7 Chapter Seven: Community Intervention in Childhood Obesity

Authored by: Sherri M. Cirignano, MS, RDN, LDN

 

Introduction

Childhood obesity continues to be of serious concern in the United States, with a 42% increase over the past 20 years.¹ The factors that contribute to this continued rise are multifactorial and include those that are social, economic, and environmental. Many of these factors are out of the control of children, increasing the challenge for changing the tide. Along with the reality of obesity in children comes the increased threat of their development of weight-related diseases such as type 2 diabetes, high blood pressure and depression,¹ and an increased risk of hospitalization and severe illness from infectious diseases such as COVID-19.² These facts lead to an urgency to work towards a slowing and eventual reversal of the obesity epidemic in children. In this chapter, we will explore factors that can lead to obesity in children, consequences of having obesity in childhood and review recommendations for, and overall effectiveness of, interventions that work to contribute to this change.

Childhood Obesity Prevalence

Domestic

According to the Centers for Disease Control and Prevention, (CDC) approximately one in five children and adolescents between the ages of 2-19 in the US are currently suffering from obesity. That amounts to close to 15 million children and adolescents overall, with a prevalence of 12.7% among those who are 2-5 years old; 20.7% among those who are 6-11 years old; and 22.2% among those who are 12-19 years old.³ Certain populations have been found to be more apt to become overweight or obese. Within the 2-19-year-old age group, obesity prevalence was found to be highest among Hispanic and non-Hispanic black children, at 26.2% and 24.8% respectively, lower among non-Hispanic white children (16.6%), and lowest among non-Hispanic Asian children (9.0%).³

Global

According to the World Health Organization, (WHO) the prevalence of and projection for overweight and obesity in children worldwide continues to be alarming. In 2020, 38.9 million children under the age of five were overweight and an increase of one million more in this category is projected by 2030.⁴ The amount of children aged 5-19 with obesity has tripled in the past 20 years, from 52.3 to 150 million, and is projected to increase another 100 million children in the 5-19 age category by 2030. Goals set by the WHO in the 2016 Report of the Commission on Ending Childhood Obesity are not on track to be met.⁴ As a result, updated recommendations and goals were provided by the WHO in 2021 including adapting a “life-course” approach in all aspects of obesity prevention and management with a focus on diet and physical activity. More specifically, recommendations include decreasing added sugars to less than 10% of total energy, decreasing sedentary behaviors and working towards a goal of at least 60 minutes per day of moderate to vigorous activity daily for children and adolescents.⁴

Determining Obesity in Children

Methods to determine the weight status in children and adolescents relative to overweight and obesity include Body Mass Index (BMI) and growth charts. BMI is a measure of body weight in relation to height, calculated by dividing weight in kilograms by the square of height in meters. For children, age and gender are also taken into consideration when determining BMI. Although BMI is considered to be a reliable source, it is only one factor in determining if a child is obese.⁵ Growth charts developed by the WHO and the CDC are also used. The WHO growth charts are recommended for use when monitoring infants and children to age two and the CDC growth charts are recommended for use when monitoring children over the age of two.⁶ A child who is found to be above the 95^th percentile for BMI would be in the obese category. The purpose for monitoring this result in children is to determine their likelihood of developing health-related issues as a result of having obesity.

Risk Factors Contributing to Childhood Obesity

Unmodifiable Risk Factors

Genetics

There are a multitude of risk factors that contribute to childhood obesity. These factors include those that are not modifiable such as genetics. Researchers have discovered that there is evidence that points towards a genetic predisposition for determining an offspring’s body fat content and the way their body ingests and expends energy as well as their likelihood of becoming obese. Studies have also indicated that genetics may play a role in certain populations’ higher probability for developing metabolic syndrome, a resistance to insulin, and type 2 diabetes.⁷ Metabolic syndrome (MetS) is defined by the National Heart, Lung, and Blood Institute as “a group of conditions that together raise (the) risk of coronary heart disease, diabetes, stroke and other serious health conditions,”⁸ and when an individual has three of the following five factors present: 1) elevated waist circumference (35 inches for women; 40 inches for men); 2) elevated triglycerides (150 mg/dl) or on medication for high TG; 3) low HDL cholesterol (<50 mg/dl for women; <40 mg/dl for men; 4) elevated blood pressure (systolic greater than or equal to 130 mm Hg or diastolic greater than or equal to 85 mm Hg, or both; 5) elevated fasting glucose (greater than or equal to 100 mg/dl or on medication for elevated glucose.⁹ MetS is an important potential consequence of obesity in children and adults alike.

Modifiable Risk Factors

Early Factors

There are risk factors that can contribute to overweight and obesity in children that have been identified through research and can be modified primarily through changes in lifestyle. There has been a consistent presence in the research of the need to start with prevention as early as possible, including as early as prior to conception.^1,10,11 Parental factors for which a consistent association has been demonstrated include a higher maternal pre-pregnancy BMI, prenatal maternal exposure to tobacco,^1,10,11 and maternal excess gestational weight gain.^1,10 Other factors with a consistent association include a high infant birth weight and an accelerated weight gain by the infant.^1,10 Although there are several other potential associated factors such as gestational diabetes, breastfeeding, sleep, and feeding and sedentary behaviors, these factors have been less consistent in the literature.^10,11 Systematic and other reviews on breastfeeding’s role in obesity in children or adolescents is an important possible modifiable risk factor with results that have been mixed in the literature. Some reviews indicate a benefit of breastfeeding reducing obesity risk^1,11 and others indicate it is unclear at this time.^7,10

Dietary Factors

Early assumptions regarding the contributing factors of increasing childhood obesity levels after the early years of a child’s life have been reexamined to include more specific potential factors. Dietary factors that may contribute to obesity, although important to consider in all aspects of a child’s diet, have been found to be particularly connected to calorie-dense foods such as those containing trans-fats and added sugars.⁷ Even more specifically, studies indicate eating fast foods more than twice a week,⁷ especially among white children,¹² or having an increased intake of sugar sweetened beverages, are associated with increasing weight measurements in children.⁷

Other dietary factors with possible associations to decreasing the risk of a child having obesity include addressing patterns of eating. This includes not using food as a reward, encouraging eating only when hunger is present, and providing regular mealtimes, such as always including the breakfast meal.⁷ Breakfast intake, in particular breakfast meals that include nutrient dense as opposed to energy dense foods, continue to be considered beneficial in modifying being overweight and other health indicators in children.

Environmental Factors

Environmental factors have also been found to play a role in childhood obesity. Where and how children spend their time, whether at home with family and caregivers, in school, or in their neighborhood can be important predictors of their future health and tendency towards obesity. Children spend a majority of their time with their family. Evidence indicates that family dynamics such as single-parent households and low amounts of time that are devoted to regular physical activity can play a role, as can approaches towards screen time.⁷ There is a clear relationship between low levels of physical activity and high levels of sedentary behaviors with rates of obesity. Children who spend much of their free time watching television, or using computers, tablets or phones may contribute to less physical activity and increased sedentary behaviors. Television viewing and its relationship to obesity may also be impacted by the food and beverage advertisements of items of often poor nutritional quality. Children, in particular those who are overweight, have been found to respond favorably to this advertising, affecting their choices long term.⁷

The school environment can mold food choices made by children due to influences from available foods and beverages in vending machines and physical activity behaviors of children due to influences from their peers.⁷ Along with a decrease in being physically active, changes in neighborhood planning and concerns over safety in most areas over the past several decades has led to children being transported rather than walking or biking to and from school, friends’ houses and as a part of playtime.

Another contributing factor to childhood obesity is the high incidence of food insecurity in the US that is affecting children and adolescents. Some research has indicated that food insecurity is an indicator of obesity due not only to a variety of socioeconomic factors including poverty, but also potentially due to some underlying causes.¹ According to the Trust for America’s Health report The State of Obesity: Better Policies for a Healthier America 2022, this association may be due to 1) our bodies storing extra fat as “an evolutionary response” to the expectation of times of lower amounts of food; 2) the theory that those who are food insecure also do not have access to grocery stores with healthful choices or places to be physically active; 3) the social environment one lives within promotes certain habits and learned behaviors; 4) the realities of financial instability such as stress, anxiety and possible emotional responses to these realities including stress eating; 5) and studies suggest that the method of monthly food access via the Supplemental Nutrition Assistance Program (SNAP) may promote overeating during the first few weeks of the month and then a lack of food in the final weeks before more SNAP benefits are available.¹

Consequences of Obesity in Children and Adolescents

Health Consequences

As with adults, the potential consequences of obesity in children and adolescents, including those that are health-related and otherwise, can be significant and life-altering. In most cases, the health consequences children are experiencing as a result of obesity today were found only in adults a generation ago. The potential health consequences include type 2 diabetes, cardiovascular risk factors including hypertension and high cholesterol, breathing problems such as asthma and sleep apnea, joint issues, gallbladder disease^13,14 and a liver disorder known as nonalcoholic fatty liver disease.^14,15 A recent systematic review reported by Sharma et al in Obesity Reviews suggested that the prevalence of certain health-related issues were associated with a child’s or adolescent’s weight level as follows: those with obesity were “1.4 times more likely to have prediabetes, 4.4 times more likely to have high blood pressure, 26.1 times more likely to have nonalcoholic fatty liver disease and 1.7 times more likely to have self-reported asthma.”¹⁴

A recent systematic review found that although persistent obesity from childhood to obesity is associated with risk factors of cardiovascular disease, this risk can be “reduced or completely removed” if normal weight is achieved in adulthood.¹⁶ This finding underscores the importance of working towards the prevention of obesity in children in the first place but also continuing measures that work towards weight management of those children and adolescents with obesity.

Another important potential consequence of childhood obesity includes an increased risk for a severe case of COVID-19.^17,18 According to the CDC, children under the age of eighteen with obesity “had a 3.1 times higher risk of hospitalization and a 1.4 times higher risk of severe illness when hospitalized.”¹⁷ A “severe illness” was defined as being admitted to the intensive care unit, needing to receive medical ventilation or dying from the disease. It has been hypothesized that the COVID-19 pandemic may have also led to an uptick in overall childhood obesity levels. One study showed that the rate of BMI in a group of over 400,000 children ages 2-19 years almost doubled from March 1, 2020-November 30, 2020 in comparison to the pre-pandemic period of January 1, 2018-February 29, 2020.¹⁹ This may have been due to many factors that include increased screen time due to virtual learning, decreased physical activity due to lockdowns and for those living in apartments or homes without a space for activity, and increased snacking and consumption of food not previously consumed in the same quantities due to pandemic-related issues with obtaining groceries and an increase in food security.^19,20,21

Psychological and Social Consequences

Additional potential issues include those of a psychological nature including anxiety and depression, low self-esteem, a lower quality of life²² and social issues including being bullied^22,23,24 and experiencing weight bias.^22,24 A recent review of 26 studies worldwide that looked at the risk of weight status for school bullying showed that children and adolescents with obesity or those who were overweight were more likely to experience bullying than their healthy weight peers. This was also more likely to occur with boys with overweight or obesity than with girls with overweight or obesity.²³ The stigma that can be associated with obesity, even in children, has been found to be present in the classroom as early as kindergarten and “that teachers may serve as a significant source” of this bias, especially in girls. This bias has in turn been found to affect the academic achievement of these young girls.²⁴

Economic Consequences

Does family income have a role in having childhood obesity and is having childhood obesity a predictor in an individual’s future economic success? Some research has indicated that although income is considered by the CDC²⁵ and Healthy People 2030²⁶ to be one of many social determinants of obesity, it is not always the case. Improvement in a family’s income and thus expendable income, as shown in a study conducted by a Pennsylvania State University researcher,²⁷ did not result in any change in youth obesity rates. Although more research is needed in this area of study, this finding indicates a need to look at other reasons why family income seems to be linked to childhood obesity levels. The author suggests considering the educational level of the parents and the community’s environment and support, or lack thereof, towards obesity prevention.

On the other hand, obesity in childhood may affect an individual’s future economic success as indicated in two separate studies, one in the United Kingdom²⁸ and one in the United States.²⁹ The UK study found that there was an association between obesity at age sixteen and having a significantly lower income. This was true for women, not men, and was linked to both their lower likelihood of marriage and their spouse’s lower income if they were married.²⁸ The study in the US compared bankruptcy by consumers in counties with high obesity rates and found that there is an association between the two. After controlling for factors such as county demographics and the economic conditions of the counties, those counties with higher obesity rates also had higher bankruptcy rates.²⁹

Recommendations for the Prevention of Childhood Obesity

Federal Guidance

Guidance for designing interventions that meet national objectives are provided from government-based entities such as the CDC, evidence-based reports such as the Dietary Guidelines for Americans, (DGA) and large-scale initiatives such as Healthy People 2030. The CDC provides the Spectrum of Opportunities Framework to assist states with ways they can “embed” obesity prevention standards at early care sites³⁰ and School Health Guidelines to Promote Healthy Eating and Physical Activity for students in grades K-12.³¹ The Spectrum of Opportunities Framework provides ways to incorporate healthy eating, physical activity, breastfeeding, and reduced screen time among young children in early care settings. The School Health Guidelines include nine guidelines that provide a starting point for schools to create, implement and evaluate policies to promote healthful environments in schools.

The Dietary Guidelines for Americans 2020-2025, (DGA) compiled by the United States Department of Agriculture, includes “healthy dietary patterns” for ages across the lifespan, including for infants and toddlers for the first time in DGA history.³² The key recommendations in summary for infants and toddlers in the current DGA are 1) exclusively feed infants human milk for at least the first six months; 2) introduce solid foods to infants at about six months; 3) encourage infants and toddlers to consume a variety of foods from all food groups; 4) avoid foods and beverages with added sugars and limit sodium.³³ These recommendations are the basics of building a foundation for creating a healthy dietary pattern for children for the rest of their lives. Continuing with this premise in children and adolescents with an overall healthy dietary pattern that includes nutrient-dense foods and beverages is recommended. Use of the DGA for these age groups can be helpful in incorporating them into obesity prevention dietary interventions for children of all ages.³⁴

Healthy People 2030 is developed under the direction of the US Department of Health and Human Services, within their Office of Disease Prevention and Health Promotion. Healthy People’s Mission is “To promote, strengthen, and evaluate the nation’s efforts to improve the health and well-being of all people.”²⁶ This includes reducing the proportion of children and adolescents with obesity. Evidence-based strategies for achieving this objective include making changes to policies and curriculums in schools to allow for consuming healthy foods and being physically active.³⁵

Non-Government National Guidance

Recommendations are also provided from non-government entities such as the Trust for America’s Health. (TFAH) TFAH is a “nonprofit, nonpartisan public health policy, research, and advocacy organization that promotes optimal health for every person and community…”¹ In its report, The State of Obesity: Better Policies for a Healthier America 2022, TFAH outlines recommendations including those that aim to promote obesity prevention community programs for children and their families. The report stresses the importance of addressing many aspects of childhood nutrition including the benefits of providing healthful meal options to children, whether at home or through national programs such as the National School Breakfast (NSB) and National School Lunch Program, (NSLP) to promote examples of healthy choices to work towards lifelong healthful eating habits. To achieve the recommendations put forth by the TFAH 2022 report, requires a systems approach to assure any policy changes within a community will benefit all. Recommendations from the report are provided for future planning by federal, state and local governments and are focused on the following five areas:¹

1. Advance health equity by strategically focusing on efforts that reduce obesity-related disparities;
2. Decrease food insecurity while improving nutritional quality of available foods;
3. Update marketing and pricing strategies that lead to health disparities;
4. Make physical activity and the built environment safer and more accessible for all;
5. Work with the healthcare system to close disparities and gaps in clinic-to-community settings.

A number of federal programs that benefit children are mentioned within the report’s more specific recommendations to achieve the above goals including expanding access and eligibility for national summer food programs such as the Seamless Summer Option, increasing investments in the educational portion of the Supplemental Nutrition Assistance Program (SNAP-Ed) and enhancing benefits and access to the Special Supplemental Nutrition Program for Women, Infants, and Children also known as WIC.¹

Registered Dietitians Nutritionists (RDN) are a professional group of individuals who are often involved in the development and implementation of community interventions towards preventing overweight and obesity throughout the lifespan, including for children. Guidance for the RDN when creating educational programming or seeking community level policy changes comes from many sources including those mentioned above and the professional organization of the RDN, the Academy of Nutrition and Dietetics. (AND) The AND has provided the position paper Prevention of Pediatric Overweight and Obesity: Position of the Academy of Nutrition and Dietetics Based on an Umbrella Review of Systematic Reviews with a review of the current literature regarding this topic and includes the following Position Statement:

It is the position of the Academy of Nutrition and Dietetics that prevention of pediatric overweight and obesity requires multilevel, multicomponent, and culturally appropriate interventions with family involvement to improve and sustain intake of healthy dietary patterns and physical activity in a developmentally appropriate manner throughout childhood and adolescence. Registered dietitian nutritionists are uniquely qualified to advocate for and deliver nutrition counseling in child-based settings; develop and deliver theory-based nutrition education programs; and implement environmental and policy changes to improve access to healthy foods.³⁶

Effectiveness of Obesity Prevention Interventions in Children

Interventions for the prevention of childhood obesity are numerous, many of which have been in place for over two decades. Interventions are created and delivered on the national, state and local level in a variety of locations and by a variety of government entities and non-government organizations. In Chapter 6, community interventions that work towards child obesity prevention in early care sites, schools and the community and evidence regarding their effectiveness are presented. This section will explore the evidence currently available in the literature regarding the effectiveness of community interventions.

Overall evidence for the effectiveness of interventions on obesity prevention in children indicate limited effectiveness for all age groups in the most recent systematic reviews.^37–40 Although past reviews of studies indicated “strong” child obesity prevention benefits in school-based interventions for children ages 6-12, caution of this interpretation was encouraged due to the studies’ designs and limited availability of studies on interventions for all age groups to consider.⁴¹

The most promising evidence for decreasing the risk of obesity was found in interventions where the focus was on both diet and physical activity in young children ages 0-5,³⁸ and a small benefit to BMI with school-based interventions for children ages 6-18.³⁷ Over the past few years, there have been mixed outcomes reported from three separate literature reviews for older children.^38-40 Some studies reported benefits in reducing the risk of obesity from interventions that focused on physical activity alone for children ages 6-12 years and adolescents ages 13-18 years,³⁸ and while one review found limited benefit that was not statistically significant from physical activity interventions for adolescents ages 10-19 years of age,³⁹ another found little or no effect on obesity prevention of any interventions reviewed on this same age group.⁴⁰ All studies reported that there is a lack of studies, in particular high-quality studies, available for reviews of this nature.

Also of importance is to consider if obesity prevention interventions that target children are in any way detrimental to them. Some, but not all, studies include this aspect of research as a part of their interventions. Potential adverse effects of interventions for the prevention of obesity through the promotion of a healthful diet and/or increasing physical activity could include developing negative body images or damaging views about themselves or their weight, experiencing high amounts of weight loss or bodily injury or suffering from psychological effects such as depression. Studies that included this were limited, but for those that did, no adverse effects were reported.^36-38

Summary

The rate of obesity in the US and the world over continues to be alarmingly high with goals set by the WHO in 2016 not on track to be met. According to the WHO, globally, childhood obesity has tripled over the past two decades. The list of modifiable risk factors that may work towards preventing childhood obesity is growing as studies on the subject also grow. Risk factors regarding weight start prior to conception and during pregnancy and include modifying parental pre-pregnancy weight and monitoring gestational weight, a high weight of the infant at birth and quickly after birth, as well as eating and sleeping behaviors of the infant. Whether or not breastfeeding is a modifiable risk factor is recently being further scrutinized as some systematic reviews have found the results of studies on this topic to be mixed at this time. Other risk factors that can be addressed during a child’s preschool and school years include decreasing calorie-dense foods, especially fast foods and sugar sweetened beverages, (frontiers in endo) and decreasing screen time and increasing physical activity. Another risk factor that is not easily modifiable but critical to address is the high incidence of food insecurity that is affecting children and adolescents in the US.

Health and other consequences of childhood obesity include type 2 diabetes, cardiovascular disease, asthma, sleep apnea, joint issues, and gallbladder and liver disease, an increased risk for a severe case of COVID-19, as well as psychological issues including anxiety and depression and social issues such as being bullied and experiencing weight bias.

Many recommendations and guidelines are available for professionals to develop evidence-based interventions including from the Dietary Guidelines, Healthy People 2030 and the Academy of Nutrition and Dietetics. Interventions that have been implemented over the past twenty or more years have been reviewed to determine their effectiveness. The most current review suggests there is limited effectiveness for all age groups in the most recent systematic reviews, with a small benefit to BMI with school-based interventions for children ages 6-18. Despite this information, it continues to be imperative for the work to continue towards the prevention of overweight and obesity in children of all ages through interventions that focus on education and policy changes.

Resources

Dietary Guidelines for Americans 2020-2025

Trust for America’s Health. The State of Obesity: Better Policies for a Healthier America 2022 from the Trust for America’s Health

The World Health Organization

Centers for Disease Control and Prevention BMI Percentile Calculator for Child and Teen

Centers for Disease Control and Prevention Healthy School Guidelines

Healthy People 2030

Academy of Nutrition and Dietetics

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