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Jornal de Pediatria - Vol. 76, Supl.3, 2000 S305
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Jornal de Pediatria
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© 2000 by Sociedade Brasileira de Pediatria
REVIEW ARTICLE
Childhood and adolescent obesity
Maria Arlete M.S. Escrivão1, Fernanda Luisa C. Oliveira2,
José Augusto de A.C. Taddei3, Fábio Ancona Lopez4
Abstract
Objective: to review the medical literature in the last 5 years regarding obesity in children as well as
its treatment.
Methods: literature review.
Results: obesity is a chronic disease that presents high percentages of therapeutic failure and
recurrence, leading to serious physical and psychological consequences, especially in its most severe
forms. Health care professionals and families usually neglect the treatment of obesity in the hope of a
spontaneous reversal of the condition during adolescence. There is a great probability that obese children
and adolescents will continue to be obese in adulthood, thus increasing morbidity and mortality of several
diseases.
Conclusion: Pediatricians are supposed to early identify children at greater risk for obesity, taking
effective control measures in order to achieve a more favorable prognosis.
J. pediatr. (Rio J.). 2000; 76 (Supl.3): S305-S310: obesity, epidemiology, diagnosis, prognosis.
Introduction
Obesity is a chronic multifactorial disease triggered by
the combination of genetic and environmental factors.1
Obesity is present in 95 to 98% of cases, and only a small
percentage (2 to 5%) originates from genetic syndromes
that evolve into obesity (Prader-Willi, Bardet-Biedl),
craniopharyngioma or endocrine disorders (hypothyroidism,
Cushing’s syndrome).
Regarded as one of the major health problems in
industrialized countries, obesity has become a growing
threat to developing countries as well, coexisting with
malnutrition.2,3 Obesity is not a recent phenomenon in
human history; however, it had never been so epidemically
spread as it is today.4 This significant increase in the
number of obese individuals is related to changes in lifestyle
and eating habits. We observed that the frequent use of
high-calorie industrialized foods containing saturated fat
and cholesterol,5 and technological advances encourage
children and adolescents to adopt sedentary habits 6 such as
television viewing, playing videogames, and sitting in front
of computers for hours.7
1. Master in Pediatrics, Department of Pediatrics, UNIFESP/EPM.
2. PhD in Medicine, Department of Pediatrics, UNIFESP/EPM.
3. Associate professor and head professor of Nutrition and Metabolism,
Department of Pediatrics, UNIFESP/EPM.
4. Head professor of Nutrition and Metabolism, Department of Pediatrics,
UNIFESP/EPM.
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S306 Jornal de Pediatria - Vol. 76, Supl.3, 2000
Early weaning with inadequate food supplementation
may lead to obesity during the first year of life in predisposed
individuals.
Family disorders, especially mother-child relationship
changes, are important determinants of obesity in children.8
Obesity may initiate or be aggravated in adolescence
due to a physiological increase in adipose tissue mass
(especially in females), higher intake of high-calorie fast
food, in addition to emotional disorders.
Family history of obesity is the most important factor
that puts children at a higher risk of becoming obese due to
genetic and environmental factors such as eating habits,
which determine energy intake, family lifestyle, in relation
to energy expenditure, and the whole family context.9 The
probability of children becoming obese is greater if their
parents are obese. This probability is lower if neither their
mother nor their father is obese, high when only one parent
is obese and very high if both parents are obese.
It is known that obesity in childhood and adolescence
tends to continue in adulthood if not properly controlled,
causing an increase in morbidity and mortality, and a
reduction in life expectancy.10,11 Therefore, the earlier
identification of obesity-prone children by pediatricians
allows for effective control measures, thus helping prognosis
in the long run.
Epidemiology
The prevalence of childhood obesity has been increasing
in industrialized countries. In the United States, the
comparison of data obtained in 1965 and 1980 showed a
67% increase in obesity among male children and a 41%
increase among female children aged between 6 and 11
years.12
Environmental theories are used to explain these changes
from an epidemiological view, since no substantial changes
in genetic characteristics of these populations have occurred
in the last few decades, in opposition to significant changes
in eating habits. The factors that should be considered when
analyzing the increased prevalence of obesity among children
include habits such as TV viewing and electronic gameplaying for long hours, and practices such as the suspension
of breastfeeding, use of milk formulas and replacement of
homemade foods with industrialized foods, which usually
have higher energy density, are tastier and are always
spearheaded by vigorous advertising campaigns.
In Brazil, some remarkable changes in leisure and eating
habits have taken place in the last few years, but these
changes do not involve a great share of the population,
which is still squeezed out of the target market. As a result,
the number of obese adults has been increasing. The
comparisons of national surveys conducted in 1974 and
Childhood and adolescent obesity - Escrivão MAMS et alii
1989 showed an increase of respectively 75% and 60% in
the number of obese men and women.2
In 1989, there were approximately one and a half
million obese children in Brazil with a slightly higher
prevalence of obesity among female children (5% and
4.8%). The prevalence rates of obesity for the southern
(7.2%) and southeastern (6.2%) regions were more than
twice the rates observed for the northeastern region (2.5%),
while the northern and mid-western regions presented
intermediate prevalence rates. Among children born into
high-income families, the percentage of obese individuals
was around 8% compared to 2.5% in children who were
born into low-income families. As far as age was concerned,
obesity was more frequently present in the first two years of
life, drawing our attention to the importance of breastfeeding
and an adequate weaning diet.
Environmental theories were confirmed by the high
prevalence of obesity in developed regions of the country
where industrialization occurs much faster, resulting in
remarkable changes in eating habits. Still in agreement with
these theories, we found that obesity is more frequent
during the first years of life, having an association with early
weaning practices and inadequate dietary recommendations,
which encourage overfeeding and even award obese infants.
The data obtained from the national survey carried out
in 1996, which only included children younger than five
years, revealed that our country is already going through the
process called nutrition transition.3 In this process, mothers
who have a better level of education tend to acquire adequate
knowledge about nutrition (conveyed either by their doctors
or the media), and end up providing their children with
better nutrition, thus reducing the prevalence of obesity.
Therefore, the prevalence of obesity among children younger
than five years, born into mothers who have a better level of
education, fell from 9.9 % in 1989 to 4.5% in 1999.
On the other hand, the population in the northeastern
region is still living the previous phase of the so-called
nutrition transition. Nutritional inadequacy such as the
intake of foods rich in salt and fat occurs due to the
increased availability of industrialized foods that result
from urbanization and lack of adequate information.
Consequently, a 2.5% obesity prevalence rate in 1989
among children younger than five years reached 4.5% in
1996.
We conclude that, although nutritional disorders
associated with insufficient food intake are still a priority
for health policies and programs targeted on child nutrition,
aggravation caused by excessive intake of food due to
sedentary habits should not be overlooked. In times of
demographic and epidemiological transition in Brazil, in
which urbanization, life expectancy, deaths caused by
chronic degenerative diseases, and violence are higher and
higher, while fertility and deaths caused by infectious
diseases are on the wane, nutrition transition should also be
Childhood and adolescent obesity - Escrivão MAMS et alii
considered, especially in regard to obesity, its determination,
and measures aimed at its individual and collective control.
Pathophysiology
The physiopathology of obesity is not totally clear.
Breakthroughs have recently occurred in the field of
molecular biology, helping to elucidate the disease.
Research usually follows two complementary
approaches: a physiochemical approach, in which variations
in energy balance are studied; and the molecular biology
approach, which isolates specific genes responsible for
controlling the different factors that determine this energy
balance.13
Obesity is an energy metabolism disorder, in which
triglycerides are excessively stored in the adipose tissue.
Body energy stores are regulated by the intake and
expenditure of energy. When intake and expenditure of
energy are balanced, body weight is maintained. A low
positive balance causes low weight gain, but the chronic
imbalance between intake and expenditure of energy leads
to obesity with the passing of time.
In short, we can say that the causes of obesity are
associated with excessive energy intake, reduced energy
expenditure, and changes in the regulation of energy
balance.14,15
Breakthroughs in molecular biology began after the
observation of gene mutations in obese mice, which resulted
in new forms of body weight regulation.16 There are several
components that have been identified and participate in the
regulation of body weight; however, their precise roles have
not been defined yet. Therefore, we are going to discuss the
mechanisms of two well-defined components: leptin and
neuropeptide Y.
Leptin is a protein codified as the ob gene (in mice),
produced and secreted by mature adipocytes, acting as an
afferent feedback signal.17
Obese mutant mice (ob/ob) produce biologically inactive
leptin. Therefore, they do not receive a feedback signal,
continue to ingest excessive amounts of food, and gain
excessive weight. The exogenous administration of leptin
to these mice drastically reduces food intake and body
weight.
Other obese mutant mice (db/db) produce normal leptin.
However, there is a problem with the leptin receptor, and
these mice are resistant to the effects of leptin. Consequently,
they do not receive a feedback signal, continue to ingest
food excessively, and end up gaining excessive weight.18
There was a great expectation after the discovery of
leptin, and several research studies were then conducted.
Nevertheless, studies with humans revealed that when obese
and nonobese adults and children are compared, obese
individuals present higher serum leptin concentrations, and
Jornal de Pediatria - Vol. 76, Supl.3, 2000 S307
these high concentrations are positively associated with
adipose tissue mass.19 A hypothesis is that obese individuals
could be less sensitized to leptin.
Neuropeptide Y, a neurotransmitter released by
hypothalamic neurons, plays an important role in the control
of body weight. Differently from leptin, the effects of
neuropeptide Y, also studied in mice, are: increase in food
intake, increase in serum insulin concentration, reduced
sympathetic activity, thus reducing the release of energy,
building up triglyceride stores in adipocytes, consequently
leading to body weight gain. The secretion of neuropeptide
Y is inhibited by leptin through a feedback mechanism.20
Several research studies on obesity are targeted on the
assessment of the mechanisms involved in its
physiopathology. Other components concerned with the
control of body weight such as peptides (cholecystokininCCK, urocortin, CART); receptors (beta 3-adrenergic,
glucocorticoid, and serotonin); and uncoupling protein
(UCP) are also under study.?13
Diagnosis
The diagnosis of obesity may be obtained through
anthropometric methods, which are easy to use, harmless,
relatively inexpensive, and ideal for daily practice. 21
Normally, weight and height are used. Skinfolds and some
circumference measurements may also be used.
The weight/height ratio, which is the relation between
measured weight and ideal weight for height/age in the 50th
percentile (P50), multiplied by 100, is expressed in
percentage. NCHS is used as reference standard.
Weight/height measurement is commonly used in
children. When the value exceeds 110% and is less than
120%, children are considered to be overweight; when the
values are equal to or higher than 120%, they are considered
to be obese.
For adolescents, the most adequate method is the BMI
(Body Mass Index), which is the relation between weight
(kg) and squared height (m). The result obtained through
this measurement must be checked against percentile tables
according to gender, age (above 6 years), and race. A BMI
above the 85th percentile (P85) and below the 95th percentile
(P95) is interpreted as overweight, and above P95, as
obesity.22
Laboratory measurements of body mass are more precise
but more expensive, with sophisticated equipment commonly
used in specialized centers. These lab measurements include
electrical bioimpedance, infrared, and DEXA (dual-energy
x-ray absorptiometry), which is a very reliable, not so
invasive method that assesses lean and fat body masses.
Female adolescents with regular menstrual cycles, and male
adolescents should have respectively around 26% and 15%
of fat mass.23
S308 Jornal de Pediatria - Vol. 76, Supl.3, 2000
Consequences
Obesity is associated with important metabolic changes,
which depend upon duration and severity, and whose
consequences are more common in adults.10,24 However,
obese children are at greater risk for some diseases, and
psychosocial disorders, caused by the social stigmas
surrounding obesity, are totally relevant at this stage of
personality formation.
Hyperinsulinemia is one of the metabolic changes found
in obesity, presenting a significant correlation with body fat
mass. Fasting serum insulin levels are reduced due to weight
loss and calorie restriction. The finding of basal
hyperinsulinemia and postglucose-load, with normal or
increased glycemia, suggests resistance to insulin. Insulin
resistance seems to be related to changes in receptor levels
in peripheral tissues.25
Another important metabolic consequence of obesity is
related to adverse lipid concentrations. Several studies have
already shown an association between obesity and increase
in total cholesterol levels and LDL cholesterol, with greater
risk for the development of atherosclerotic disease and low
HDL cholesterol levels; the risk is even greater because of
antiatheratogenic fraction. Atherosclerosis may begin in
childhood, and high cholesterol levels at this stage play an
important role in the development of adult atherosclerosis.26
The body distribution of adipose tissue implies different
risks for the development of metabolic changes. Fat
deposition in the trunk is clearly associated with a higher
risk for diabetes, cardiovascular diseases, and high blood
pressure.
There is also an association between obesity and high
blood pressure;27 the mechanisms that predispose the
occurrence of high blood pressure are not well known.
Systolic and diastolic pressures increase as body mass
index increases. Hemodynamic studies have shown increased
heart deficiency in obese patients and reveal the expansion
of blood volume as a cause for high blood pressure. There
is a narrow relationship between blood pressure and body
weight, in which blood pressure is reduced as weight is lost.
Another mechanism that may be responsible for high blood
pressure in obese individuals is reduced sodium excretion
caused by hyperinsulinism. We observed that the renin angiotensin - aldosterone system is stimulated in obese
individuals, especially those with abdominal obesity, thus
explaining the increase in blood pressure.28
Obesity is one of the major causes of high blood pressure
in children and adolescents, originating future
cerebrovascular and cardiovascular diseases.29
Orthopedic disorders are also frequent in obese
individuals due to the trauma inflicted by excessive weight
on their joints. Knee joints are the most commonly involved,
and slipped capital femoral epiphysis is very common in
obese individuals.
Obese individuals may present changes in their
pulmonary function with reduction in the residual volume
Childhood and adolescent obesity - Escrivão MAMS et alii
and maximum expiratory volume, and a tendency towards
general reduction in pulmonary volume. Pickwickian
syndrome, which is characterized by hypoventilation, diurnal
sleepiness, and sleep apnea, may occur in severe cases of
obesity.30
Type II diabetes mellitus is an important chronic disease
associated with obesity. This type of diabetes is rare in
children and adolescents, but very common in obese adults.
Usual dermatological disorders found in obese
individuals include striae, fragile skin in skinfold regions,
with a tendency to fungal infection, and acanthosis nigricans,
with skin darkening under the arms and around the neck.
Treatment
The best way to treat obesity is the use of a
multidisciplinary approach due to the multifactorial nature
of the disease. The treatment must be performed by a
pediatrician, nutritionist, psychologist, and physiotherapist.31,32
Patients need to establish a good relationship with the
professionals involved since the treatment is long-lasting.
Children and adolescents are not clearly aware of time;
therefore, we should not show them just the potential risks
of obesity but also assess its current implications, that is, the
problems overweight is causing.
Treatment should be initiated as early as possible since
the older the children and the more overweight they are, the
more difficult it will be to reverse the case due to the
assimilation of eating habits and metabolic changes.
The pediatrician establishes the first contact with the
patient through anamnesis, which should emphasize the age
of onset, development of the condition, and its possible
triggering mechanisms. Previous family history of obesity,
cardiovascular diseases, high blood pressure, dyslipidemia,
and diabetes should also be investigated. The amount of
physical activity performed by children should be assessed,
in addition to disorders related to behavior, school, and
family. On physical examination, blood pressure has to be
checked, and possible complications such as orthopedic,
postural, dermatological and respiratory problems have to
be identified. Subsidiary tests include serum dosage of
triglycerides, total cholesterol, and fractions. If possible,
laboratory measurements of body mass should be conducted.
When lipid concentration is normal, the procedure has
to be repeated the following year. If results are not normal,
nutritional recommendations are made, and a new sample is
collected within three months (Table1.0). The lipid
concentration in children and adolescents may be evaluated
according to Kwiterovich method (1989).33
In cases of severe obesity, hyperinsulinism may be
detected through serum basal insulin dosage and fasting
glycemia (insulin/glycemia 0.5).
Childhood and adolescent obesity - Escrivão MAMS et alii
After nutritional anamnesis, the patient is instructed to
gradually reduce food intake, not to eat more than the
recommended portion, to chew food properly, not to eat in
front of TV, and to stick to meal time.34,35
In cases of dyslipidemia, patients are encouraged to
limit their amount of calories obtained from fats that account
for 30% of total calories required, reducing the intake of
saturated fat and cholesterol, having a preference for
polyunsaturated fats, complex carbohydrates and fibers.36
In hypertensive obese children, the reduction in salt
intake is important in order to normalize blood pressure.
Children who have not entered the enhanced growth
stage yet need to normalize their weight/height ratio, which
can only be attained through development and maintenance
of body weight.
Strict diets are contraindicated, and could lead to muscle
tissue loss and reduce growth speed.
No medications should be used to treat childhood obesity
due to their side effects and the risk of chemical and/or
psychological dependence.
Physical activity must always be recommended,
respecting every patient’s limitations. Regular aerobic
exercises are indicated, with the aim of energy expenditure
and change in lifestyle.37,38
Psychologists play a vital role in encouraging and
supporting patients during treatment, which is slow and
long-lasting.
Jornal de Pediatria - Vol. 76, Supl.3, 2000 S309
A longitudinal study carried out in England to assess the
weight and height of individuals up to the age of 26 years
revealed that 40% of obese children aged 11 and 50% of
them at the age of 15 were still obese by the age of 26. At all
ages, the lower the relative weight, the lower the risk of
becoming obese in adulthood.41
In the study conducted by Bogalusa between 1973 and
1983, with patients aged on average 7.3 years at the beginning
and 15.7 years at the end of the survey, 66% of the children
who suffered from severe obesity and only 32% of those
with moderate obesity at the beginning of the study continued
to be obese. Severe obesity and the consecutive increase in
its levels enhanced the probability of persistence.42
In a follow-up study of obese children over a 40-year
period, carried out in Stockholm (Sweden), the maximum
weight for height ratio was achieved at the pubertal stage
(higher than 3.5 SD) while 47% still presented obesity in
adulthood. Family history of obesity (parents and
grandparents) and the degree of obesity at the pubertal stage
were the most important factors that influenced the
persistence of obesity in adulthood. This study also showed
that severe obesity in adolescents was associated with high
morbidity and mortality in adulthood.43
The probability of obese children becoming obese adults
gradually increases with age. Therefore, the older obese
children are, the greater their risk of becoming obese adults
is.
References
Prognosis
Obesity is not easily controlled, presenting a high rate of
therapeutic failure and recurrence, with possible organic
and psychosocial consequences during its development,
especially in more severe cases.
The treatment of obese children is usually neglected by
the family and health care providers since a spontaneous
resolution is expected. However, there is a great probability
that obesity will persist in adulthood. 39
Several studies were carried out to assess the evolution
of obesity in children and its continuity in adulthood. The
results of these studies are variable and hard to compare due
to differences in sample selection, criteria used for the
definition of obesity, analysis and presentation of data.
These studies, however, tend to show that obese children
and adolescents have a higher risk of becoming obese adults
when compared to nonobese individuals.
The risk of childhood obesity extending into adulthood
is related to its duration and severity. Resolution rates
decrease with age and the increase in severity increases the
risk for persistence. Approximately one third of obese
adults were obese children, and when obesity is severe, the
ratio increases to ½ or ¾.40
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Correspondence:
Dr. Fábio Ancona Lopez
Rua Loefgreen, 1647
CEP 04040-032 – São Paulo, SP, Brazil
Phone/Fax: + 55 11 5576.4484
E-mail: [email protected]