Study Points

Childhood Obesity: Impact on Health Care

Course #32013 - $20 • 5 Hours/Credits

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    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Which of the following countries has the highest known obesity rate?

    PREVALENCE

    The current prevalence of obesity ranges widely worldwide, from 4.7% to 10% of the population in some African and Asian countries to more than 62% percent in Nauru and Samoa, which have the highest known rates [11,113]. Obesity has infiltrated the developing world in recent years, causing concern to healthcare economists worldwide [2,11]. This has caused a double burden of disease in low-and middle-income countries, where high levels of infectious disease still occur [7,11]. Although malnutrition and famine have historically been and continue to be huge health issues in African countries, obesity is now a looming concern as well [7,11]. In addition to African nations, almost every country in the world is facing an obesity epidemic. The World Obesity Federation estimates that by the year 2025, 1 in 5 adults will be obese, and one-third of those will be severely obese [11]. Furthermore, a report published in 2020 following up on the goal to prevent obesity levels from increasing between 2010 and 2025 globally indicated that most countries have a less than 10% chance of achieving that goal; the United States has a 0.0% chance [11].

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  2. The annual direct costs of childhood obesity in the United States are estimated at

    ECONOMIC IMPACT OF CHILDHOOD OBESITY

    The annual direct costs of childhood obesity in the United States as of 2016 are an estimated $14.3 billion [18,19,112]. The total economic effects of obesity may be two to three times this figure, when impaired quality of life, reduced longevity, and other costs outside the medical care system (e.g., lost work days, reduced work performance) are considered [4,20,21]. Globally, obesity and obesity-related diseases cost $990 billion per year, more than 13% of all healthcare expenditure [11]. These economic burdens are born most heavily by overweight/obese individuals, but also by the general public through higher public and private health insurance costs, diminished employee productivity, and reduced public revenue [22,23]. As today's children—heavier than any generation in history—reach adulthood, these tangible and intangible costs will escalate [11,21].

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  3. Individuals with increased metabolic efficiency

    ETIOLOGY

    The pathophysiology of obesity in childhood can be viewed from one of three perspectives: as an imbalance in the intricate homeostatic or energy-balance physiology, as an epidemiologic issue, or as a pathologic issue (focusing on the consequences of excess fat on the risk of future disease) [31]. Changes in energy expenditure may be the result of physical or chemical changes, or both. A heterogeneous group of disorders can result from an extended period of time during which energy intake exceeds the expenditures. Essentially, it is superficially apparent that obese people ingest a greater amount of food relative to their needs [32]. However, whether calorie intake differs between overweight and normal-weight individuals has been the subject of debate. Obese individuals may have increased metabolic efficiency, meaning they may expend relatively fewer calories to maintain body weight. This metabolic state may be the result of lean body mass losses after repeated weight reductions attempts, alterations in body composition, and decreased fat-free mass (FFM). Overall, multiple alterations in metabolic rates set the stage for the development of overweight and obesity [6].

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  4. Which of the following statements regarding the role of culture, race, and ethnicity in the development of childhood obesity is TRUE?

    RISK FACTORS

    Obesity and obesity-related complications such as type 2 diabetes disproportionately affect minority populations, specifically black Americans and Hispanic Americans of all ages [30]. 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 [16]. 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 [14]. 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 [38]. 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 [38]. When presented with images of children with BMIs in the 95th percentile, the women generally described the children as "slightly overweight" [38].

    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 [14].

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  5. Approximately what percentage of children with two overweight parents will be obese?

    RISK FACTORS

    It has been shown that parental obesity is related to future obesity in their children [2]. An estimated 80% of children with two overweight parents will be obese; this number is decreased to 40% if only one parent is obese [6]. When both parents are considered a healthy weight, the prevalence of obesity in offspring is diminished to 14% [6]. 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 [39]. Scientists have isolated more than 250 genes that influence weight. 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]. Some research has supported the presence of a human obesity syndrome thought to be linked to genetic defects [40]. Many of these genetic differences are manifested in the body's regulatory hormone levels.

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  6. Leptin, a hormone mainly released by adipose tissue, acts to

    RISK FACTORS

    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 [39].

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  7. Which of the following characteristics of the modern environment have contributed to the childhood obesity epidemic?

    RISK FACTORS

    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 [44]. The obesogenic environment is characterized by increased accessibility and affordability of energy-dense foods in conjunction with declining levels of physical activity [39]. 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 [30]. 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 [36]. 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 [14].

    According to the 2017 National Youth Risk Behavior Survey, nearly 6% of high school students had not eaten fruit or drunk 100% fruit juices and more than 7% had not eaten vegetables in the seven days before the survey [45]. Of the same group, 18.7% had consumed a can, bottle, or glass of soda (not including diet soda) one or more times per day in the seven days preceding the survey, and only 27.8% did not consume any soda (not including diet soda) in the seven days preceding the survey [45]. In the past few decades, adolescents consumed twice as much milk as soda; this proportion has completely switched today [45]. 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 [46]. 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 [14].

    Data from the 2017 National Youth Risk Behavior Survey indicate that, nationwide, 15.4% of students had not participated in at least 60 minutes of any kind of physical activity on at least one day during the seven days before the survey; 46.5% had been physically active at least 60 minutes per day on five or more days; and 26.1% had been physically active for 60 minutes a day on all seven days. The prevalence of having been physically active at least 60 minutes a day on five or more days has not changed significantly between 2015 (48.6%) and 2017 (46.5%) [45]. The current trend is for schools to decrease the amount of free play or physical activity available to children during school hours [14]. 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 [46]. 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 [47].

    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 [45].

    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 [14]. 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 [14]:

    • Working parents probably rely more heavily than non-working parents on prepared, processed, and fast food, which in general contains increased calories, greater levels of fat, and a decreased nutritional content.

    • Children left unsupervised after school may make poor nutritional choices and engage in a greater amount of sedentary activities.

    • Childcare providers may not offer as many opportunities for physical activities and may provide less nutritious snack and meal selections.

    • Unsupervised children may spend an increased amount of time indoors as a result of safety concerns, watching television or playing video games more readily than engaging in outdoor activities.

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  8. A child in the 96th percentile for weight is considered

    DIAGNOSIS

    There may be a reluctance to label infants as overweight or obese or to delay this diagnosis until toddlerhood. Even if the topic is raised, parents of overweight or obese preschoolers may not perceive their child's overweight status as a problem or health concern and may not be receptive to the discussion. 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 Centers for Disease Control and Prevention (CDC) BMI growth charts can be utilized clinically beginning at 2 years of age [48]. BMI is calculated by weight (in kg) divided by height (in meters) squared, or weight (in pounds) divided by height (in inches) squared, which is then multiplied by 703. Diagnosing overweight and obesity in children 5 to 14 years of age may be difficult because there is no standard definition of childhood obesity applied worldwide [7]. Although BMI is utilized in the process of diagnosing overweight and obesity in children, the determination also takes into account age-and sex-specific percentiles. The CDC recommends using the WHO growth charts to diagnose overweight in children younger than 2 years of age and using the CDC charts for children and adolescents older than 2 years of age [48]. Using these growth charts, the following categories have been established [49]:

    • Underweight: Less than the 5th percentile

    • Healthy weight: 5th percentile to less than the 85th percentile

    • Overweight: 85th percentile to less than the 95th percentile

    • Obese: 95th percentile and greater

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  9. Based on data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), what percentage of preschool-aged children were obese in 2016?

    RESEARCH RELATED TO CHILDHOOD OBESITY

    In 2007–2008, the prevalence of children 2to 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. Although the rates of obesity are still high, data show that the prevalence of obesity among preschool-aged children declined from 15.9% in 2010 to 13.9% in 2016, indicating progress [53]. In that time (2010–2016), 41 of the 56 WIC state or territory agencies reported statistically significant decreases in the prevalence of obesity [53].

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  10. According to the National Health and Nutrition Examination Survey (NHANES), what percentage of black children 2 to 19 years of age are overweight?

    RESEARCH RELATED TO CHILDHOOD OBESITY

    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 [13]. NHANES has established that black and Mexican American adolescents 2 to 19 years of age are more likely to be overweight (20.2% and 22.6%, respectively) compared to non-Hispanic white adolescents in the same age-group (14.1%) [54].

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  11. Which of the following may result in impaired pulmonary function in obese children and adolescents?

    COMPLICATIONS OF OBESITY IN CHILDREN

    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 [64]. The work of breathing is increased in obese individuals, and larger body mass places increased demands for oxygen consumption and carbon dioxide elimination [6]. 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 [64]. This is characterized by increased ventilation of upper lobes and increased perfusion of the lower lobes [6].

    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 [64]. 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 [6]. During sleep apnea, oxygen levels in the blood can diminish dramatically [65]. Obstructive sleep apnea occurs in up to 60% of obese children [66].

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  12. A key risk for overall negative psychosocial outcomes among the overweight pediatric populations is

    COMPLICATIONS OF OBESITY IN CHILDREN

    The psychologic stress of social stigmatization can cause low self-esteem, which can alter academic and social functioning even into adulthood [36]. The social stigma of weight-based teasing has been identified as a key risk for overall negative psychosocial outcomes among the overweight pediatric population [31].

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  13. In general, the first-line treatment for overweight and obese children is

    TREATMENT OPTIONS

    Numerous factors contribute to childhood obesity, including genetics, environment, metabolic, biochemical, psy.chologic, and physiologic factors. The complex interaction of all of these possible causes makes it unlikely that a single intervention will be successful for all obese children [78]. In general, the first-line treatment is behavior changes and lifestyle modification. This should include [79]:

    • Changes to the family's lifestyle

    • Developmentally appropriate approaches, with parents being the "agents of change" for younger children

    • Long-term behavioral changes, including monitoring behavior, setting and reviewing goals, rewarding successful changes in behavior, and controlling the environment

    • Changes in dietary intake, including modified eating patterns, parental modeling of healthy food choices, consumption of lower fat and lower calorie foods, increased vegetable intake, decreased portion sizes, and reduced intake of sweetened drinks

    • Increased unstructured physical activity, through active transport and access to play equipment, and parental role-modeling of an active lifestyle

    • Decreased sedentary behavior through limiting combined television and computer (or Internet-connected device) time to less than two hours per day

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  14. Which of the following medications is approved by the U.S. Food and Drug Administration for weight loss and weight management in adolescents?

    TREATMENT OPTIONS

    Pharmacologic therapy for weight loss in children and adolescents remains an area of research. As of 2020, there are only two medications approved by the U.S. Food and Drug Administration (FDA) for weight loss and weight management in adolescents: phentermine and orlistat [80,120].

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  15. Orlistat acts by

    TREATMENT OPTIONS

    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 [12,80]. 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 [80,81]. Patients using orlistat should take a fat-soluble vitamin supplement [80]. This agent is contraindicated in patients with chronic malabsorption syndrome or cholestasis and should be used with caution in those taking cyclosporine.

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  16. Which of the following is a contraindication to adolescent bariatric surgery?

    TREATMENT OPTIONS

    Contraindications to adolescent bariatric surgery include [84,121]:

    • A medically correctable cause of obesity

    • An ongoing substance abuse problem (within the preceding year)

    • A disability that would impair adherence to postoperative dietary and medication regimens

    • Current or planned pregnancy within 12 to 18 months of the procedure

    • An unwillingness to comprehend and acknowledge the procedure's consequences

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  17. Gastric bypass involves

    TREATMENT OPTIONS

    Various types of surgical procedures have been used to change eating behavior and induce weight loss. The most commonly used procedures are [81,83,85,87,121]:

    • Gastric bypass: The most common form of bariatric surgery, gastric bypass involves creating a small proximal gastric pouch with a tight outlet and a Roux-en-y configuration of the small bowel.

    • Laparoscopic adjustable gastric band: Approved in the United States in 2001, this procedure consists of a device placed around the stomach just below the esophagogastric junction, creating a pouch that holds only a few ounces. Saline is used to inflate the band and adjust the diameter of the gastric pouch outlet.

    • Vertical sleeve gastrectomy: This technique involves the longitudinal resection of the stomach and sleeving of the remaining portion into a narrow tube.

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  18. Which of the following is NOT a commonly used bariatric surgery?

    TREATMENT OPTIONS

    Various types of surgical procedures have been used to change eating behavior and induce weight loss. The most commonly used procedures are [81,83,85,87,121]:

    • Gastric bypass: The most common form of bariatric surgery, gastric bypass involves creating a small proximal gastric pouch with a tight outlet and a Roux-en-y configuration of the small bowel.

    • Laparoscopic adjustable gastric band: Approved in the United States in 2001, this procedure consists of a device placed around the stomach just below the esophagogastric junction, creating a pouch that holds only a few ounces. Saline is used to inflate the band and adjust the diameter of the gastric pouch outlet.

    • Vertical sleeve gastrectomy: This technique involves the longitudinal resection of the stomach and sleeving of the remaining portion into a narrow tube.

    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.

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  19. Counseling topics that should be addressed with overweight or obese children/adolescents and their parents include

    TREATMENT OPTIONS

    Counseling topics that should be addressed with both parents and overweight or obese children/adolescents include [81]:

    • Food management: 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.

    • Behavior modification: Behavior and lifestyle modification techniques are utilized to help overweight people cope with an environment that promotes over-eating and inactivity.

    • Exercise: Dietary management in childhood obesity should be combined with exercise to promote long-term weight loss.

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  20. The Child Health Insurance Program Reauthorization Act included provisions and some funding to

    TREATMENT OPTIONS

    The Child Health Insurance Program Reauthorization Act (CHIPRA) was enacted in early 2009 to increase children's health coverage through Medicaid expansion and the Children's Health Insurance Program (CHIP). The Act includes provisions and some funding to improve child healthcare quality, measure outcomes, and address childhood obesity. In many respects, this starts with the content and quality of primary and preventive health services for children. Having the right care is especially important from birth through 5 years of age, because these earliest years establish health trajectories that extend into adulthood [105]. Likewise, investment of substantial resources will be required to develop effective treatment approaches for normalizing or improving body weight and fitness in children and adolescents and to determine the long-term effects of weight loss on comorbidities of childhood obesity [103].

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.