Childhood Obesity: Much More Than Diet

The world is getting heavier, and that includes kids.

The World Obesity Federation estimates childhood obesity could more than double by 2035, from 2020 levels. Rates are predicted to double among boys and more than double among girls.

September is Childhood Obesity Awareness Month, an opportune time to share information and insight on childhood obesity to do two things: Present an overall picture of the issue and let you know what Lehigh Valley Health Network (LVHN) can do to help.

While unhealthy diets and inactivity are certainly primary factors in being overweight or obese, there’s a lot more behind the waistline.

The Centers for Disease Control and Prevention says childhood obesity is “a complex disease with many contributing factors.” The American Academy of Pediatrics (AAP) adds obesity, “long stigmatized as a reversible consequence of personal choices, has complex genetic, physiologic, socioeconomic, and environmental contributors.” 

AAP’s recent clinical guidance on childhood overweight and obesity notes an extensive list of factors that can affect child weight, ranging from lack of access to healthy foods, to adverse experiences such as exposure to violence or physical or emotional abuse, to the use of certain medications, and much more.

The AAP says “understanding the underlying genetic, biological, environmental, and social determinants that pose risk for obesity is the bedrock of all evaluation and intervention. Allowing the family to have a safe space to understand and process the complexity of obesity and its chronicity requires tact, empathy, and humility.”

The pediatrician group says the societal stigma around obesity results in pervasive weight bias, making compassionate and sensitive communication with patients and families even more important.

“Obesity is a chronic medical disease – not a character flaw,” says Robin Schroeder, MD, bariatric medicine physician at LVHN. “Society treats obesity as ‘just eat less and exercise more,’ but that’s not always true. For people like our adolescent patients, obesity is a multifactorial issue that needs medical assistance.”

The National Institutes of Health designated obesity as a chronic disease 25 years ago. Ten years ago, the American Medical Association (AMA) recognized obesity as a complex, chronic disease that requires medical attention.

“Childhood and adolescence are periods of rapid growth and development,” says pediatric endocrinologist Stacey Beckford, MD, part of the pediatric endocrinology team at Lehigh Valley Reilly Children’s Hospital. “The physical and hormonal changes that young people are experiencing during this time can bring forward health challenges, including obesity.”

The evaluation of obesity by the pediatric endocrinology team is guided, in part, by a child’s age and stage of development.

When obesity begins before age 5, it is important to rule out potential genetic causes, such as Prader-Willi syndrome. In older children, it is important to rule out any primary hormonal disturbances that could be contributing to their weight gain.

The team also focuses on identifying and treating any complications of obesity before they progress and worsen. “For example, insulin resistance and prediabetes are reversible if we address them early,” says pediatric endocrinologist Resmy Gopi, MD. “But if we don’t address them, they could lead to type 2 diabetes.”

The pediatric endocrinology team prioritizes healthier eating and physical activity habits, as well as educating parents and caregivers on beneficial lifestyle changes. Healthy habits provide youth a springboard to become healthy adults.

Teens living with obesity are at risk for type 2 diabetes, heart disease and high blood pressure. Other health concerns include sleep apnea and nonalcoholic fatty liver disease (NAFLD). In addition to medical concerns, many teens living with obesity can have negative body images, low self-esteem and experience bullying.

In addition to lifestyle and diet changes, there are medical options for children, depending on their age. The Food and Drug Administration has approved three medications for treating obesity in children 12 and older.

It is only in recent years that medications have become available to assist in weight loss for adolescents. “These medications are approved for children as young as 12,” says Dr. Beckford. “While very effective, it does not replace regular physical activity and a well-balanced diet. Unfortunately, we are seeing children develop obesity at ages younger than 12 years. It’s important to try these lifestyle modifications as soon as the child’s weight is identified as a potential concern.”

Dr. Beckford says prevention is key, but doctors know that losing weight at any age is very difficult for some people. “I’m optimistic that these new medications will help address some of our biological differences that contribute to abnormal weight gain,” Dr. Beckford says.

In addition to lifestyle and diet changes, there are medical options for children, depending on their age. The Food and Drug Administration has approved three medications for treating obesity in children 12 and older.

“The adolescents that come to see us suffer from ‘food noise’ in their head due to a very heightened connection to food. The adolescent-approved medications we have available – liraglutide and semaglutide – help quiet this noise,” says Dr. Schroeder. “Varying from daily to weekly, these injectable medications are hormones that impact the gut and brain’s desire for food and the feeling of fullness. Affecting their appetite and satiety, adolescents on these medications can’t physically eat as much and are mentally less interested in eating.”

It is only in recent years that medications have become available to assist in weight loss for adolescents. “While very effective, it does not replace regular physical activity and a well-balanced diet,” says Dr. Beckford. “Unfortunately, we are seeing children develop obesity at ages younger than 12 years. It’s important to try these lifestyle modifications as soon as the child’s weight is identified as a potential concern.”

Dr. Beckford says prevention is key, but doctors know losing weight at any age is very difficult for some people. “I’m optimistic that these new medications will help address some of our biological differences that contribute to abnormal weight gain,” Dr. Beckford says.

LVHN began offering bariatric surgery in 2021 for youth starting at age 16. LVHN offers this surgical option in partnership with Lehigh Valley Reilly Children’s Hospital and Lehigh Valley Institute for Surgical Excellence.

Weight-loss surgery is a tool, not a quick fix. Permanent changes in lifestyle and diet must be incorporated to achieve success. But for adolescents living with obesity, it can change their lives.

“Our major goal with adolescent patients who are interested in bariatric surgery is to make sure the maturity is there, and that they are able to have the surgery safely and successfully,” Dr. Schroeder says. “There is an extensive pre-surgery preparation period patients have to undergo. During which, they learn about nutrition and how to make better choices on their own. They also are taught the directions they need to follow through on what they’re supposed to be eating and when post-op. There are a lot of changes that need to be made before their surgery happens and afterward. It’s a process that is intentionally long so we can observe behaviors.”

Obesity can a have a negative impact on an adolescent’s physical and mental health, according to bariatric surgeon Richard Boorse, MD, with Lehigh Valley Institute for Surgical Excellence.

“The primary focus of the adolescent bariatric program is improving the long-term health of teens struggling with obesity,” Dr. Boorse says. “But the added benefits to self-esteem and life experiences are immeasurable.”

The medical community is seeing a shift away from using body mass index (BMI) as the sole measure of determining obesity.

BMI is determined by dividing a person’s weight (in kilograms) by the square of their height (in meters). Because children and teens are growing, the ranges of height, weight and BMI vary by age and sex. BMI categories for children and teens are based on sex- and age-specific BMI percentiles, but BMI categories for adults are based on BMI only.

The AMA recently adopted a policy aimed at clarifying how BMI can be used as a measure in medicine. The AMA said because BMI is based primarily on data collected from previous generations of non-Hispanic white populations there are “significant limitations” with its widespread use in clinical settings. While BMI numbers may correlate to the general population, they lose predictability at the individual patient level, says the AMA. The AAP has also noted BMI is useful, but not as a one-size-fits-all measure.

The AMA suggested BMI be used in conjunction with other valid measures of risk, including measurements of visceral fat (belly fat deep within your abdomen), body adiposity (much or too much fatty tissue) index, body composition, relative fat mass, waist circumference and genetic/metabolic factors.

AAP early this year said it supported “early treatment at the highest level of intensity appropriate for and available to the child.”

If you believe you child is overweight, start by speaking with their pediatrician or primary care doctor about next steps. They may recommend a weight-loss plan tailored to your child’s needs or refer you to a weight-management specialist, registered dietitian, or a pediatric endocrinologist. You shouldn’t put your child on a weight-loss plan without consulting a health care professional.

Any treatments work best when your child is physically active and consumes healthy foods and beverages. You can show the way by getting the whole family involved in building healthy eating, drinking, physical activity and sleep habits. Everyone benefits, and your child won’t feel singled out.