In the late 1980s and early 1990s, the adage “eating fat makes you fat” dominated marketing campaigns and drove the development of a multitude of “fat-free” food selections, ranging from everyday snacks to prepackaged meals. Coinciding with the sharply increasing obesity rates in the United States, the new dogma taught that our fast-food craze and diets heavily laced with saturated fats were taking their toll on our waistlines. This simple and seemingly logical thinking was scientifically unproven,
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and as rates of overweight and obesity in the United States continued to rise despite our low-fat diets, some argued that our excessive sugar and simple-carbohydrate consumption was responsible, while others simplified our health crisis down to a mathematical equation: calories consumed exceeded calories expended.1
Today, fad diets, cleanses, pharmaceuticals, probiotics, and lifestyle interventions are aimed at combating the societal, nutritional, technologic, metabolomic, and microbiomic contributors to the obesity epidemic.While the causes of obesity are undoubtedly multifactorial and remain to be clearly defined, it is undeniable that our children have been affected by this global health epidemic. The estimated percentage of children and adolescents in the United States affected by obesity has more than tripled since the 1970s, although rates are slowly beginning to stabilize and/or improve.
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, Centers for Disease Control and Prevention. Childhood Obesity Facts [online]. Available at: https://www.cdc.gov/healthyschools/obesity/facts.htm. Accessed August, 2018.
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Nearly 1 in 5 school-aged children and adolescents (aged 6–19 years) in the United States is considered obese. The number of overweight or obese infants and young children (aged 0–5 years) worldwide increased from 32 million in 1990 to 41 million in 2016. The majority of these children live in developing countries, where the obesity rates are >30% higher than in developed nations. According to the World Health Organization, “if current trends continue, the number of overweight or obese infants and young children globally will increase to 70 million by 2025.”The State of Obesity: Better Policies for a Healthier America [online]. Available at: https://stateofobesity.org/rates. Accessed August, 2018.
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World Health Organization, Commission on Ending Childhood Obesity. Facts and Figures on Childhood Obesity [online]. Available at: http://www.who.int/end-childhood-obesity/facts/en. Accessed August, 2018.
Diet recommendations, exercise guidelines, nutrition education, and family-lifestyle interventions remain the mainstays of obesity treatment in children.
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However, studies have shown that, similar to in adults, initial successes in weight loss and weight management in children are difficult to sustain in the long term.7
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These findings mandate that we strive to develop new strategies for treating and potentially preventing obesity to combat this epidemic and improve the generational health of our society. In this Themed Update in Clinical Therapeutics, we explore novel preventive strategies aimed at reducing childhood obesity through maternal interventions prior to conception, as well as modifications of lifelong risks of obesity through changes in the maternal diet during breastfeeding. We discuss the confounding effects of the rise in childhood obesity on the diagnosis and management of childhood diabetes, and we tackle the often-difficult decision of when and whether to perform bariatric surgery in adolescents.- Jones J
- Wyse R
- Finch M
- Lecathelinais C
- Wiggers J
- Marshall J
- Falkiner M
- Pond N
- Yoong SL
- Holis J
- Fielding A
- Dodds P
- Clinton-McHarg T
- Freund M
- McElduff P
- Gillham K
- Wolfenden L
Effectiveness of an intervention to facilitate the implementation of healthy eating and physical activity policies and practices in childcare services: a randomized controlled trial.
Implement Sci. 2015; 10: 147
Perhaps there is no better way to combat childhood obesity than to prevent it. And, while a pound of prevention is worth an ounce of cure, this task is far easier said than done. Genetic predisposition combined with environmental factors make the prevention of obesity, particularly in our youth, extraordinarily challenging. However, Barbour and Hernandez
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highlight exciting data regarding the potential causes of obesity in children born to mothers whose pregnancies were complicated by gestational diabetes. While it has long been believed that elevated maternal glucose levels during gestation are solely responsible for large for gestational age in infants, research now suggests that maternal lipid profiles may be as, if not more, predictive of neonatal outcomes. In their aptly titled commentary “Maternal Lipids and Fetal Overgrowth: Making Fat From Fat,” Barbour and Hernandez9
report that maternal triglyceride levels, in both the fasting and postprandial states, are predictors of adiposity in newborns, a risk factor for childhood obesity. As fetuses increase their own insulin response in the setting of maternal hyperglycemia, the additive effect of excess free fatty acids from the mother may result in increased fat storage and fat development in the newborn. Thus, lowering maternal lipid profiles, ideally prior to pregnancy, in addition to aiming for a euglycemic state throughout gestation, may “mitigate the intrauterine contribution toward childhood obesity and metabolic disease.”In a complementary article, Penfield-Cyr et al
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explored the Ω-6 to Ω-3 fatty acid ratio (Ω6:Ω3) in 440 pregnant women, 51% of whom were overweight or obese. As a marker of inflammation, higher Ω6:Ω3 fatty acid concentrations during gestation have been associated with greater prevalences of metabolic comorbidities and fetal complications. In this cohort analysis, the authors found that overweight and obese mothers with elevated Ω6:Ω3 fatty acid ratios were more likely to have adverse perinatal and neonatal outcomes. These findings support targeting maternal lipid profiles prior to conception in order to reduce the risks for complications and metabolic syndromes in infants and children.Dr. Maria Ramos-Roman's commentary
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extends the potential for developing modifiable perinatal treatment strategies to prevent childhood obesity through lactation. In “Breast Milk: A Postnatal Link Between Maternal Life Choices and the Prevention of Childhood Obesity,” Dr. Ramos-Roman discusses the important role that maternal hormones in breast milk play in the early programming of insulin resistance and/or vulnerability to metabolic disease.11
She stresses the importance of appropriate nutrition in mothers during breastfeeding in order to modify milk composition and affect subsequent weight and glucose tolerance in infants and children. There must be continued diligence in maintaining healthy diet and lifestyle choices throughout breastfeeding, rather than simply limiting these modifications throughout gestation. She writes, “The ideal intervention to prevent obesity in . . . offspring would address the amount and quality of maternal adipose tissue stored before pregnancy, the amount and composition of diet during lactation, and maternal glucose tolerance.” Combined, these 3 reports featured in our Youth and Children Topic Issue highlight an often-overlooked period in development, in which lifestyle and diet interventions in the mother may be the best means by which to limit obesity risks in the child.Although novel treatment strategies to prevent childhood obesity are emerging, treating obesity, particularly morbid or extreme obesity (body mass index percentile, >99.5%), in our youth remains a challenge. Concerns regarding bariatric surgery in adolescents have limited it as an accepted therapy in this population. Chenoguz and Chwals
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review the data surrounding parental, patient, caregiver, and ethics concerns associated with bypass surgery in our youth, including the risks for surgical complications, the adolescent consent process, and the long-term effects of surgical interventions to treat obesity. Ultimately they conclude that “early conversation about bariatric surgery with adolescents struggling with obesity will create a healthy environment for careful and thoughtful patient selection and remove the emotional barriers that cloud sound medical judgment.” The time to act is now.Completing our Youth and Children Topic Issue is the work of Agrawal and Gensure,
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who bring awareness on the inherent challenges that now exist in correctly diagnosing and treating types 1 and 2 diabetes mellitus in our overweight and obese children. Shared similarities in clinical presentation and phenotype have turned what once was a seemingly clear-cut diagnostic dichotomy between adult-onset (type 2) and childhood-onset (type 1) diabetes mellitus into a blurred line that many children cross early in their lifespans. Timely recognition of key clinical features will help to better define and appropriately treat these individuals.There is no denying that the challenges before us to reduce obesity rates and sustain lifelong healthy weights in our youth are significant. Since former US First Lady Michelle Obama began to tackle the childhood obesity epidemic at a national level in 2009, we have seen only mixed results. While childhood obesity among children between ages 2 and 5 years was reduced by 3.7% from 2010 to 2012, the rate increased by 2.1% in children aged 12 to 19 years during the same period, and the overall childhood obesity rate remained constant, at 16.9%, from 2008 through 2012.
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Although these statistics may seem daunting, with every challenge comes opportunity. As our authors contributing to this month's Topic Issue have shown, we can broaden our understanding of the causes of childhood obesity, expand beyond current-day therapeutic approaches of diet and lifestyle changes, develop and integrate treatment strategies aimed at preventing obesity, and thoughtfully provide existing, albeit controversial, treatment modalities to combat this epidemic. Confronting and tackling childhood obesity's a moral obligation and a mandate for all of us who care for children. As former US Surgeon General Dr. Richard Carmona stated, “If the childhood obesity epidemic remains unchecked, it will condemn many of our kids to shorter lives, as well as the emotional and financial burdens of poor health.”References
- How the ideology of low fat conquered America.J Hist Med Allied Sci. 2008; 63: 139-177
- PURE diet score recommends 7 foods, including dairy and meat.MedScape. 2018; ([online])
Centers for Disease Control and Prevention. Childhood Obesity Facts [online]. Available at: https://www.cdc.gov/healthyschools/obesity/facts.htm. Accessed August, 2018.
The State of Obesity: Better Policies for a Healthier America [online]. Available at: https://stateofobesity.org/rates. Accessed August, 2018.
World Health Organization, Commission on Ending Childhood Obesity. Facts and Figures on Childhood Obesity [online]. Available at: http://www.who.int/end-childhood-obesity/facts/en. Accessed August, 2018.
- Interventions for preventing obesity in children.Cochrane Database Syst Rev. 2011; 7 (CD001871)
- Effects of multidisciplinary interventions on weight loss and health outcomes in children and adolescents with morbid obesity.Obes Rev. 2018; 19: 931-946
- Effectiveness of an intervention to facilitate the implementation of healthy eating and physical activity policies and practices in childcare services: a randomized controlled trial.Implement Sci. 2015; 10: 147
- Maternal lipids and fetal overgrowth: making fat from fat.Clin Ther. 2018; 40: 1638-1647
- Maternal BMI, mid-pregnancy fatty acid concentrations and perinatal outcomes.Clin Ther. 2018; 40: 1659-1668
- Breast milk: A post-natal link between maternal life choices and prevention of childhood obesity.Clin Ther. 2018; 40: 1655-1658
- Bariatric surgery needs a seat at the children's table: Bridging the perception and reality of the role of bariatric surgery in the treatment of obesity in adolescents.Clin Ther. 2018; 40: 1648-1654
- A commentary on the impact of obesity on the diagnosis and management of pediatric diabetes types 1 and 2.Clin Ther. 2018; 40: 1631-1637
- This chart shows how hard it is to end childhood obesity.Time Health. 2015; ([online]) (Accessed August, 2018)
Article info
Publication history
Published online: September 19, 2018
Accepted:
August 31,
2018
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
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