes processed foods more affordable than fresh foods, and the food industry and mass media market energy-dense foods to children [2]. Evidence is limited regarding specific dietary patterns that may contribute to excessive intake in children and adolescents [44]. There has been considerable debate regarding whether exposure to food advertising affects the incidence of childhood obesity. While a positive correlation between the hours of television viewed, BMI, and obesity has been documented, the exact mechanism by which this occurs are still being investigated [16].

According to the 2019 National Youth Risk Behavior Survey, nearly 60% of high school students had not eaten fruit or drunk 100% fruit juices and 60% had not eaten vegetables in the seven days before the survey [59]. Of the same group, 15.1% had consumed a sugar-sweetened soda (not including diet soda) one or more times per day in the seven days preceding the survey, 10.6% had drunk a sports drink one or more times per day, and 44.6% had drunk three or fewer glasses of plain water each day [59]. A higher percentage of male students than female students had drunk sugar-sweetened soda more than once per day (18.2% versus 11.7%) [59]. Often, individuals do not compensate for the calories consumed in the form of sugar-sweetened beverages with a reduction in solid food intake, partially because liquid forms of energy may be less satiating [60]. In addition to the increase in calorie consumption, average portion sizes have also increased, with sugared drinks increasing from an average 12 ounces to almost 20 ounces [16].

Data from the 2019 National Youth Risk Behavior Survey indicate that, nationwide, 23.2% of students had been physically active 60 minutes or more on all seven days preceding the survey; 49.5% had exercised to strengthen or tone their muscles on three or more days per week; 16.5% had met both aerobic and muscle-strengthening physical activity guidelines; 25.9% had attended physical education classes on all five days in an average school week; and 57.4% had played on one or more sports team [59]. During 2011–2019, a significant decrease occurred in the percentage of students who had been physically active for 60 minutes or more per day on all seven days preceding the survey [59]. The current trend is for schools to decrease the amount of free play or physical activity available to children during school hours [16]. Among high schools in the United States, only 4% require daily physical education or its equivalent for students in all grades for the entire year [60]. Furthermore, only 8% of elementary schools schedule recess on a regular basis. While some schools lack the space for free play, others feel that recess is a waste of time [60].

Sedentary activities have become more prevalent with the evolution of technology and its availability to children and adolescents [2]. According to the 2017 National Youth Risk Behavior Survey, 20.7% of high school students watch three or more hours of television per day during the average school week (down from 42.8% in 1999 and 32.5% in 2013). However, it is clear that other screen usage is replacing television among this age group—43.0% play video or computer games or utilize a computer for activities unrelated to school work for three or more hours per school day [61].

Over the past several decades, the number of dual-income families has increased dramatically, as has the number of women serving as the sole provider for their families. It has been hypothesized that the increase in rate and hours of parental employment may be correlated with the increased rate of overweight and obesity in children [16]. Studies have revealed that children residing in a single-parent household are more likely to be obese than children residing in a two-parent household. Several potential mechanisms have been proposed to explain this phenomenon, including [16]:

As children's television viewing has increased, children have become a marketing target of the food industry. Of the approximately 10,000 food advertisements children view each year, more than 95% are for candy, fast food, soda, sugared cereals, and other unhealthy foods [38]. Furthermore, children's toys and books are linked to beverages and food products, including learn-to-count books branded by candy manufacturers [2]. These changes have impacted the foods available in the homes and the degree of influence parents have when children make food selections [16].

In the late 1960s, the United States Ten-State Nutrition Survey characterized the nutritional status of children from low-income families as being less than satisfactory [65]. Specifically, calories, calcium, iron, and vitamins A and C were less likely to be consumed in adequate amounts by low-income black and Hispanic children. In response, the CDC began working with five states (Arizona, Kentucky, Louisiana, Tennessee, and Washington) in 1973 to develop a system for continuous monitoring of the nutritional status of selected high-risk populations [66]. This evolved into the Pediatric Nutrition Surveillance System (PedNSS), which provided data on the prevalence and trends of nutrition-related indicators among specific pediatric populations. The PedNSS was the only source of nationally compiled obesity surveillance data obtained at the state and local level for low-income, preschool-aged children participating in federally funded health and nutrition programs. It used existing data from the following public health programs:

A majority of data was from the WIC program, which serves children up to 5 years of age, and the PedNSS has been replaced by the Special Supplemental Nutrition Program for Women, Infants, and Children Participants and Program Characteristics report (WIC PC) [67].

In 2007–2008, the prevalence of children 2 to 5 years of age participating in WIC was 10.1%, decreasing to 8.4% in 2011–2012 but again increasing to 13.9% in 2015–2016. The CDC and the U.S. Department of Agriculture analyzed WIC data from 56 U.S. states and territories from 2010 to 2020. During this time, 28 WIC agencies reported significant declines in obesity among children 2 to 4 years of age. The prevalence of obesity reported in 2020 ranged from 8.3% to 19.9% [68]. After adjusting for age, sex, and race/ethnicity, obesity decreased by more than 3% in Nevada, New Jersey, New Mexico, Utah, Virginia, and in two U.S. territories. Obesity increased significantly in Washington (0.5%), North Carolina (0.9%), Hawaii (1.3%), Delaware (1.4%), North Dakota (1.8%), West Virginia (2.1%), and American Samoa (2.4%) [68]. In 2020, 14.4% of WIC participants 2 to 4 years of age had obesity, a decrease from 15.9% in 2010. The prevalence of overweight and obesity combined decreased from 32.5% in 2010 to 29.8% in 2020 [68]. The largest drops were among children 4 years of age, boys, and children who were American Indian or Alaska Native. The prevalence of obesity in 2020 was higher among young children who were Hispanic (17.4%) and American Indian or Alaska Native (18.4%) than among those who were non-Hispanic White (12.3%), non-Hispanic Black (11.9%), or Asian or Pacific Islander (10.7%) [68].

The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States [69]. The survey is unique in that it combines both interviews and physical examinations. The NHANES program began in the early 1960s and has been conducted as a series of surveys focusing on different population groups or health topics. In 1999, the survey became a continuous program that has a changing focus on a variety of health and nutrition measurements to meet emerging needs [69]. The survey examines a nationally representative sample of about 5,000 persons each year. These persons are located in counties across the country, 15 of which are visited each year [69].

The NHANES interview includes demographic, socioeconomic, dietary, and health-related questions. The examination component consists of medical, dental, and physiologic measurements, as well as laboratory tests administered by medical personnel [69]. NHANES data published in 2020 indicate that Black and Mexican American adolescents 2 to 19 years of age are more likely to be overweight (29.1% and 24.9%, respectively) compared to non-Hispanic White adolescents in the same age-group (14.8%) [70].

With few exceptions, the clinical features of cardiovascular disease are usually not apparent until the third or fourth decade of life. However, there is substantial evidence that the atherosclerotic process is initiated during childhood and may be advanced in the presence of childhood overweight and obesity [10]. As a result, these children may be at an increased risk for metabolic syndrome.

Metabolic syndrome is defined as a cluster of cardiovascular risk factors, including hyperglycemia, central adiposity (increased waist circumference), hypertension, hyperlipidemia, low levels of high-density lipoprotein, and insulin resistance [2]. It is believed to be caused by visceral fat, as chemical signals from adipose cells trigger inflammation [2]. Before the development of comorbidities, children 9 years of age who are obese already demonstrate alarming elevations of inflammatory and prothrombotic factors that correlate with body fat mass. In studies with long-term (60-year) follow-up, it has been shown that being overweight as an adolescent is a more powerful predictor of development of multiple obesity-related diseases than being overweight in adulthood. This risk persists even if the weight is lost during the adult years [74].

Acute inflammation induces a cascade of reactions by the immune system. When too much adipose tissue is present, an individual also has a chronic overabundance of inflammation-triggering chemicals [75]. This, along with the presence of atherosclerotic plaque, results in blood vessel narrowing [10]. Ruptures of these inflamed vessels can cut off the flow of blood to the myocardium or cerebral tissue [2].

In one study of children and adolescents 5 to 17 years of age with obesity, 70% had at least one cardiovascular disease risk factor, and 39% had two or more risk factors for cardiovascular disease [76]. It could be expected that the impact of these risk factors initiating earlier in life, especially during childhood, would result in more dramatic adverse effects over an individual's lifespan [10]. Using current childhood obesity figures, historical trends, and scientific models, researchers at the University of California, San Francisco, project that by 2035 the prevalence of cardiovascular disease in the United States will increase as much as 16%, with more than 100,000 excess cases of the disease attributed to the rise in childhood obesity [23].

The relationship between obesity, cardiovascular disease, and diabetes is well established [40]. Obesity has been identified as a direct causative factor for many conditions that contribute to the development of diabetes, including hyperinsulinemia, glucose intolerance, elevation in hemoglobin A1C levels, and hyperglycemia [77]. Indeed, glucose intolerance alone in adolescence increases the risk of premature death (before 55 years of age) by 73%, and a BMI in the highest quartile more than doubles the risk of premature mortality [78].

Although only one-third of obese children and adolescents have insulin resistance, it is present with increased frequency and severity in up to 50% in morbidly obese children [10]. This increase in insulin resistance has been a contributory factor in the increased prevalence of type 2 diabetes in children [79]. A 1996 study of 1,027 consecutive records of children up to 19 years of age with diabetes revealed that 16% were diagnosed with type 2 diabetes (while the rest had type 1 diabetes) [80]. As of 2019 in the United States, the total prevalence of diabetes in children and adolescents younger than 20 years of age is [33,81]:

Because type 2 diabetes has only relatively recently been recognized in adolescents, it is not possible to forecast what the future holds. However, it is known that 44.4% of adults with adolescent-onset type 2 diabetes will develop diabetic nephropathy after 30 years [79].

There has been little focus on the impact of obesity on respiratory diseases; however, there are clear effects on pulmonary function and inflammation, both of which can increase the prevalence and morbidity of lung disease [82]. The work of breathing is increased in obese individuals, and larger body mass places increased demands for oxygen consumption and carbon dioxide elimination [10]. Increased body weight can also lead to worsening of pulmonary function as a result of the mechanical effects of truncal obesity and the metabolic effects of adipose tissue [82]. This is characterized by increased ventilation of upper lobes and increased perfusion of the lower lobes [10].

Abdominal fat may alter the pressure volume characteristics of the thorax and restrict the descent of the diaphragm, thereby limiting lung expansion, especially if the patient is lying on his or her back [82]. Parents of obese children and adolescents report their children snore loudly and may appear to stop breathing during the sleep cycle, which is indicative of sleep apnea [10]. During sleep apnea, oxygen levels in the blood can diminish dramatically [83]. Obstructive sleep apnea occurs in up to 60% of obese children [84].

In addition to obstructive sleep apnea, a significant association exists between excess weight and asthma incidence [10,83,85]. It has been suggested that obesity decreases lung volume while increasing resistance, which can lead to symptoms of asthma [82]. An estimated 28% of asthma cases that develop in female patients older than 9 years of age are attributable to overweight [10].

An additional consequence of childhood obesity is the development of depression and anxiety. As stated, obese children and adolescents often become targets of early and systemic social discrimination, and lowered self-image, heightened self-consciousness, and impaired social functioning have been noted in individuals who either develop or remain obese during adolescence [10,55]. It has been reported that one in five obese children in the United States has a mental health problem resulting in at least mild functional impairment [86]. Research has demonstrated an increased level of depression among children with the greatest BMIs [19].

The psychologic stress of social stigmatization can cause low self-esteem, which can alter academic and social functioning even into adulthood [44]. The social stigma of weight-based teasing has been identified as a key risk for overall negative psychosocial outcomes among the overweight pediatric population [39,55].

Overweight and obese children and adolescents have the increased potential to develop orthopedic complications, believed to be primarily related to a mechanical alteration [44]. During childhood, slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and genu valgum tend to be more common in overweight individuals [10]. Children and adolescents who are obese are more likely to experience persistent symptoms six months after an acute ankle sprain, suggesting increased risk of chronic orthopedic morbidity in obese individuals following acute injury [87].

Obesity has also been identified as a risk factor for pseudotumor cerebri, a condition characterized by idiopathic intracranial hypertension [88]. Although most common in women of childbearing age, this condition can occur in children and adolescents [89]. Signs of pseudotumor cerebri are similar to those seen with brain tumor and include headache, blurred or dimmed vision, nausea, vomiting, and tinnitus. More than 50% of children who develop this disorder are obese, and the only effective treatment is weight loss [88].

Studies have documented a strong relationship between hepatic steatosis and insulin resistance [90]. This may progress over the years from inflammation and fibrosis (non-alcoholic fatty liver disease), to steatohepatitis, fibrosis, cirrhosis, and more rarely, hepatocellular carcinoma [91]. Pediatric non-alcoholic fatty liver disease is the most frequent chronic liver disease in children and adolescents in industrialized countries and is primarily a consequence of childhood obesity and overweight [92].

In one study of adult patients with diabetes and obesity, 100% presented with some degree of steatosis, 50% had steatohepatitis, and 19% had cirrhosis [93]. Liver disease is often clinically silent for many years, although fatty liver, a precursor to non-alcoholic steatohepatitis, has been identified in 22% of obese children 4 to 12 years of age and fatty changes have been documented in 10% to 25% of obese adolescents [91,92]. The true prevalence could be significantly higher as the hormonal changes in adolescence, especially in boys, favor insulin resistance and fat accumulation in hepatocytes [92].

Insulin resistance and hyperinsulinemia are associated with increased activity of both the renin-angiotensin-aldosterone system and sympathetic nervous system activities, resulting in increased renal sodium reabsorption, fluid retention, and endothelial cell proliferation [91]. Therefore, renal function may be impaired in pediatric patients with obesity and type 2 diabetes, but further studies are needed [94,95,96]. Obesity may affect the kidneys via development of systemic arterial hypertension and/or diabetes, or directly, by ectopic accumulation of adipose tissue in the kidneys [97]. Glomerular hyperfiltration that manifests as elevated glomerular filtration rate is a frequent manifestation in obesity. One cross-sectional study involved 49 adolescents with higher BMIs (28 overweight, 21 obese) and 49 normal-weight adolescents. The participants were subjected to clinical examination, anthropometric measurements, and laboratory investigation using standard techniques. Estimated glomerular filtration rates (eGFR) were calculated. Hyperfiltration was defined as eGFR ≥140 mL/min.1.73 m2. Hyperfiltration was observed in 20 (40.8%) of the overweight/obese adolescents. The prevalence of hyperfiltration among the overweight and obese adolescents was 24.5% and 16.3%, respectively. Additionally, a higher prevalence of hypertension was observed among the overweight/obese adolescent with glomerular hyperfiltration [98].

Pharmacologic therapy for weight loss in children and adolescents remains an area of rapidly evolving research [55]. The AAP recommends that it may be offered to children 8 through 11 years of age as an adjunct to health behavior and lifestyle treatment [55]. Children with more immediate and life-threatening comorbidities, those who are older, and those affected by more severe obesity may require additional therapeutic options [55].

The European Society of Endocrinology and the Pediatric Endocrine Society suggest that FDA-approved pharmacotherapy for obesity be administered to children and/or adolescents only with a concomitant lifestyle modification program of the highest intensity available and only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions.

(https://academic.oup.com/jcem/article/102/3/709/2965084 Last Accessed: November 21, 2023)

Level of Evidence/Strength of Recommendation: 2|⊕○○○ (Suggestion based on very-low-quality evidence)

As of 2023, there are four medications approved by the U.S. Food and Drug Administration (FDA) for weight loss and weight management in adolescents: phentermine, orlistat, liraglutide, and semaglutide. In addition, setmelanotide, a melanocortin 4 (MC4) receptor agonist, was approved in 2020 for chronic weight management in patients 6 years of age and older with monogenic or syndromic obesity confirmed by genetic testing [104,105,106,107].

Phentermine is approved for short-term (<12 weeks) use in obese adolescents 16 years of age and older with a BMI ≥30 or ≥27 in the presence of other risk factors. A fixed-dose combination product of phentermine/topiramate (3.75 mg/23 mg) is approved for obese adolescents 12 years of age or older [104]. It is approved as an adjunct in a weight-reduction regimen involving exercise, behavior modification, and calorie restriction. Phentermine is an amphetamine analog—a class IV controlled substance [104,107]. Common side effects may include increased blood pressure and heart rate. There is limited availability of long-term data for phentermine [107].

Orlistat is approved for use in obese adolescents 12 years of age and older with a BMI of at least 30, or 27 in the presence of other risk factors. However, the efficacy of orlistat has not been tested extensively in young patients [19,104]. Orlistat acts by inhibiting gastrointestinal lipases and blocking the absorption of up to one-third of fat intake. It has no systemic activity, but it is associated with some side effects, including gastrointestinal effects (e.g., flatulence, fecal fat loss, incontinence, and diarrhea), back pain, and upper respiratory infection [104,108]. Patients using orlistat should take a fat-soluble vitamin supplement [104]. This agent is contraindicated in patients with chronic malabsorption syndrome or cholestasis and should be used with caution in those taking cyclosporine.

In 2020, daily liraglutide injections were approved for patients 12 years of age or older; in 2023, a weekly semaglutide injection was also approved for patients 12 years of age and older [104,105,106]. These agents should be used along with lifestyle changes (e.g., diet and physical activity changes).

In 2012, lorcaserin was approved to be used, in conjunction with diet modification and exercise, for adults with a BMI ≥30 or adults with a BMI ≥27 with at least one weight-related comorbidity (e.g., hypertension, dyslipidemia, sleep apnea) [104,109]. However, was voluntarily withdrawn from the market by the manufacturer in 2020 due to results from safety clinical trials showing an increased occurrence of cancer [110].

Some overweight children or adolescents may be taking metformin, a common medication utilized for type 2 diabetes and insulin resistance [104]. Metformin has been shown to increase cellular sensitivity of insulin, leading to reductions in appetite and body weight in obese children and adults. In a two-month study, metformin 850 mg and a low-calorie diet demonstrated a significant weight loss in adolescents as well as improvements in fasting insulin, leptin, and lipid levels [108]. However, long-term efficacy and safety are unknown, and metformin has not been approved as a weight-loss drug [19,55].

As obesity rates in children and adolescents continue to increase, the number of bariatric surgeries performed on this population does as well [111]. Weight-loss goals and reduction of morbidity are often achieved with bariatric surgery [39]. Given the unknown long-term risks of bariatric surgery in the still-developing adolescent, more stringent criteria have been proposed for this population. In 2009, the International Pediatric Endosurgery Group (IPEG) published updated guidelines with similar BMI cutoffs for surgery in adolescents as in adults (i.e., BMI >40 or BMI >35 with comorbidities). The IPEG included important stipulations concerning growth, commitment to lose weight, assent for surgery, and long-term follow-up, and added requirements for surgery in adolescents (i.e., Tanner stage 4 or greater, 95% skeletal maturity, demonstrated commitment to lifestyle change, stable psychosocial environment) [112]. The 2012 American Society for Metabolic and Bariatric Surgery (ASMBS) pediatric best practice guidelines largely aligned with those guidelines; however, significant milestones in the understanding of obesity led the ASMBS to update their guidelines in 2018 [113]. The 2018 ASMBS guideline recommends BMI cutoff for surgery in adolescents (i.e., BMI >35 or 120% of the 95th percentile) with clinically significant comorbidities, such as obstructive sleep apnea, type 2 diabetes, pseudotumor cerebri, severe nonalcoholic steatohepatitis, gastroesophageal reflux disease, or hypertension; they also recommend a cutoff BMI of >40 (or 140% of the 95th percentile) regardless of comorbidities [113,114]. Previous guidelines required a comorbidity with a BMI of >40; however, it was found that requiring a comorbidity puts children at a significant disadvantage to attaining a healthy weight. Earlier surgical intervention (at a BMI of >45) can allow adolescents to reach a normal weight and avoid lifelong medication therapy and end organ damage from comorbidities [113,114]. In addition, the ASMBS indicates that prior weight-loss attempts, Tanner stage, and bone age should not be barriers to definitive treatment [113].

Contraindications to adolescent bariatric surgery include [112,113]:

The importance of adhering to these criteria cannot be understated. Until the long-term outcomes of bariatric surgery in adolescents are known, surgery should ethically be limited to patients with comorbidities [115].

In addition, the American Academy of Pediatrics (AAP) follows the 2018 guidelines from the ASMBS, but also recommends that other factors unique to overweight youths be taken into account [55,111,116]. According to the AAP, adolescents being considered for gastric bypass surgery should be assessed for endogenous causes of obesity, as addressing these causes may resolve obesity without the necessity of surgical intervention. All adolescents being considered for surgery and their parents should undergo thorough psychiatric evaluations in order to "facilitate assessment of the family unit, determination of the coping skills of the adolescent, and assessment of the severity of psychosocial comorbidities" [111]. A supportive family environment is necessary for a successful outcome. The AAP does not recommend surgery for all children and adolescents who have severe obesity but rather the opportunity should be provided for children and their families to consider and undergo evaluation [55].

Not surprisingly, bariatric surgeries among teens increased eightfold, from 200 procedures in the United States in the year 2000 to more than 1,600 in 2009 [117,118]. Studies and publications by the AAP and ASMBS indicate that bariatric surgery is safe and effective for adolescents, and the organizations are calling for reduced barriers and improved access [55,113,116]. Barriers include insurance coverage and a low referral rate from pediatricians and primary care. While bariatric surgery is now being shown to be safe and effective for adolescents, major health organizations agree that it should be offered only by experienced multidisciplinary teams and presented to families with appropriate informed consent [39,55,113,116].

Various types of surgical procedures have been used to change eating behavior and induce weight loss. The most commonly used procedures are [108,111,113,115,119]:

Laparoscopic adjustable gastric band procedures are approved only for patients 18 years of age and older. Use has declined in both adults and youth because of worse long-term effects and higher-than-expected complication rates [55]. Many other procedures have been used in bariatric surgery, but for the most part they have fallen out of favor. These include jejunoileal bypass, vertical banded gastroplasty, and biliopancreatic diversion.

Bariatric surgery has been shown to be effective in inducing weight loss in adolescent patients. These patients also may experience durable reduction in BMI as well as significant improvement and/or complete amelioration of several obesity-related comorbid conditions [55]. A study of 13 obese adolescents demonstrated significant weight loss at the 12-month postoperative point, with a reduction in BMI from an average of 59 to 38 [120]. Percentage of body fat also decreased, from 47% before surgery to 36% after. In general, weight loss plateaus after 12 to 18 months. According to evidence related to bariatric surgery in adolescents, patient safety and weight-loss outcomes in extremely obese adolescents are at least as good as those demonstrated in adults [121,122]. In addition, a study of adolescents who underwent gastric bypass surgery found improvements in depressive symptoms and health-related quality of life within one year of the surgery [123]. A decrease in hypertension, resolution of type 2 diabetes, and improvements in insulin resistance have been noted in adolescents who have undergone bariatric surgery [113,124,125,126,127].

Although considered safe, complications from these surgeries can occur both immediately following the procedure and over time [55]. Early complications can include leaks, hemorrhage, gastric or bowel perforation, obstruction due to edema, and slippage of the band. Late complications may include ulcers, obstruction, vitamin and mineral deficiencies, hernia, and migration or erosion of the band [128,129]. Additionally, data showing multiple micronutrient deficiencies following surgery highlight the need for routine and long-term monitoring [55].

Although there are no absolute contraindications to gastric bypass surgery, it is important to assess each patient's risks and willingness to engage in the necessary lifestyle modifications [130]. Contraindications for gastric banding have been established and include [131,132]:

New behavior patterns should be established through counseling and peer support groups to achieve sustained weight loss. Systemic research indicates that inclusion of mental health professionals in the management of childhood overweight and obesity is essential [114,133]. Although childhood obesity has a clear impact on an individual's health, particularly over many years, the most immediate and common consequences of obesity among children are psychosocial. Therefore, treatment plans for these patients should address psychologic consequences of the disease, including alienation, depression, and anxiety.

During the past century, a comprehensive public health approach utilizing medical and community interventions has been found to provide significant protection and benefit [134]. A collaborative approach provides the greatest potential for success, and involvement by parents, children, healthcare professionals, and the community is needed to provide the basic foundation for a complete paradigm shift [108].

Counseling topics that should be addressed with both parents and overweight or obese children/adolescents include [108]:

Of all the studies conducted, positive result findings were significant for the presence of parental involvement, especially when pediatric subjects were 8 years of age and younger [99]. The inclusion of a registered dietician and an exercise physiologist or physical therapist in the interdisciplinary team is also fundamental for patients of any age [114].

Abundant opportunities exist for healthcare professionals to take leadership roles in this critical area of child health, including action in promoting opportunities for physical activity, the fresh food supply, research, and third-party reimbursement [10]. Change is desperately needed in opportunities for physical activity in child-care centers, schools, after-school programs, and other community settings [2]. Some managed care organizations are beginning to offer benefits for the treatment of childhood obesity through better access to established community childhood obesity programs [10]. Foods that are nutrient rich and palatable, yet low in excess calories from added sugars and fat, should be readily available to parents, school and child-care food services, and others responsible for feeding children. Potential affordable sources include urban gardens, community-supported agriculture, and farmers' market projects [135].

Regulation of advertising and promotion of calorie-dense, nutrient-poor food products to children may be necessary. The increase in sugary beverage intake has been linked to obesity; therefore, the sale of such beverages should not be promoted at schools [2]. Healthcare professionals are encouraged to work with school administrators and others in the community on strategies to decrease the dependence on vending machines, snack bars, and school stores for school revenue [136]. Advocacy is also needed for physical education programs that emphasize and model daily activities for personal fitness (as opposed to physical education limited to a few team sports) [135].

Collaboration among nutrition, behavioral health, physical therapy, and exercise physiology professionals is essential [108]. Working with communities and schools to develop needed counseling services, physical activity opportunities, and strategies to reinforce the gains made in clinical management is also important [2]. Pediatric referral centers should develop specialized programs for treatment of complex and difficult cases, and for research into etiology and new methods of prevention and treatment [136].

There are several elements to providing the right care for young children [137]:

Supporting community programs is also a part of advocacy. The National Football League has partnered with several organizations, including the American Heart Association, GENYOUth, Shriners Hospital, St. Jude Children's Research Hospital, United Way, Special Olympics, Subway, GoNoodle, and FitnessGram, to create the NFL Play 60. This initiative develops national public service announcements and online programs and helps implement in-school, after-school, and team-based programs at the local level [138]. This program has supported more than 73,000 schools and has provided resources to increase activity levels to more than 38 million children [138].

Due to the potentially devastating effects of childhood obesity on public health, the government has established programs to address the problem. In 2023, the CDC's Division of Nutrition, Physical Activity, and Obesity (DNPAO) funded 17 states, 41 community and tribal organization, and 16 land grant universities to decrease obesity and other chronic diseases related to nutrition and exercise [135]. The program has three goals related to risk factors for illness, disability, and premature death [135]:

To meet these goals, strategic public health efforts are aimed at the following program objectives [135]:

The program focuses on increasing physical activity, reducing obesity, and reducing health disparities, including, but not limited to, those related to race/ethnicity, socioeconomic status, geography, sex, age, and disability [135].

In addition, other options utilizing potential stimulus funding from the federal government have been proposed, focusing on the treatment and prevention of childhood obesity. Projects that could provide immediate economic stimulus and also act as part of a long-term public health strategy for reducing childhood obesity include [24]:

The WHO began spearheading a series of expert and technical consultations regarding childhood obesity in the 1990s. Public awareness campaigns were also initiated to sensitize policy-makers, private sector partners, healthcare professionals, and the public at large [2]. Because obesity is predominantly a "social and environmental disease," the WHO is helping to develop strategies that will make healthy choices easier to make. In collaboration with the University of Sydney, Australia, the WHO is calculating the worldwide economic impact of overweight and obesity. It is also working with the University of Auckland, New Zealand, to analyze the impact of globalization and rapid socioeconomic transition on nutrition and to identify the main political, socioeconomic, cultural, and physiologic factors that promote obesogenic environments [139].

Curbing the childhood obesity epidemic requires sustained political commitment and the collaboration of many public and private stakeholders. Governments, international partners, civil society, and the private sector have vital roles to play in shaping healthy environments and making healthier diet options for children and adolescents affordable and easily accessible [139]. Therefore, the WHO's objective is to mobilize these partners and engage them in implementing the Global Strategy on Diet, Physical Activity, and Health (DPAS). The WHO has demonstrated increased support for the designation, implementation, monitoring, and leadership of these actions. The Global Strategy has four main objectives [139]:

Patient T is a newborn boy. At birth he is 20 inches in length and weighs 10 pounds 4 ounces. Everyone who meets Patient T comments on how beautiful he is and how healthy, big, and strong he looks. His mother revels in the comments and expresses pride in her new baby boy.

During Patient T's early childhood, he maintains a weight in the 95th percentile and a height in the 75th percentile on the growth charts. He is a playful, active child with a love for a variety of foods, including apples, pears, bananas, ham sandwiches, potato chips, and pizza. Although the patient's weight is in the 95th percentile, his pediatrician feels he is developing well and does not want to raise any red flags at this point. He does caution Patient T's mother to be attentive to his caloric intake and to ensure that he remains active. The patient's mother is taken aback and a bit offended at the insinuation that her son is "chubby."

Patient T continues to grow and experience a normal childhood, but he is considered a hefty boy when he enters kindergarten. He is quiet and shy at school and soon finds it difficult to make friends. As he continues through elementary school, he becomes the object of taunting from his classmates due to his physical appearance and submissive nature. His grades begin to decline, and he begins to spend more time watching television and playing video games. Snacking on potato chips and soda becomes a source of comfort for Patient T; soon he is consuming eight cans of soda every day. The patient's parents have become concerned but are reassured by family members who attribute the weight gain to a phase or a growth spurt. They are sure that Patient T will grow up big and strong like his father, who is 6 feet tall and 350 pounds.

As a result of Patient T's decreased activity level, his weight continues to increase. By 12 years of age, he is even more withdrawn from social activities and mainly retreats to his virtual world of video games.

In high school, Patient T starts playing football as a defensive lineman. His performances are worthy of college scouts, and there is talk of scholarships. His parents are thrilled that he is finally fitting in and finding acceptance. As a result, Patient T's grades improve and he enjoys an active social life. During his senior year, Patient T is offered a scholarship to play football at a Division I college. When he leaves for college, he is 6 feet 5 inches tall and weighs 315 pounds.

In his second year of college, Patient T hyperextends his knee and tears his meniscus during the homecoming game. The resulting damage ends his football career. He remains focused on his studies, but alcohol and parties become an alternative to the hours previously spent conditioning in the weight room. Beer, buffalo chicken wings, nachos, and pizza become staples in his diet.

At his college graduation, Patient T weighs 400 pounds. He is hired by a large manufacturing firm as an accountant. He is 24 years of age and is looking toward his future.

One year later, Patient T meets some friends after work to play a game of basketball. His knee is still weak, and his weight, still nearly 400 pounds, slows him significantly. However, Patient T remembers the years he spent as a withdrawn child and does not want to revert back to being lonely and unsocial; he is going to play the best he can.

An hour into the game, Patient T feels a strange sensation in his jaw and a sharp pain down his left arm. He is sweating profusely and becomes dizzy. He describes the sensation as an elephant sitting on his chest. His friends call emergency medical services, and Patient T is taken to the hospital. His electrocardiogram (EKG) reveals ST segment elevation, indicative of a myocardial infarction. He is admitted to the hospital and undergoes cardiac catheterization and angioplasty. Further testing reveals type 2 diabetes, hyperlipidemia, hypertension, and mild kidney disease.

Despite the seriousness of his condition, Patient T takes the news in stride. He reasons that because he is still young, only 25 years of age, he has plenty of time to make the needed changes. Over the next five years, Patient T does not monitor his blood glucose levels or diet and exercises as time allows. He is started on insulin after six years, although he is resistant to this change. He often misses doses, particularly when he is out with his friends. He has also tried to better monitor his diet, but finds this difficult at restaurants and social events.

After missing two appointments, Patient T returns to his physician's office in order to renew his prescriptions. At this visit, Patient T's A1C is 10.5%, his weight has increased 6 pounds, and his cholesterol is at its highest level ever. Most seriously, however, is the discovery of the early stages of renal failure. Patient T takes the news to heart and makes changes to improve his renal status, but these changes only last a few weeks before he falls back into his old patterns. Weakened by blockages and years of hyperlipidemia, Patient T suffers a mild myocardial infarction the week before his 34th birthday. He is rushed to the hospital for a cardiac catheterization and another angioplasty. Although he recovers from the infarction, the damage to his kidneys is great. With his blood urea nitrogen (BUN) test and creatinine levels dangerously high, Patient T is started on hemodialysis three days a week.

The next five years are spent on this dialysis schedule. Patient T is unable to maintain his job as an accountant and applies for and receives Medicare and Medicaid services. During this time, the patient develops a vascular wound on his left lower extremity that requires a home health nurse to visit twice daily for dressing changes. To complicate matters more, Patient T has begun to show signs of diabetic retinopathy. The patient passes away at 42 years of age as a result of massive myocardial infarction. At the time of his passing, he is blind, on dialysis, and has a chronic open wound. His premature death is a consequence of years of obesity and obesity-related complications that started in the patient's childhood.

Patient M is born in Tucson, Arizona, the daughter of second-generation immigrants from Mexico. Her mother did not receive any prenatal care, although she was overweight prior to conception and has a strong family history of diabetes, hypertension, and heart disease. When born, Patient M weighs 10 pounds 6 ounces and is 20 inches in length. Everyone in the family and community admires the infant and comments on how beautiful and healthy she is. Her precious, cherub-like features, specifically her round cheeks, are declared "perfect" and "the picture of health."

Patient M has many risk factors for obesity, even in her infancy. There is a greater rate of childhood overweight and obesity in Hispanic families, and obese parents impose a great risk that their children will be overweight. Because Patient M had a greater than average weight at birth, it is possible that her mother had gestational diabetes. A prenatal exposure to a sugar-rich environment caused by maternal diabetes can predispose a child to overweight/obesity. Although Patient M was a larger than average infant, the Hispanic view of overweight is generally one of health and strength and is not associated with that of disease or illness.

During Patient M's early childhood, her weight is maintained in the 95th percentile and her height is in the 70th percentile on the growth charts. She is playful and rambunctious, often playing with her two older brothers outside all day. As a child, the patient's favorite foods are rice and beans and fresh fruits. As is common in their Hispanic community, Patient M admires and looks up to her brothers and wants to mimic them. As a result, she develops a taste for American foods, including potato chips, nachos, soda, and pizza.

For children, the diagnosis of overweight or obesity is determined with the use of growth charts that give percentages of height, weight, and/or BMI. The CDC's BMI growth charts can be utilized clinically beginning at 2 years of age. Obesity in any individual is the end result of an imbalance between food taken in and energy expended, but the underlying causes are greater in complexity. Children observe the behaviors and preferences of others around them influencing the future of food selection, especially when the role model is perceived as being powerful.

Although her weight is in the 95th percentile, Patient M's pediatrician is not alarmed because of the amount of outside playtime she receives. When the pediatrician stresses the importance of monitoring the child's weight and physical activity, Patient M's mother thinks it is absurd for an American physician to understand the genetics of a Hispanic person and what is healthy for her daughter.

Patient M continues to grow and experience a normal childhood but is considered overweight when she enters kindergarten. There are a few of the other boys and girls in the classroom who are overweight, which reassures her mother that she is fine and there is nothing to worry about. Patient M is a confident girl, ready to play tough with the boys and join the other girls in playing house. She especially likes to be the cook in the pretend kitchen making all of her favorite foods. At recess, everyone wants Patient M to "make" them a snack.

Before Patient M starts the fifth grade, her father is transferred and the family moves to Miami, Florida. The first few weeks are difficult. She misses her extended family, and life in a big city is different. On the first day of school, Patient M is apprehensive for the first time in her life. When she arrives she notices many of the girls are very thin.

As the school year progresses, Patient M begins to feel self-conscious about her weight for the first time. Eventually, she is able to start making friends and is invited to a beach party. Although Patient M expresses fear of going to a party in a bathing suit, her mother encourages her to embrace her curves.

At the party, some of the boys are joking and teasing the girls, comparing them to different animals. When they compare Patient M to a manatee, she is devastated. Although she holds her head up high and stands up for herself, she is deeply hurt.

Obese children and adolescents become targets of early and systemic social discrimination. The psychologic stress of social stigmatization can cause low self-esteem, which in turn can alter academic and social functioning and potentially persist into adulthood.

The next three years are a series of learning experiences for Patient M. Although she has made some good, close friends, the sting of the teasing still penetrates her memory. When the time comes for the end-of-eighth-grade semi-formal dance, all of her friends have dates and Patient M feels left out. Her father reassures her and tells her that the boys just do not realize how special she is yet. Still, Patient M feels less attractive than other girls. One day, her mother sees her examining and critiquing her body in the mirror. When questioned, Patient M says she is fat and starts crying. Devastated, Patient M's mother realizes that her confident daughter is fading away and a change is necessary.

After speaking to a dietitian, Patient M's mother starts to supplement their regular diet with fresh vegetables and to provide fresh fruits for dessert and snacking. She encourages Patient M to find an activity to occupy some of her free time during the summer vacation. Her brothers go to karate class on Tuesdays and Thursdays, and Patient M's father encourages her to join them and start taking karate lessons. She finds she enjoys the precision and strength of karate immensely. Her self-esteem and confidence start to return, and she is laughing and joking more.

Obesity in any individual is the end result of an imbalance between food taken in and energy expended, but the underlying causes are greater in complexity. Diets are more likely to succeed if individualized according to eating patterns, cultural concerns, degree of motivation, intellect, amount of family support, and financial considerations.

At the end of the summer, Patient M finds that her school uniforms are too big. Her parents are glad to see how much happier and healthier she seems. Although some of the dietary changes have affected the whole family, Patient M's father has found it difficult to give up some of his favorite comfort foods. Seeing the difference in his daughter, he makes a commitment to try to change his diet and become more active. It is a joyful time for Patient M and her family.

Two months later, Patient M's father falls unconscious and is taken to the emergency department. After undergoing several tests, including a computed tomography scan, he is diagnosed with a cerebral vascular accident. The physician tells the family that Patient M's father has a high blood glucose level and that the stroke may have been caused by long-term uncontrolled type 2 diabetes. When Patient M first visits her father in the hospital, she barely recognizes him. He has a ventilator tube, intravenous lines, and a heart monitor. As a result of the stroke, her father is paralyzed on his right side and is unable to speak. Although he regains consciousness, the paralysis will most likely be permanent and he will be unable to work. Eventually, her father is discharged to a rehabilitation center for therapy.

Needing an income to pay for growing medical expenses, Patient M's mother obtains a job as a legal secretary. With both of her brothers in college and her mother working full-time and caring for her father, Patient M spends an increasing amount of time alone. Most meals come from one of the many fast-food establishments near their home. With the financial difficulties, she also has to stop karate lessons. Patient M feels alone and abandoned; the only place she finds solace is in food. By the end of the school year, Patient M weighs 230 pounds and is 5 feet 3 inches tall. Her grades start to decline, and she finds herself spending more time watching television or on the Internet.

The summer prior to her senior year of high school, Patient M and her friends take a trip to the Florida Keys to camp and snorkel for one week. Although she is hesitant, her mother encourages her to go for a change in scenery and relaxation. Although her friends have always been accepting of her and look past her obesity issues, Patient M is depressed at the image of herself in a bathing suit.

On the last day of the trip, Patient M wakes feeling tired and nauseous. She decides to stay at the camp and sleep while her friends go snorkeling one last time. Over the next two hours, the patient feels simultaneously anxious and fatigued while also experiencing an overwhelming sense of dread. When her friends return to camp and find her looking pale and shaky, they pack and return home in hopes she would start feeling better. When they arrive, Patient M's mother takes her directly to a local emergent center for evaluation. The results of the laboratory test completed at the center are:

Patient M is hospitalized until her condition stabilizes. She is diagnosed with type 2 diabetes and is started on simvastatin and metformin. The physician also prescribes diet, exercise, and other lifestyle changes. This diagnosis compounds the patient's depression regarding the future. She can only think of her father, now a resident of a long-term care facility.

After she is diagnosed, Patient M attends education classes and meets with a dietitian to help her understand her disease and the changes she will need to make to control her diabetes and obesity. She has made her mind up to take whatever steps necessary to avoid the path her father has taken. Patient M becomes inspired by her new knowledge and by a television show focusing on adolescents working to control their weight. Starting back at karate class is frightening, but she perseveres and eventually is hired to work with young children just starting in the classes.

Within three months, Patient M's weight is down 15 pounds and her A1C has decreased to 7.5%. She continues to take metformin for her diabetes and simvastatin for hyperlipidemia management. Her goal is to be medication-free by 20 years of age. She exercises daily and has adopted a meal plan she is able to live with. Her long-term outlook is promising because of the decisions she has made and her determination not to face the same future as her father. She is being proactive, which over time should prevent many of the complications of childhood obesity.