OBESITY
Overview
Pediatric obesity is a major concern in the United States, affecting approximately 17% of children between 2 and 19 years of age. Defined as a body mass index (BMI) at the 95th percentile or above, obesity has been linked to several serious comorbidities, both physiological and psychological. Nurses play an important role in educating families around specific guidelines that have been developed for children with obesity.
Background
In children, obesity is defined as having a BMI at or above the gender-specific 95th percentile according to the Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts. Most recent estimates indicate that 17% of the U.S. population between the ages of 2 and 19 years have obesity. The prevalence of obesity is higher for non-Hispanic Black children (19.5%) and Hispanic children (21.9%), compared to non-Hispanic White children (14.7%). The overall prevalence is also higher for 6- to 11-year-old children (17.5%) and 12- to 19-year-old children (20.5%).
Obesity comorbidities may include hypertension, sleep apnea, type 2 diabetes, hyperinsulinemia, nonalcoholic fatty liver disease, dyslipidemia, polycystic ovarian syndrome and other menstrual irregularities, and orthopedic conditions such as Blount’s disease and slipped capital femoral epiphysis. Psychosocial comorbidities, including bullying or isolation from peers, decreased the quality of life, and anxiety or depression are also common (Barlow & Expert Committee, 2007).
In 2013, the American Heart Association brought attention to the additional health risks for children and adolescents with severe obesity. Consequently, a standardized definition of severe obesity was recommended (Kelly et al., 2013). Based on this recommendation, the most widely accepted definition of severe obesity is now 120% of the 95th percentiles of gender-specific BMI-for-age (i.e., 1.2 times the absolute BMI at the 95th percentile for the child’s gender and age). Estimates indicate that 5.8% of the U.S. population aged 2 to 19 years have severe obesity (Ogden et al., 2016). Mirroring the trends for obesity overall, prevalence is higher for non-Hispanic Black and Hispanic children compared to non-Hispanic White children, and also for older children compared to younger children.
The etiology of obesity is extremely complex and most likely involves both environmental and genetic factors (Kumar & Kelly, 2017). Collectively referred to as “lifestyle behaviors,” diet and physical activity play a large role in the development of obesity. High caloric consumption from sugar-sweetened beverages, fast foods or restaurant foods, and large portion sizes can contribute to energy 77imbalance. In addition, reduced physical activity and increased screen time contribute to decreased energy expenditure. Several additional environmental factors that are further outside of individual control, such as parental feeding styles, perinatal factors (i.e., maternal weight gain during pregnancy), breast feeding status, antibiotic use, gut microbiota, and adverse life experiences have also been implicated as causes of obesity. However, multiple gene sites related to appetite, satiety, and fat distribution have been identified as being associated with obesity, clearly indicating heritability (Barlow & Expert Committee, 2007). Certain medications, particularly antipsychotics, are known to contribute to weight gain, and for a small percentage of children, obesity may be related to a genetic syndrome such as Prader–Willi syndrome (Kumar & Kelly, 2017).
Clinical Aspects
ASSESSMENT
Nurses and other health care professionals should use BMI percentile to identify obesity in children aged 2 years and older. Weight and height should be measured at least annually, and BMI percentile should be calculated at each measurement. Many electronic health record systems can be configured to automatically calculate and display BMI percentile for children, which removes the burden of calculating BMI percentile from the medical staff. If BMI percentile is not available in the electronic health record, gender-specific BMI-for-age, CDC growth charts, or the CDC’s (n.d.) online BMI percentile calculator should be used. The American Academy of Pediatrics does not recommend screening children for obesity before the age of 2 years.
Severe obesity is more difficult to assess as growth charts defining 120% of the 95th percentile are not readily available, nor are they easily configured into electronic health records. Clinicians may use an absolute BMI of 35 kg/m2 or greater as a proxy for severe obesity in children. However, young children with severe obesity may not approach this BMI cutoff. For clinicians to whom it is important to know whether a child has obesity versus severe obesity, a manual calculation of 120% of the BMI at the 95th percentile for that child may be necessary (Kelly et al., 2013).
If a child is found to have obesity, the nurse may look for physical signs of the comorbidities related to obesity, such as elevated blood pressure, acanthosis nigricans (a darkening of the skin around the neck, which can be indicative of hyperinsulinemia), or problems with gait. The nurse may also ask about snoring, which may be a sign of obstructive sleep apnea. Common laboratory assessments for children with obesity include fasting blood glucose and/or hemoglobin A1c (HbA1c), fasting lipid panel, alanine transaminase (ALT), and aspartate aminotransferase (AST). Elevated values for any of these studies may indicate an obesity-related comorbidity (Kumar & Kelly, 2017).
Health care professionals should also assess diet and physical activity behaviors for children with obesity. Nutrition-related assessment may include sugar-sweetened beverage consumption, the frequency of dining out, fruit and 78vegetable consumption, and typical composition and portion size of meals and snacks. Physical activity behaviors may include the amount of daily or weekly active play or vigorous activity as well as the amount of daily screen time. Owing to the psychosocial comorbidities that are common among children with obesity, the quality of life is often assessed as well. Several validated tools exist to assess the quality of life in children, including the Pediatric Quality of Life Inventory (Peds-QL) and the Impact of Weight on Quality of Life-Kids (IWQOL-Kids; Bryant et al., 2014). The nurse may also ask the child about teasing or bullying experiences.
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
Nursing-related problems for the child with obesity may include a knowledge deficit and/or imbalanced nutrition. To address these problems, nurses and other health care professionals should provide education around eight specific guidelines for families and children with obesity: (a) consume five or more servings of fruits and vegetables per day, (b) minimize sugar-sweetened beverages, (c) limit screen time to 2 hours per day or fewer (d) participate in 1 hour or more of physical activity per day, (e) eat breakfast daily, (f) limit meals outside the home, (g) eat family meals at least five or six times per week, and (h) allow the child to self-regulate his or her meals and avoid overly restrictive behaviors (Spear et al., 2007). In addition, children with obesity should be referred to a primary care provider or registered dietitian with additional training in pediatric weight management and behavioral counseling. Older children, or those with more severe obesity, may benefit from a referral directly to a multidisciplinary pediatric weight management clinic or tertiary care center where more aggressive options such as pharmacological treatment or weight loss surgery can be discussed.
OUTCOMES
In the early stages of obesity treatment, the goal is for the child to maintain his or her weight while age and height increase, thereby decreasing his or her BMI and BMI percentile. If a child loses weight, weight loss should be limited to an average of 2 pounds per week, with lesser weight loss suggested for younger children (Spear et al., 2007).
Summary
Pediatric obesity is a common yet complex disease with a variety of potential causes. Nurses play an important role in ensuring that BMI percentile is assessed and that the recommended education is provided. Children with obesity should also be referred to health care professionals with training in pediatric obesity management. The high prevalence of obesity has led to the existence of multidisciplinary weight management centers where nurses specialized in obesity are part of the treatment team. The goal for children with obesity should be weight maintenance or a weight loss of no more than 2 pounds per week
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