Have The Concerns of Obesity in Children and Young People

Introduction

         The obesity can be considered as one of the major concerns in the modern society.  In the era of the presence of processed foods as well as the increasing health consciousness is present, the obesity of the population can be considered as one of the health problems that are needed to be given attention.  The problems relating to obesity is continuously increasing that every age of the population can be considered susceptible.  For that matter, both the cases of obesity in the children and in the adults are needed to be given attention.

         In the study undertaken, the main objective is the presentation of the view that tackles the concern of the society and the health authorities on the obesity of the people across different age classes, both children and adult.  For that matter, the presentation of the different factors and issues that are related to obesity of the children and adults is the main focus of the study undertaken.

Background Information on Obesity Defined

         To be able to clearly present the different concerns that are related to the problem of obesity, it is a preliminary step to be able to define the term obesity.  It can be considered that obesity is a weight classification that falls above normal range of body weight and mass on the basis of different factors such as height.  There are also other factors that can be included in the main basis of the determination of obesity.

         Due to the abnormality in the body functions of an obese person, the different related data are needed to be considered.

1. Causes

         On the basis of the fact that the said condition has a great effect to the person and the people around, the main causes of obesity are needed to be given attention.  When it comes to the said issue on the possible causes of obesity, there are different reasons that can be sited.  Some believe there is a definite genetic link for obesity.  For that matter, the relationship to hereditary factors is of great consideration.  This can be related to the fact that it can increase the susceptibility of the people for having unhealthy eating behaviour.  Also in addition it can result to a lesser extent affect how the body absorbs and processes energy and the food intake (Dehghan et al 2005).

1. Effects

         Aside from being a health concern, it is also a common social issue.  This can be attributed to the fact that the life of the obese person can evidently be affected by the said health issue one way or another.  For that matter, the perceptions of the public regarding the issue on obesity is also an important concern.  These are just a few common perceptions the public have of people who are over their ideal body weight.  Due to the said fact, it is important to consider that being overweight or obese carry with it a myriad of health risks, economic burden, social problems and psychological stress.

         Basically, in terms of the malfunction in the metabolism and other processes in the systems of the obese person, it can result to a lesser extent affect how the body absorbs and processes energy and the food intake.  This can in turn make the person that has lower capability for metabolism to have higher deposits of different body nutrients as compared to that of the person with higher metabolism (Dehghan et al 2005).

         Due to the said possible reason behind the cases of obesity it can then be perceived that the condition is much more complicated, thus the solution is not as simple as dieting or exercise.  If cases pointing to genetic make up as the main reason for the development of obesity, then a more serious medical treatment and attention is required.

         Aside from the danger that obesity can bring about to the health of the population, the effects on the personal level of the affected person is also important.  These effects can be attributed to different facets of life such as social and economic aspects.  The increasing health risks do not exclude any member of the population.  Such risks can include heart diseases, NIDDM, hyperlipdemia.  Aside from these direct costs, the cost for loss in wages, premature pensions as well as intangible costs such as reduced sense of well-being and health makes prevention a much more viable alternative to treatment. (Macdiarmid 2002).

1. The Current State of Obesity in the Population

         In relation to the seriousness of the case of obesity and the continuous rise in the number of people that are affected, the need for research and the development is continuously becoming more urgent.  The said need for research in relation to the said condition is triggered by the morbidities associated with obesity.  Aside from the obvious effects of the obesity in different aspects of a human person, it can also affect other issues in the social and health arena.  Obesity poses significant costs in health and healthcare.  This is as high BMI increases the risk of some cancers and also NIDDM, heart disease and hyperlipidaemia. In terms of financial costs, many developed countries disburse as much as 7% of their total healthcare expenditures for treatment of obesity, translating to US$99 billion in 1995 for the US, for example.

Aside from these direct costs, the cost for loss in wages, premature pensions as well as intangible costs such as reduced sense of well-being and health makes prevention a much more viable alternative to treatment. (Macdiarmid 2002)

In general, obesity occurs when the body takes in more energy than it expends, and this propensity for storing excess energy or fat is attributed to several factors interacting in complex ways.  The common idea is that it is caused by the intake of excessive amounts or high-fat, high-energy foods and beverages, whether processed or not.  Others perceive that being fat means prosperous, hence high socio-economic status, but then it leads to different more profound issues such as obesity.  The escalating problems on obesity can be related to the said simple misconceptions of the people.

The said misconceptions lead to more serious problems.  In obesity, the seriousness of the problem then can be related to the effects associated to different age classes.  For that matter the cases that are focused on the adults and the children are the main concern of the study undertaken.

Cases of Obesity in Different Age Classes

         The study on the basis of the different age groups is important on the basis that the main reason that can be the causes of the problem of obesity can be comparatively observed on the basis of the differences on the age.  For that matter, the age-related factors that can be related to the said ailment can be controlled.  Also in the determination of such factors, other related issues can also be defined.  An increased knowledge on the disease can aid in the decrease of the risk for the said ailment.

1. Obesity in Children

         On the basis of obesity, the most important concern on the issue is related to the effect on the children of the population.  The said concern can be related to the fact that during the past eras, the children are considered to be the healthiest members of the population and are commonly free of different types of health conditions.  But due to the different factors that can also be considered to bring about obesity in children, the concern and the attention that is needed covers a variety of issues relating to the total condition of the health of the young people.

1. Children obesity in the present era

         The present cases of obesity in children that had been recorded in different studies are considered to be the main reason for alarm in health authorities and the other members of the society.  In the study of 79 countries that focused on children that belong to the childhood age, which is below the teenage age, there are approximately 22 million children below the age of 5 are diagnosed to be obese (Macdiarmid 2002).

         On the other hand, a focused on the developed nations resulted in the determination that there are 10 to 40 percent children that are aged 5 to 14 that are overweight.  The said data is higher that of the gathered information on obesity during the past 2 decades (Macdiarmid 2002).

The data in the United States presented an increase of 17% through the duration of 30 years.  These children are commonly predicted to have an overweight body condition even on the onset of adulthood.  In addition, contacting obesity at a young age can increase the susceptibility to different kinds of ailment during the adult age (Gidding et al 1996; Macdiarmid 2002).

Due to the higher susceptibility of the children that had obesity to a serious attention and examination specifically on the basis of the health conditions that are related to obesity such as heart problems and NIDMM.

The cases of obesity are continuously becoming prevalent in young children.  In addition the cases of Type 2 diabetes which were considered to be in rare occurrence about 3 decades ago had been observed to have early occurrence in the present era, thus it means that it can affect the children too.  What is alarming is the fact that 50 percent of the Type 2 diabetes had been recognized to have occurred in children.  Due to the fact that diabetes can be closely associated with the causes of the obesity, the relationship of the two issues can be considered to exist in a very evident manner.  The said view if even affirmed by the fact that in the period prior to development of diabetes, many severely obese children exhibited glucose intolerance and insulin resistance (Ebbeling et al 2002).

Basically, the presented notions are considered to be important events in the present case study of the prevalence of obesity on children in the present era.  Cases then can develop in to more serious conditions in the future society.

2. The mechanisms of obesity-associated morbidities

The mechanisms in children can be considered important on the basis of the fact that, the possible causes of the disease and other related issues can be considered.  Also a clearer view can be achieved if the mechanisms and the possible scenarios that are related to acquiring the disease are considered and presented.

Basically the main concern in terms of the effects of obesity is related to the consequences that can be immediate or that can occur in the later part of life.  The said concerns can be related to the risk factors that are related to that during adulthood and even through the course of childhood.  Based on the study presented by Daniels the children cannot be considered safe through the course of childhood.  This can be attributed to the fact that the ailments that are related obesity can even affect the health condition of the child during childhood (2006).  Children do not have to wait for adulthood to experience health problems. Discharge records show that more and more children are developing obesity-associated diseases that had hitherto been exclusive to adults.

In a study regarding Australian children, about a quarter of the children were obese.  According to Batch and Baur (2005), one of the morbidities associated with childhood obesity is paediatric non-alcoholic steatohepatitis (NASH), as evidenced by liver biopsies from children with the disease.

The said morbidities are some of the conditions and ailments that can affect the children associated to obesity.  The said ailments can also be related to the health risks that are connected to the disease.

3. Health risks in relation to obesity

There are different health risks that can be attributed to the condition of obesity.  For children, the risk is not limited to contacting during the adult stage.  Even during the stage of childhood towards teenage years, the said conditions and health risks to certain diseases can be contacted.  Basically there are different reasons that can be considered on the basis of the high risk conditions of children which are obese.  Children who are persistently overweight carry over these mechanisms at work to adulthood, the risks of developing various obesity-triggered diseases increases (Gidding et al 1996)

In children, the health risks include the hardening of the arteries, high blood pressure, asthma and left ventricular hypertrophy.  These risks can be related to the reason for which obese people and even children are very prone to heart failures.  Other health risks are non-alcoholic liver disease, increased triglyceride and decreased HDL-cholesterol concentrations, diabetes mellitus, sleep apnoea and gastroesophageal reflux.  Such risks can also be related to NIDDM.

The link between obesity and development of non–insulin-dependent diabetes mellitus and cardiovascular disease as well as increased left ventricular mass, dyslipidemia and high blood pressure has been definitively established. It is also suggested that obesity has an effect on other systems of the body including the skeletal, pulmonary, immunologic and endocrinologic (Gidding et al, 1996).

The association between obesity and diabetes mellitus is based on the mechanism of higher insulin levels and insulin resistance due to high body fat percentages that leads to the development of type 2 diabetes mellitus.  Moreover, increased levels of insulin in the body results in increases in renal sodium levels, norepinephrine and other hormones, and water retention, which in turn increases the risk of cardiovascular disease, can be considered as included in the complicated health risks that can be associated with obesity.

It can be a common notion that obesity is a health abnormality.  This can be attributed to the fact that it can lead the patient to be very susceptible to all the serious conditions that are in relation to the fact of being overweight and other matters in excess in the body of the obese children.

Due to the presented fact that children are not safe from life threatening diseases and conditions even during the young age, the life spans of children that are obese can also be considered as comparatively shorter than normal children.  This can be attributed to the fact that the conditions that are related can be considered potentially fatal.  Due to the said reason, it is important to be able to give proper attention to the conditions of the said children.

Aside from the aforementioned risks and diseases, there are other conditions that are due to the fact that a child is obese.  There are physiological effects that can result to abnormalities such as skin problems, hypoventilation, premature onset of puberty, and orthopaedic irregularities. The overweight or obese adolescent also increases the risks of developing gout, arthritis and colorectal cancer (Gidding et al 1996).

Obesity occurs when the body takes in more energy than it can expend.  The energy which can be equated to fat and the body’s propensity for storing excess energy (fat) is attributed to several factors interacting in complex ways.  The common idea is that it is caused by the intake of excessive amounts or high-fat, high-energy foods and beverages, whether processed or not. Others perceive that being fat means being prosperous, hence high socio-economic status on the part of the obese person.

1. Prevalence of childhood obesity

The prevalence of childhood obesity can be considered an important issue.  Through the determination of the number of children that are affected by the obesity, the real source of the problem and the continuous increase in the number of affected children can be determined.

In the US, particularly, 32% of American children are considered overweight, and 15% are obese (BMI >30), no distinction based on gender.  Projections based on existing conditions put the number of obese adults to reach 50% by 2025, and children are not likely to be far behind (Macdiarmid 2002).

“Many countries have experienced a startling increase in obesity rates over the last 10-20 years (Figure 2). Over the past decade levels have increased on average between 10-40% (Seidell & Flegal 1997).”  “In England the prevalence of obesity has doubled since 1980. Based on current trends, it is predicted that the levels of obesity will continue to rise unless action is taken now. The WHO recently stated the growth in the number of severely overweight adults is expected to be double that of underweight during 1995-2025 (WHO 1998).”  “Crude projections, from extrapolating existing data, suggest that by the year 2025 levels of obesity could be as high as 45-50% in the USA, between 30-40% in Australia, England and Mauritius and over 20% in Brazil.”

The Pro Children Cross-Sectional Survey was conducted in Austria, Norway, Belgium, Denmark, Spain, The Netherlands, Portugal, Iceland, and Sweden to assess the prevalence of obesity, overweight, underweight and stunting among 11 year olds across countries.

The countries ranked according to obesity prevalence were The Netherlands and Denmark (1.1%) to Portugal (10.7%).  Portugal and Spain were found to have the highest prevalence of obesity and overweight, which also had the highest prevalence of stunted children.  The study emphasized the importance of including height in comparison studies across countries, rather than relying solely on BMI (Yngvel et al 2007)

Obesity has become a problem for developing countries as well as developed countries. It ranges from as much as 75% for urban Samoan adults to as less than 5% in rural China and some African populations.

In countries with widely divergent ethnicities such as the US, the variance in obesity levels may be quite large. Nevertheless, the World Health Organization predicts that by 2025, half of the US adult population will be obese, as much as 40% in Australia, England and Mauritius, with Brazil possibly at 20% (Macdiarmid 2002)

Papadimitriou et al (2006) considered the prevalence of obesity in Greek schoolchildren in Northeast Attica between the ages of 6 and 11 years old.  The authors found that obesity prevailed in 12.3% for boys and 9.9% for girls. Immigrant children in the same area exhibited a lower increase at 7.9% for boys and 8.7% for girls.  The authors stated that the prevalence is comparable with children of other Mediterranean countries such as Italy and Spain and that in general children in the southern part of Europe are heavier than those in North Europe.  In comparison with a previous study by the authors in 1994, obesity increased by 2.9% for boys and 1.6% for girls.

A cross-sectional study of children between 2 to 6 years old in Italy showed that 32% were obese or overweight, and those who lived in the south having a higher prevalence than in the north.  The figures are closely aligned to findings for the US (Maffeis et al 2006)

Children in Scandinavian countries appear to have a lower, albeit still increasing, prevalence of obesity as compared with children in Mediterranean countries.  In the Middle East and Eastern European countries, the rising rates of childhood obesity are high, with Iran exhibiting the highest prevalence according to a 1998 WHO report on cardiovascular disease.

In Saudi Arabia, more than 20% of children between the age of 6 and 18 years old are obese, and proportionately more girls suffer from the disease than boys (Dehghan et al 2005)

Contrary to the general trend, however, is a study of 334 children with a mean age of 5.66 years in Aberdeen (Scotland) that shows a significant decline in obesity prevalence from figures in 1997 and 2004. It is suggested that this decline may be due to the influence of raising parental awareness of the problem and the encouragement of healthy eating and physical activities (Mitchell et al 2007).

Based on the result of the determination of the prevalence of obesity among children, it can be considered that due to varying factors, the percentages of the people that are obese are generally increasing.  On the other hand, the countries that have shown to lower the prevalence of obesity are needed to be studied to be able to achieve the techniques and methods that can be used to be able to have a lower number of occurrence in the future.

1. Obesity in Adults

The problem of obesity can be considered to have covered different age groups.  For that matter due to the fact that it can be considered as less common in children, the cases obesity can be considered to be more prevalent in older age groups.

As any other health condition, it can be considered that the children have higher resistance to different types of diseases as compared to adult.  Thus, in the case of obesity wherein the children are also highly affected, the adults can be considered of more danger.

1. The State of Adult Obesity in the Present Era

The cases of .obesity can be considered as a serious illness in adults on the basis of the fact that their body are more sensitive and susceptible to life threatening scenarios.

The state of obesity can be considered by the amount of knowledge that the public have on the issue.  On the basis of the definition that is commonly presented, the terms “overweight” and “obesity” are related and are basically determined by the standands set by the International Obesity Task Force (IOTF) (Papadimitriou et al, 2006).  Presently, the said non-government organisation based in London collaborated closely with the World Health Organization as well as other health organizations to be able to develop programmes to help prevent and effectively treat obesity (Macdiarmid 2002)

In addition, the said programs are targeted to the accumulation of in depth and greater knowledge that are related to the condition of obesity.  The urgency of the said actions can be considered essential on the basis of the fact that the prevalence of the people that are becoming obese are continuously increasing.  Also, if inadequate information to counteract and find solutions to the problem are achieved, the future generation can have irreversible cases of obesity which can have less attention on the basis of the number of other illnesses that are needed to be given focus.

In a report for the IOTF, in excess of 300 million people are considered obese worldwide.  The Body Mass Index (BMI) measures body fat and obesity is on average having a BMI of 30 kg/m2 or more for adults.  The said measurement can be considered as an important factor in the determination of obesity on the basis of the fact that it measures the body fat.

Determination of Obesity

1. Measurement by the BMI

The Body Mass Index (BMI) was first introduced by Belgian scientist Adolphe Quetelet early in the 19^th century as part of his work on population statistics, and was originally called the Quetelet Index.  BMI is calculated by dividing weight (in kilograms) by height (in meters) squared, and expressed as kg/m².

1. Adult Obesity BMI Range

According to the WHO, the normal BMI range for adults is 18.5 to 24.9, while a BMI of less than 18.5 is considered below the normal weight (underweight).  Adults in the BMI range of 25 to 29.9 are considered pre-obese while those with BMI values over 30 are considered obese (International Obesity Task Force 2005).

More importantly, however is the presence of excess fat on particular areas of the body.  Health risks are mostly associated with an excess of abdominal fat or central obesity which is related to higher risk for hypertension, heart disease and non-insulin dependent diabetes mellitus (NIDDM), especially for populations with relatively low BMI but high abdominal fat (Macdiarmid 2002).

2. Children Obesity BMI Range

Recommendations by the CDC (2002) for the screening, assessment and management of obesity focused on the correct identification of at-risk populations. Children and adolescents are considered obese (or overweight, which is considered a more politically correct term) if their BMI is between the 85^th and 95^th percentiles on the CDC growth charts.

While the WHO had established international obesity cut off points for adults, such standards have not been established for children and adolescents. Cole et al (2000) developed a table of cut off points to define obesity for male and female children between the ages of 2 to 18 based on growth studies from the Netherlands, Brazil, Great Britain, Singapore, Hong Kong, and the United States (refer to Table 1).

Table 1.  The BMI Values Covering Obesity in Children (2-18 yrs old).

                                                                  BMI

                                          25kg/m²                                30kg/m²

Age (yrs)                        M                F                          M                F

2                                    18.41          18.02                   20.09          19.81

2.5                                 18.13          17.76                   19.80          19.55

3                                    17.89          17.56                   19.57          19.36

3.5                                 17.69          17.40                   19.39          19.23

4                                    17.55          17.28                   19.29          19.15

4.5                                 17.47          17.19                   19.26          19.12

5                                    17.42          17.15                   19.30          19.17

5.5                                 17.45          17.20                   19.47          19.34

6                                    17.55          17.34                   19.78          19.65

6.5                                 17.71          17.53                   20.23          20.08

7                                    17.92          17.75                   20.63          20.51

7.5                                 18.16          18.03                   21.09          21.01

8                                    18.44          18.35                   21.60          21.57

8.5                                 18.76          18.69                   22.17          22.18

9                                    19.10          19.07                   22.77          22.81

9.5                                 19.46          1945                    23.39          23.46

10                                  19.84          19.86                   24.00          24.11

10.5                               20.20          20.29                   24.57          24.77

11                                  20.55          20.74                   25.10          25.42

11.5                               20.89          21.20                   25.58          26.05

12                                  21.22          21.68                   26.02          26.67

12.5                               21.56          22.14                   26.43          27.24

13                                  21.91          22.58                   26.84          27.76

13.5                               22.27          22.98                   27.25          28.20

14                                  22.62          23.34                   27.63          28.57

14.5                               22.96          23.66                   27.98          28.87

15                                  23.29          23.94                   28.30          29.11

15.5                               23.60          24.17                   28.60          29.29

16                                  23.90          24.37                   28.88          29.43

16.5                               24.19          24.54                   29.14          29.56

17                                  24.46          24.70                   29.41          29.69

17.5                               24.73          24.85                   29.70          29.84

18                                  25               25                        30               30

 (Source: http://www.bmj.com/cgi/reprint/320/7244/1240)

Previous to the standards imposed by the IOTF, there were various benchmarks for adults that prevailed in different countries, and no consensus on what the cut-off was for childhood obesity.  A 1992 ratios study by Williams et al established that a body fat ratio of 25% classifies a child as overweight for males and 30% for females.  A range of 85^th to 95^th percentile BMI is considered by the Centre for Disease Control and Prevention as at-risk for obesity while in Europe researchers considers the 95^th percentile as the threshold for childhood obesity (Dehghan et al, 2005)

1. Other Methods of Determining Obesity

The methods for measuring body fat percentages vary as well, although consensus is not so crucial in terms of discovering trends. These include research techniques such as densitometry or weighing under water, magnetic resonance imaging (MRI) and bioelectrical impedance analysis (BIA) using multiple frequencies. Of these three, BIA is most widely used for studies involving large populations.

In clinical studies, aside from BMI, methods include measuring the waist circumference and skin fold thickness to establish the risk of obesity. For childhood obesity in particular, the BMI method has been found to be less accurate than direct measurement of body fat such as waist circumference because BMI does not distinguish between fat, muscle and bone, which may be of significance for rapidly growing children of different ethnicities. (Dehghan et al 2005)

Causes of obesity

Trends in obesity prevalence in the US were fairly stable throughout the 1970s but in the period between 1988 and 1994 the rates rose sharply, doubling for children and overall doubling across age categories. This spurred a flurry of studies that aimed to understand this trend.

The resulting data showed that it was during this period of considerable change in the environment of children, including the easy availability soft drinks and convenience foods, the rise in the number of two-income or single-parent households and increase in crime incidence that limited the advisability of outside activities for children.  This was also the period when cable television came into being; computers began to invade homes in the form of games, and later the Internet encouraged more children to spend more indoors and more time sitting down (Anderson and Butcher 2006).

It has also become apparent in these studies that there is no one factor that could be pinpointed as the definitive cause for obesity; in fact, none of the factors believed to cause obesity has been proven without doubt to have a causal relationship with the disorder.  This appears to indicate that obesity is a disease that occurs when conditions that favour its development work in conjunction.

Three to 7-year old Pacific children in New Zealand were surveyed for obesity prevalence considering lean tissue mass, fat mass, height, weight and body circumferences. Results show that up to 49% of the population studied were obese.  Non-dietary factors such as television viewing and physical activity exhibited no association with body fat percentage (Gordon et al 2003)

Because of the global nature of the disease, a consensus from 65 health professionals and physicians from nine countries was solicited to discover the extent of the problem and possible solutions for childhood obesity.  The discussion during the three-day meet in Israel brought about certain facts, including the possible aetiology of childhood obesity (Speiser et al 2005)

1. Genetics

The role of genes to promote obesity is a permissive one, encouraging the interaction with environmental factors to bring about the condition. The initial genes to be associated with obesity are the leptin-melanocortin genetic pathways are, supported by findings of severe and early-onset obesity in subjects with the identified phenotype. These genes are believed to have an important role in regulating body weight.

In recent studies, 430 other genetic markers have been linked to obesity. However, only about 5% of cases of obesity can be attributed solely to genetic predisposition, although as much as 50% of childhood obesity may be triggered by a tendency to store excess fat. (Speiser et al 2005)

The significance of genetic factors as a factor for obesity is strongly indicated in several studies involving families and twins, such as those by Guo et al (1994), Gidding (1995) and Stunkard et al (1986). These studies indicate that the predisposition for developing body fat is at as high as 75%, meaning that if one or both parents are obese or overweight, there is a 75% chance that the child will also be obese or overweight. The genetic factors that seem indicated in genetic predisposition to obesity are resting metabolic rate, basal rate of lipolysis, eating behaviour and metabolic resistance to changes in food intake. (Gidding et al 1996)

Anderson and Butcher (2002) cite twin studies where identical twins that were raised in different environments had a close BMI correlation, indicating that hereditary factors influence susceptibility for weight gain.

Obesity has been linked to age.  The said connection can be considered related to the genetic reasons for being obese.  The increase in body weight as a person gets older is considered natural as the body’s metabolism slows down, peaking at age 50 for adults in developed countries and 40 in developing countries (Macdiarmid 2002)

1. Parental influence

Parents have a considerable influence on the eating habits of their children, most notably food preferences, and the social context in which food is introduced.  This will influence food selection when outside the home in the future (U.S. Department of Health & Human Services).

Low birth weight due to unhealthy maternal behaviour and high birth weight due gestational diabetes mellitus are associated with future obesity.  During infancy, breastfeeding for the first trimester of the baby’s life is thought to have a positive influence in regulating weight gain in early childhood.  It is also believed that delaying the introduction of solid food and sweetened liquids would be advisable (Speiser et al 2005).

1. Ethnicity

Whitaker et al (2006) made a cross-sectional study of 2,452 children from 20 large US cities from 2001 to 2003 to discover the impact of ethnicity on the incidence of obesity.  The population was divided into white, non-Hispanic (19.3%), black, non-Hispanic (52.2%), Hispanic-any race (25.4%) and other race, non-Hispanic (3.1%). The data was analysed in terms of maternal education, food security status and household income.

Results showed that obesity was more prevalent among Hispanics compared to whites, but not among blacks, and did not statistically alter when adjusted for maternal education, food security status and household income. In other words, socio-economic status has no significant influence over prevalence of obesity when controlled by race.

The National Health and Nutrition Examination Survey (NHANES) of 1999-2002 found that there is a disproportionate number of African American and Hispanic-American adolescents who are overweight compared to non-Hispanic white adolescents (U.S. Department of Health & Human Services).

In a three-year study of 4,399 affluent Indian students from ages 4 to 17, results showed that 6.4% were obese while 22% were overweight, more boys tending to be overweight than girls.  Most of the overweight subjects were to be found in the middle of the age range, tending to taper as the children grew older, most probably due to reduced caloric intake due to aesthetic preferences.  In considering the relation of birth weight, subjects with high birth weight (more than 3 kg.) were more likely to have high BMI. (Sharma 2006).

Data from Coronary Artery Risk Development in Young Adults (CARDIA) and the Bogalusa Heart Study show that among US populations, Hispanics and Native Americans have the highest relative rates of prevalence for obesity and is less common in the Southern and Western US than the Midwestern and Northeastern parts of the country (Gidding et al 1996).

1. Gender

Gender is another factor associated with obesity where patterns show that men have a tendency to gain more weight than women (Macdiarmid 2002).  The role of gender in obesity is on its influence on the socio-economic status of the person.

In studies on the US adult population, a woman of low socio-economic status is twice more likely to be obese than a man in the same situation while the opposite is true for people of high socio-economic status.  Within the same gender, however, a man of means is more likely to be obese than a poor man.  The American Obesity Association reports that 34% of adult women between 20 and 74 years old are obese with 6.3% considered severely obese while for men, 28% and 3.1% respectively is true (Speiser et al 2005).

1. Psychological factors

The psychological effect of obesity on children seems well established, but whether there is a cause-and-effect relationship remains unresolved.  Children as young as five years old perceive fat people as lazy, socially isolated, unintelligent and unhealthy, whether they themselves are obese or not.  Low self-esteem occurs more in females than in males.

Among the severely obese teenagers, almost half exhibit moderate to severe depression, one-third experience high anxiety and tend to be socially inept. They are more likely than non-obese peers to develop unhealthy lifestyles and behaviour and suffer from psychosocial distress.  Girls are more likely to commit suicide than their trimmer counterparts (Speiser et al 2005)

1. Food choice

There has yet to be a definitive study that obesity is caused by the diet or eating patterns. A study by the USDA Economic Research Service that surveyed 3,064 children over a three-year period found only a weak link between consumption of low-fat, nutrient-dense food (i.e. vegetables) and body weight (U.S. Department of Health & Human Services)

A surprising finding by a 2001 study by Carruth and Skinner as well as a 2003 longitudinal study by Skinner et al on the role of calcium in the body fat of children is that increasing dairy intake of children to two servings a day would lessen the risk of childhood obesity by 70%, and reduce the risk of developing diabetes in adulthood by 21% according to another study by Pereira et al (2002) (Dehghan et al 2005).

In considering the impact of eating habits on obesity, it was found that obese adolescents who skipped breakfast in Wales where twice as many as those who were of normal weight (Mathieson and Koller 2006).  While the lack of physical activity rather than caloric intake is pinpointed as the more significant factor in obesity, it has been suggested that binge eating in childhood can be carried over to adulthood.  Up to 40% of severely obese adults are binge eaters.  They exhibit lower self-esteem and are more likely to be depressed and anxious than obese non-binge eaters (Speiser et al, 2005).

Food has become much cheaper as industrialization and efficient management of raw products has made it more available in larger quantities and varieties.  Rather than a mere means of subsistence, the consumption of rich, not necessarily nutritious, food has become a status symbol.

For children, fast food has become a staple, made available in school canteens and even at home when a two-income family finds little time for a home-cooked meal.  Frequent consumption over the long-term of these energy-rich, nutrition-poor meals that require considerable physical activity to burn off probably have a cumulative effect on children.

It must be noted, however, that the mere increase in calorie and fat intake explains the increasing prevalence of childhood obesity from the 1970s to the 1990s. Studies for these periods found that overall energy intake of obese and lean children in the same population were approximately the same, and in the case of the US fat intake had actually fallen (Dehghan et al 2005)

The link between advertising and food preference of children is strongly indicated by several studies, including a literature review by The Kaiser Family Foundation as well as that conducted by the University of Strathclyde in the UK under the supervision of Gerald Hastings (U.S. Department of Health & Human Services)

Ludvigsen and Sharma (2004) interviewed students in England, Scotland and Wales to investigate their food preferences as part of the policy making process. The interviews showed that peer pressure had a strong influence on children’s food preferences and they tend to choose the same kinds of food their friends choose, and teachers have little influence.  Fast food is considered tasty and desirable, and adults find it natural for children to prefer these kinds of food.  Parents also exercise very little control over what their children choose to eat at school.

1. Physical activity

There is a strong indication that physical activity, rather than diet, has a significant influence on the prevalence of childhood obesity.  It is estimated that 25% of a child’s waking hours in the US are spent in front of the television and computer.

Swinburn and associates coined the term “obesogenicity” in a 1999 article published in Preventive Medicine and described the physical, socio-cultural, economic and political aspects of the environment that encourages obesity (Batch and Baur, 2005).  Data from the Department of Education’s Early Childhood Longitudinal Survey show that girls in the first grade who are at-risk for obesity found that an additional hour weekly of physical education resulted in a 1.8% drop in the BMI (U.S. Department of Health & Human Services).

Outdoor activities for urban children outside of school are limited by considerations of safety and security due to the prevalence of crime and busy traffic.  Installation of bicycle walks and footpaths, enabling travel on a bicycle or on foot to school and back would increase physical activity considerably (U.S. Department of Health & Human Services).

Dehghan et al (2005) considers that in terms of contributing factors, the lack of physical activity is of major importance in explaining the increasing rate of weight gain among children, with chronic, prolonged television and computer use chief among the sedentary habits that have become the norm.  Participation in sports and outdoor activities has also been in steady decline, the former the choice of children who have become enamoured of more sophisticated and passive pastimes, and the latter as a result of parental convenience and safety issues.

HBSC 2001/2002 data show that sedentary habits increase the risk of obesity in Canadian and Welsh adolescents.  Television viewing of more than four hours a day was found to have a significant association with the prevalence of obesity in Norwegian adolescents.  The study also established that Greek adolescents who watched television were more likely to eat snacks and sugared beverages and less likely to consume fruits and vegetables (Mathieson and Koller 2006).

Studies indicate that African Americans and Hispanics use entertainment media more heavily than non-Hispanic whites and are thus more likely to be influenced by marketing promotion of unhealthy food and beverage products. (Kumanyika and Grier 2006).

1. Social and economic factors

One of the factors being considered for the aetiology of obesity is socio-economic status.  In a report by Mathieson and Koller (2006) to The Regional Office for Europe of the WHO, the authors emphasized the need for policies that would go beyond individuals and address sectors of society that have a direct influence on the obesogenic environment of today’s children and adolescents.

These include initiatives in education, legislation, city and regional planning, agriculture, transport, social protection and welfare and sport and culture for member nations. It is sustained in the report that childhood obesity is largely a product of prevailing social and economic conditions that can only be effectively addressed at the national level. One of the suggested routes for change is the adoption of the European Charter on Counteracting Obesity.

A cross-sectional survey of 498 children ages 9 to 12 years from a low-income, multi-ethnic urban environment assessed obesity prevalence considering height, weight, physical activity, lifestyle, diet and other demographic factors.

It was found that 39.4% of the population were overweight.  This prevalence is higher than for children from families of higher income.  Moreover, children of single parents and Canadian-born mothers were more likely to have higher dietary fat intake. Higher intakes of calcium, zinc, iron and energy were observed for more active children. (Johnson-Down 1997)

There is an interesting socio-economic pattern in the prevalence of obesity.  Developed countries show higher levels of obesity in the lower socio-economic classes while in developing countries the opposite is true, which may be accounted for by the move from the rural to urban lifestyle (Macdiarmid 2002).

In the 2001-2002 collaborative cross-national study Health Behaviour in School aged Children (HBSC) with the WHO, obesity in adolescents in developed countries is inversely related to socio-economic status.  In Norway, children in the lower socio-economic levels are twice as likely to be obese. The consumption for fruit, for instance, increased as socio-economic status increased. In northern, western and southern European countries consumption of soft drinks decreased with the increase in socio-economic status (Mathieson and Koller 2006).

An interesting study by Christakis and Fowler (2007) considered the influence of social networks on the spread of obesity.  More than 12,000 people in the Framingham Heart Study were assessed for weight gain between 1971 and 2003.  Results showed that subjects with an obese friend exhibited an increased risk of becoming obese (57%) while a spouse has a 37% of becoming obese if the other spouse is obese, and a similar pattern among siblings (40%) was observed.  The apparent influence did not extend to neighbours.  This appears to indicate a biologic and behavioural aspect to the spread of obesity.

1. Attitudes and Biases

The attitude towards children who are obese is generally negative.  Children rank fat people as less likeable than children with facial disfigurement or other handicaps.  The stereotype is that fat people are lazy, unattractive and unpopular and choose to be obese or overweight.  This lack of peer acceptance is believed to have a significant influence on how overweight or obese children perceive themselves, which in turn influences the belief that while difficult, controlling weight gain is possible with proper support (Anesbury and Tiggemann 2000).

The social stigma of being “fat” is associated with significant emotional and psychological stress for sufferers.  Even health care professionals tend to share these negative attitudes with the general public that affects the quality of care and treatment of people who are obese and overweight (Macdiarmid 2002).

While it has been acknowledged that childhood obesity is a growing problem in both developed and developing countries, many health professionals, parents and families fail to accord the issue due attention because it is not perceived as clinically important (Reilly 2006).  Adolescents who were obese or overweight were more likely to have recurrent, multiple confirmed and borderline psychological ill health (Mathieson and Koller 2006).

A literature review by Brownell and Puhl (2003) on studies focusing on the bias of health professionals against obese people showed that there are ample implicit and explicit anti-fat attitudes shared by all aspects of the health care community even among those who specialize in obesity treatment.  Health workers are more likely to ascribe negative symptoms to patients who are obese and be more severe in assessing their psychological functioning.

Many health care givers perceive overweight and obese patients as non-compliant and are easily frustrated by the apparent lack of progress and motivation during treatment.  Physicians are less likely to discuss weight management strategies and other interventions for overweight or obese patients and exhibit a general reluctance to treat the disease.

Even among physicians willing to undertake treatment of obese patients failed to maximize intervention or treatment practices that encourage lifestyle change.  These negative and underlying biases of health professionals may account for the reluctance of obese patients to seek medical help.

1. Other factors

One of the more rare causes of obesity is an endocrinological disorder such as thyroid hormone deficiency, growth hormone deficiency, and cortisol excess, although these are rare instances.  These are usually accompanied by slow growth of the child (Speiser et al 2005).

Some medications may also have an effect of developing obesity in a child.  These include chronic glucocorticoid treatment in high doses, as well as valproate, cyproheptadine, progestins and some antipsychotic medications such as clozapine and olanzapine.  The latter two drugs also increase the risk for developing diabetes mellitus and hyperlipidemia (Speiser et al 2005).

Management of Obesity

         The key to managing childhood obesity is in preventing the occurrence in the first place. Prevention has become the key strategy by health researchers worldwide for controlling the effects of obesity.  Since obese and overweight children tend to grow into overweight and obese adults, it would seem reasonable that intervention during childhood would significantly affect health outcomes in childhood (Dehghan et al 2005).

Longitudinal studies of children in weight reduction programs show that the tendency is to return to within 90% of the child’s original weight.  If the child is within 10% of the ideal weight base on age and height, then weight reduction or gain should be within reasonable grasp.  If the child is already more than 30% over the ideal weight, testing for associated diseases should be undertaken regularly to accurately assess the health risk.  Tests include assessment of lipoprotein and glucose levels as well as cardiovascular values (Gidding et al 1996).

Some strategies focusing on children for lifestyle and behaviour change are implemented in schools and after-school care institutions (Dehghan et al 2005).

Because most of the concerned population in childhood obesity are still growing, the main goal of intervention and treatment is maintenance of the current weight rather than loss as it is expected the child will eventually attain growth that will catch up with the body weight.

What is most important in these interventions is the inculcation of lifestyle changes that can be reasonably sustained, such as dietary modifications, physical exercise or activity and elimination of excessive sedentary behaviour.  In most cases, small weight losses over a protracted period is preferable to sudden weight loss that will surely rebound once the body adjusts to new demands on its reserves or when the intervention is ceased, or both (Reilly 2006).

Successful school-based interventions aimed at promoting healthy behaviour and attitudes to reduce childhood obesity include a program targeting 6^th to 8^th grade students in the US that uses the curriculum to promote physical activity, decrease sedentary behaviour such as television watching and influence eating habits.  Of special interest is the significant impact of reducing television viewing by half-an-hour every day.  But aside from restricting the time in front of the television, countries such as Sweden bans the advertising of sodas, fast food and other energy-rich foods aimed at children 12 years old and below.  Australia, Greece, Ireland, Norway and Denmark are among those who have controlled the content of commercial advertising aimed at their children (Dehghan et al, 2005).

School-based interventions are being assessed for effectiveness because it is a natural and convenient platform for behaviour change.  Randomised control trials (RCTs) are objective assessment tools that will determine if a particular strategy is having the desired effect.

One program based in Boston schools called Planet Health intervention was assessed over a two-year period using a large population and was found to be successful with girls, not boys.  The results suggested that the success of the program was based on the reduction of television watching for the subjects under study (Reilly 2006).

In Singapore, the commitment of the city-state is embodied in the “Fit and Trim” programme which are school-based as well, targeting the primary to the junior college levels.  Culture-based nutrition programs for healthy eating as well as physical exercise and activities are incorporated into the curriculum (Macdiarmid 2002).

As children are still physically growing, any intervention should be structured to make provisions for appropriate weight gain in conjunction with height increase.  Vigilance would be on excessive caloric intake and adherence to regular physical activity.  The involvement of the family would be crucial for any intervention for children. Weight reduction intervention is not recommended for infants (Gidding et al 1996).

Taxes for non-essential foods with low nutritional content is one way in which countries such as Canada and the US have been discouraging the purchase of products such as sodas, snack foods and candies.  Food labelling is another one, in which the concerned government agencies identify products that are considered healthy to help consumers make the right choice.  One such initiative is the ‘Pick the Tick’ program of the National Heart Foundations in Australia and New Zealand (Dehghan et al 2005).

One promising strategy that focuses on the physical environment of the children in terms of opportunities for physical activities in public spaces (parks, recreation centres, basketball courts, etc.) is unfortunately usually limited by the physical availability and financial feasibility of such development (Dehghan et al 2005).  Real estate in the urban areas, where such facilities are most needed, are often utilized for much needed income-generating activities such as commercial buildings, residential condominiums or parking lots.

However, with a little ingenuity and determination, these obstacles can be overcome.  The prevention of obesity among the low income and ethnic minority population need not entail major policy changes or expense, but can manage existing policies more effectively to provide the social services and physical structures needed for this purpose.  Examples include the State Child Health Insurance Program, existing nutrition programs and public parks (Kumanyika and Grier 2006).

In the UK, the government undertook initiatives to improve the food that are served to schoolchildren by ordering a review of the nutritional value of school meals as part of its Healthy living blue print.  National standards were also established for the overall health of children from pre-birth to adulthood (Ludvigsen and Sharma 2004) .

Also in the UK, “looked after” children and adolescents are children who are looked after by foster caregivers, residential or respite care facilities away from their own family.  Approximately 54,500 looked after children are considered at risk for poor nutrition and inadequate health care.  A program under the Caroline Walker Trust established health and nutrition guidelines with the help of experts for this population, and it is recommended that these become standards of care for looked after children and young people (Roberts et al 2007).

The role of the US government in improving the nutrition of schoolchildren is embodied in five programs funded by the federal government.  These are the School Breakfast and National School Lunch Program, the Child and Adult Care Food Program, the Summer Food Service Program, and the Special Supplemental Food Program for Women, Infants and Children (WIC) Program.  WIC is designed to help children at home.

These programs aim to ensure that children from low-income families get the best possible nutrition as determined by standards and guidelines established by the U.S. Department of Agriculture.  The role of these programs for preventing childhood obesity is based on ensuring that children have balanced, nutritionally sound meals at least twice a day (Parker 2005).

The US Department of Health further aims to develop intervention strategies using the Three Es model for lifestyle change.  The model makes use of interlapping strategies: encouragement (advertisements, leaflets, campaigns); empowerment (education, personal and community development, increase life skills, confidence); and environment (change in physical, social and cultural conditions) (Swanton and Frost 2007).

The belief that the drastic decrease in the consumption of certain foods and beverages and the equally drastic increase in physical activity will result in sustainable weight loss and physical well being has no basis in research.  This fact makes the message of shows like “The Biggest Loser” in the US so dangerously misleading.  The emphasis on rapid weight loss leads the viewers to believe that this kind of loss is healthy and sustainable, when in fact, weight loss of more than half a kilogram is not recommended.  Aside from the fact that subsequent weight gain is almost inevitable, the stress on the body is likely to lead to health problems later on.

Undergoing weight loss treatment is recommended only when the child has developed medical or psychological disorders associated with obesity such as hypertension, sleep apnoea, diabetes mellitus or psychosocial stress.  The condition of the child under therapy should be monitored by a qualified health professional because reducing caloric intake has links to risk for eating disorders, dysmenorrhoea, fatigue, syncope and headaches (Gidding et al 1996).

When conventional interventions fail, and the threat to the obese child’s health become severe, pharmacotherapy may be considered upon the advice and under the supervision of a sub-specialist.

This may involve the use of metabolic stimulants to increase energy expenditure, although side effects have made this route of questionable benefit.  The use of anorectic agents or appetite suppressants should also be considered with caution. The only such agent approved for obese adolescents of 16 years or older is sibutramine, a neuronal reuptake of serotonin, norepinephrine, and dopamine inhibitor.

Side effects include insomnia, depression and anxiety and the drug therapy should be complemented by exercise and diet.  It is not recommended that such treatment protocols be continued beyond two years.  Another type of pharmacological intervention is the use of drugs that limit the absorption of nutrients (orlistat) or reduce the production of insulin that stimulates the storage of fat (metformin) (Speiser et al 2005).

As a last resort, surgery may also be considered as intervention for severe cases of obesity with comorbidities.  The most common of these procedures are the Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding procedure.  However, potential complications include oesophageal dilatation, balloon rupture and infection for gastric banding.

About half of RYGB patients experience iron-deficiency anaemia, one-third suffer thiamine, folate or calcium deficiencies, about one-fifth develop cholecystitis and one-tenth have wound infections and dehiscence.  About 10% may suffer from obstruction in the small bowel, 12% from atelectasis and pneumonia and 10% from incisional hernia. Death may occur in up to 5% of cases (Speiser et al 2005).

Discussion

Obesity can be considered as one of the most important subject of concern in health care.  This can be attributed to the fact that the cases of obesity cover different age groups.  Thus, the prevalence can continuously increase due to multitude of factors and risk factors that are related to the onset of the disease.

It has become convention to treat obesity in children as a condition that they will eventually grow out of, and perhaps three decades ago this would have been true. Children in the 1970s and 1980s had far fewer and smaller processed foods, sugary soft drinks and advertising as well as far more physical activity and community participation than in the 1990s.

It is in fact a common notion that parents wanted children to be fat and even overweight which is superficial notion on the basis that fat children are tend to be healthier.  But in the present era wherein the composition of a person and child’s diet, the superficial appearance of children cannot be an indication of the real state they are in.

In a statement from the American Heart Association, atherosclerotic cardiovascular disease was identified as the top cause of death for adults in the Western population, of which the risk factors are developed in childhood.  Obesity is considered one of the major factors for the development of the disease, as well as for hyperinsulinemia and type 2 diabetes mellitus.

As a precursor to atherosclerotic cardiovascular disease, overweight and obese children who meet other criteria should undergo assessment to determine the need for intervention.  These other criteria include a family history of type 2 diabetes, membership in an ethnic minority and exhibition of early signs of insulin resistance (Steinberger and Daniels 2003).

While not all overweight children or adolescents who meet these criteria will unfailingly develop atherosclerotic cardiovascular disease, there are enough associated morbidities with obesity that would make it practical to opt for early intervention even if it is just participation in school lunch programs or patronage of community activity centres.

There is evidence that excessive sugar intake, larger portions and lack of physical activity are major contributors to obesity and high BMI.  However, approaches that employ aggressive calorie intake reduction and exercise have been ineffective largely because it cannot be sustained.  The tendency for people who lose significant weight over a short period of time is a rebound to the starting weight within a short time, resulting in frustration for both patient and the health care professional and a disinclination to persist in the intervention

Such factors can be attributed to lifestyle choices and the cultural environment, and strategies that target behaviour change in adults would have little effect on the increasing prevalence of obesity (Dehghan et al 2005).  This is one of the main reasons that research on interventions tends to focus on the child.

 In many cases, resistance to intervention begins with the obese child or adolescent because of the existing prejudice against people who are in their situation, an attitude that is unfortunately promulgated in media and the playground.  The support of parents and other family members will contribute greatly to the alleviation of embarrassment or awkwardness the child may feel and eliminate the belief that they are entirely to blame for their situation.  As it has been clearly set out in the preceding chapters, even longitudinal research studies have been unable to pinpoint the exact cause of childhood obesity.  The main thing for the obese child to realize is that the disease can be managed and hopefully eliminated in the long run.

The failure to adopt more intervention strategies for the treatment and prevention of childhood obesity is attributed to the lack of randomised control trials (RCTs) that serve as a basis for recommendation for large-scale deployment.  In order for the effective clinical management of childhood obesity, it is necessary that such RCTs should be carried out for all possible interventions (Reilly 2006).

Ebbeling et al (2006) states that barriers to more rigorous research and policy change that address the problem of childhood obesity are financially motivated.  Companies that profit from selling high calorie, nutritionally-poor processed foods to children spend large amounts of money to promote their products including striking deals with public schools in need of subsidies from private companies.

Such deals include contracts with soda companies allowing them to place vending machines on school grounds.  Fast food stalls also augment school incomes while at the same time budgetary constraints have entailed the reduction of physical activity programs.  Commercially-viable real estate have supplanted community-based activity centres that would encourage young people to engage in sports and other physical activities while health programs continue to be problematic for most urban communities.

Conclusion

From a global perspective, it seems clear that obesity is on the rise among adults as well as children. Because of the associated morbidities of the condition, the effective management of this rising prevalence is of particular interest to the global community.  The recent focus on childhood obesity is based on research findings that adult obesity may well have its roots in childhood.

Although many physicians still do not consider childhood obesity of clinical importance, international and government agencies are affecting policies that reflect their growing belief in the importance of limiting and perhaps eradicating childhood obesity by addressing the possible causes of the disease, although this is currently mostly limited to nutrition and some exercise programs.

While not definitive, studies indicate that a sedentary lifestyle and lack of physical activity rather than nutrition are the main contributory factors to the prevalence of childhood obesity across cultural, ethnic and socio-economic variables. Since these two factors are closely aligned with the family and the community, the best media for delivering interventions are schools, day care and community centres and the home. Private and government initiatives to this end would be well advised to structure their programmes for these methods of distribution.

The threat to the health of the overweight and obese child is very real, and has long-term effects on the community and the world. Having a balanced diet and an active lifestyle is beneficial for children in general, but in the interest of waging a war on obesity, policy makers and community leaders should start focusing on providing interventions that focus more on getting children up and about on a regular basis.

In general, the case of obesity can be considered to affect a significant part of the population.  For that matter, it is essential to be able to achieve adequate knowledge in relation to the said condition.  The awareness on the causes, methods of management and the health risks can be considered as ways to be able to fight the disease.

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