More treatment options, less stigma needed for children with obesity

Despite childhood obesity and overweight being recognized as a public health crisis more than a decade ago, with intensive efforts devoted to addressing it, national survey data show increases in prevalence of overweight and obesity in every age category between 1999 and 2016.

One study published in Pediatrics highlighted that recent data demonstrated a higher prevalence of overweight and obesity — 41.5% — in adolescents aged 16 to 19 years, with 9.5% meeting the criteria for class 1 obesity.

Source: Lloyd Werk, MD, MPH

The study’s researchers also reported a major increase in severe obesity in children aged 2 to 5 years between 2013 and 2016, with a prevalence of overweight and obesity of 26% for that age group.

Sarah Armstrong, MD, from the departments of pediatrics, population health, community and family medicine at the Duke Clinical Research Institute and Duke University, and senior author of this study, told Infectious Diseases in Children that when comparing current rates of pediatric obesity with the rates observed almost 20 years ago, a need to increase prevention and treatment in children and adolescents was demonstrated.

“If you compare the prevalence of childhood and adolescent obesity to the rates we saw in a national 1999 survey, the prevalence has increased across the board in all genders, ages, and races and ethnic subgroups,” she said. “If you look cycle to cycle, there is sometimes evidence of a plateauing or even declines in certain subgroups; however, the overall big picture shows us that obesity rates are still continuing to increase overall.”

The growing epidemic at increasingly younger ages underscores the need for new approaches and treatment strategies.

Despite the high prevalence of obesity among American children and adolescents, a considerable stigma surrounds the condition. This stigma, which can contribute to further mental health-related concerns, including eating disorders and depression in those with obesity, is not limited to only social interactions outside the health care setting. When the stigma is reinforced by health care professionals, some patients with obesity may be more likely to avoid care, restricting the number of people who could improve their quality of life with treatment.

To determine what prevention and treatment strategies are currently available and in development for children and adolescents, and to discuss the importance of communication with patients and their families, Infectious Diseases in Children spoke with physicians and researchers at the forefront of caring for these patients.

Management of current cases

Certain health consequences may become more likely when a child or adolescent has obesity. Some short-term outcomes may develop, including high blood pressure and cholesterol, increased risk of type 2 diabetes, sleep apnea, musculoskeletal problems, including Blount’s disease, and gastrointestinal diseases, including fatty liver disease, gallstones and heartburn. Furthermore, the CDC notes that children and adolescents who have obesity are at an increased risk of anxiety and depression, low self-esteem and quality of life and are more likely to experience psychosocial detriments like bullying.

Obesity in children is likely to continue into adulthood, according to the CDC, setting the stage for a lifelong struggle with heart disease, type 2 diabetes and several forms of cancer among other adverse events.

Jennifer Woo Baidal, MD, MPH, director of pediatric weight management at New York-Presbyterian Morgan Stanley Children’s Hospital and assistant professor of pediatrics at Columbia University Vagelos College of Physicians and Surgeons, told Infectious Diseases in Children that although the adverse health outcomes of children with obesity are well-established, identifying those who may be at risk of developing the condition as a child and then treating them in an appropriate manner is more difficult.

“Obesity is a very complicated condition because there is an interplay between genetics, environment and lifestyle behaviors like diet and physical activity,” she said. “There are disparities among racial and ethnic minorities and low-income populations. Those disparities begin very early in life, and the reasons for them are multifactorial. Some risk factors during pregnancy and infancy — such as how much parents weigh before conception, how much weight the mother gains during pregnancy, whether she is exposed to tobacco and how quickly the infant gains weight — are modifiable at the individual level. However, others require environmental or population-level changes.”

When compared with adults who have obesity, children and adolescents have few treatment options available. In a clinical review published in JAMA by the U.S. Preventive Services Task Force, the organization suggests that the weight of patients aged 6 years or older with obesity can be improved using an intensive behavioral intervention, which includes at least 26 contact hours over 12 months. This form of behavioral intervention, according to the task force, has few associated risks.

Woo Baidal mentioned that some barriers exist to implementing intensive treatment strategies in a primary care setting.

“I think that prevention is always better [than treatment],” she said. “One of the challenges with prevention and treatment is payment methods. Not all insurers will pay primary care providers to do intensive interventions. There are not many facilities that can provide the more intensive contact hours that are proven to reduce weight and thus prevent the onset of severe obesity or complications of obesity.”

Those hours can include multifactorial treatment methods, such as family-centered care, education related to healthy eating and reading food labels, information about appropriate exercise, motivational interviewing to determine the goals of children and their families, and reducing contact with tempting foods and electronic screens.

Stephen Cook, MD, MPH, associate professor of pediatrics at the Golisano Children’s Hospital at the University of Rochester Medical Center, believes pediatricians should be aware of the psychological effects of these strategies on children and their families.

“Age is important [when considering treatment],” Cook told Infectious Diseases in Children. “Physicians should be aware of mental health consequences and psychosocial stress that may occur with an intervention and be available to identify and address these. If a family is trying to address a child’s obesity and trying to use an intervention but it is causing a lot of anxiety for the parent, child or family, you must be able to step back and be able to talk about what is going on. They need mental health intervention.”

Although intensive behavioral interventions are safe in children aged 6 years and younger, experiences in early life may contribute to the risk of obesity. Mary Jo Messito, MD, clinical associate professor of pediatrics at the New York University School of Medicine, says that children can be set up for developing obesity even as an infant. Because of this risk, she is running an intervention trial conducted out of New York University designed to support behaviors, such as increasing breastfeeding, fruit and vegetable intake and activity, and reducing sugary beverage intake and screen time, that parents can use to prevent obesity in their infants.

“In this trial that we have been running at NYU and Bellevue Hospital for the last 6 or 7 years, we enrolled women during pregnancy and asked them if they were interested in promoting healthy infant growth and preventing obesity,” she said in an interview with Infectious Diseases in Children. “We really stress a positive message to promote healthy feeding, meaning that we recommend exclusive breast-feeding for 6 months, healthy formula feeding for those who do not breast feed and avoiding sugar sweetened beverages and screen time in the first year of life. We teach ways to help parents achieve these goals by practicing them in a supportive group setting, such as ways to calm children without feeding, preparing healthy baby foods and how promote infant activity with tummy time.”

Excluding family-focused interventions, there are few other treatment options for children and adolescents. No medications that are approved for the treatment of obesity in adults have been approved for use in children. Instead, some children may be prescribed metformin, a drug that prevents high blood sugars related to type 2 diabetes; however, the Endocrine Society stated in a 2017 guideline for pediatric obesity that medications should not be used for weight loss in children or adolescents unless they are participating in a clinical trial.

Additionally, the Endocrine Society notes that bariatric surgery may be an option for some adolescents who are seriously affected by obesity and have failed to lose weight with behavioral interventions.

Bariatric surgery for adolescents remains controversial in the U.S., with a relatively small 1,500 procedures performed each year, according to an AAP perspective published in 2015. The authors noted about half of pediatricians and family physicians surveyed in 2007 indicated they would not refer an adolescent for surgery. A lack of data on long-term safety and benefits may be a cause for the hesitancy, the authors reported.

Long-term data are beginning to be published on bariatric surgeries for adolescents, according to Cook.

“Adolescents have had bariatric surgery, but there are complications,” Cook said. “While the procedure is reported to be fairly safe, the key is having very close follow-up, and helping families and children remain compliant with the diet and lifestyle needed after the surgery.”

Both treatment and prevention of pediatric and adolescent obesity requires care for more than just the child or teenager. Owing to a child’s limited control over their own environment, Lloyd Werk, MD, MPH, division chief of general academic pediatrics and director of Nemours Healthy Choices Clinic, told Infectious Diseases in Children that including the family is crucial to providing adequate care.

“Much of the treatment of the child or teen is actually care for the family,” Werk said. “Unlike adults, when we treat children and adolescents with obesity, we have to take a family-centered approach. For our patients, management requires active engagement of the parent around foods purchased and activities encouraged, and we use the techniques of motivational interviewing to connect desired behaviors to personal goals.”

Prevention to action

To further promote healthy dietary changes, many cities throughout the U.S. have implemented sugary drink taxes to reduce the number of these beverages consumed by constituents. One study published in Pediatrics demonstrates that children aged between 2 and 5 years who consume these beverages have higher BMI. Furthermore, sedentary teens who watch more than 2 hours of television increased their consumption of sugary sports drinks from 17.6% (±1.0) to 19.3% (±1.3) between 2010 and 2015, according to additional study results.

Prevention strategies like these provide an opportunity for more one-size-fits-all options for children of all ages when compared with treatment, which should be individualized based on the child and family’s needs, according to Cook.

“The good thing about preventive strategies is that they are somewhat accessible to all,” Cook said. “Things that we would recommend to families for kids to have healthy lifestyles, like less screen time, adequate or more sleep, regular exercise and avoiding fast food, are behaviors that are good for a child and a family regardless of whether they have normal weight, overweight or obesity.”

Although public health and community-based approaches to obesity prevention can target multiple children who are at risk of developing the condition, one clinical report published in 2015 highlighted the unique position that the pediatrician plays in preventing obesity in their patients.

“Unlike most schools, community-based organizations or governmental programs, pediatricians often follow children over a long period of time, sometimes from fetal life through college, giving them a unique long-term perspective in preventing chronic conditions such as obesity,” Steven R. Daniels, MD, PhD, FAAP, and colleagues within the AAP Committee on Nutrition, wrote.

Preventive and treatment strategies used to combat the concerning rates of pediatric and adolescent obesity have left Werk hopeful about the future. He mentions that the recognition of obesity as a chronic condition that can be impacted by changing diet and access to physical activity is changing the way in which physicians and society are handling the topic.

“Some novel therapies have started to be used, and [our practice is] making use of telehealth and having health coaches provide ongoing care to children even after they leave the office,” Werk said.

To correctly target preventive and treatment methods, and to promote healthy discussion about weight, it is imperative that physicians and families understand the stigma associated with childhood obesity and how to better communicate with each other and with the child.

Reducing the stigma

Communication about obesity plays a pivotal role in the success of the child or teenager who is experiencing it. A review authored by Stephen J. Pont, MD, MPH, FAAP, the AAP Section on Obesity and The Obesity Society claim that current levels of stigma experienced by people with obesity are thought to encourage these children and teenagers to lose weight; however, obesity-related stigma can contribute to many physical and mental health conditions.

Pont and colleagues wrote that bullying within the school system can begin in young, preschool-aged children, where they may give negative attributes to children who have a larger body size. As children age, their risk of being targeted by bullies in verbal, physical and relational manners increases as the child’s BMI increases.

Although peer teasing and bullying are major concerns for children with obesity, research has demonstrated that a negative bias may be held among teachers. One study published in Economics of Education Review found that teachers of children aged between 5 and 12 years were more likely to rate the academic performance of children with a heavier weight negatively in reading and math. This relationship was significant for children with obesity.

Parents may also be a source of teasing and bullying. According to a survey that examined the beliefs of teenagers who were enrolled in weight-loss camps, nearly 40% reported that their parents had bullied them about their weight.

Armstrong suggests that there is no place for teasing or bias toward these children and adolescents.

“The consequences of children feeling stigmatized because of their weight are not just related to the child feeling bad about themselves. It can make the problem worse,” she said. “A child whose coping strategy when they are anxious might be to eat. When they experience an encounter where they feel stigmatized, they may eat in an unhealthier manner.”

Because negative interactions may be frequently experienced outside of the health care setting, it is essential that those within the profession find a way to communicate with their patients who have obesity.

“People do not like the word ‘obesity’ much in the way that people do not like the word ‘cancer,’” Messito said. “No one wants to hear that they have something that might be bad, so I may use this word later in our conversation. If a child starts to become visibly upset about their condition, I like to remind them that they are not alone in this. This is a problem for so many people, and this is not their fault. Some people have a metabolism that gives them asthma, and some people have skin rashes or other conditions. This is the health issue they need to work on and go from there.”

Messito also suggests that in addition to considering the phrasing used about the condition, the condition should not be placed in the forefront. Rather, the patient should take priority with patient-centered language. This line of communication stresses that patients are not their condition, such as an “obese child,” but rather a patient with a condition, or a “child with obesity.” She then proceeds to ask questions focused on the child’s perception of their own weight and then how his or her parents feel about the child’s weight.

“The discordance is tremendous,” Messito added. “Children with normal weight often have parents who think they are too skinny and want them to gain weight. Children with slight overweight or on the higher end of normal weight sometimes have parents who think they are too heavy and make them feel bad about their weight.”

Woo Baidal mentioned that although the stigma surrounding pediatric obesity may not be conducive to the betterment of patients, it may take time for children, parents, health care workers and society to learn how to turn concern into productive communication.

“For quite some time, many thought that weight on young children was just baby weight and that it would come off because ‘a healthy baby is a chubby baby,’” she said. “Now, there is a lot more awareness that obesity, even in children, can have health complications. Families are concerned about it. They are not intending to cause harm by talking about their child’s weight, but a negative conversation about weight can create a sense of shame, even for very young children. Using patient-centered language that focuses on healthy behaviors for the whole family can help empower patients and families.” – by Katherine Bortz

• References:
• CDC: Childhood obesity causes & consequences. Accessed May 15, 2018.
• CDC: Prevalence of obesity among adults and youth: United States 2015-2016. Accessed May 15, 2018.
• Childerhouse JE, Tarini BA. Pediatrics. 2015;doi:10.1542/peds.2015-0867.
• Chriqui JF. Curr Obes Rep. 2013;doi: 10.1007/s13679-013-0063-x.
• Cordrey K, et al. Pediatrics. 2018;doi:10.1542/peds.2017-2784.
• Daniels SR, et al. Pediatrics. 2015;doi: 10.1542/peds.2015-1588.
• DeBoer MD, et al. Pediatrics. 2013;doi: 10.1542/peds.2013-0570.
• Mayo Clinic: Drugs and supplements - Metformin (Oral Route). Accessed May 15, 2018.
• Pont SJ, et al. Pediatrics. 2017;doi: 10.1542/peds.2017-3034.
• Puhl RM, et al. Pediatrics. 2013;doi: 10.1542/peds.2012-1106.
• Skinner AC, et al. Pediatrics. 2018;doi: 10.152/peds.2017-3459.
• Styne DM, et al. J Clin Endocrinol Metab. 2017;doi: 10.1210/jc.2016-2573.
• US Preventive Services Task Force. JAMA. 2017;doi: 10.1001/jama.2017.6803.
• Zvodny M. Econ Educ Rev. 2013;doi: 10.1016/j.econedurev.2013.02.003.

• For more information:
• Sarah Armstrong, MD, can be reached at the Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27705; email: Jill Boy, jill.boy@duke.edu.
• Stephen Cook, MD, MPH, can be reached at the Golisano Children’s Hospital at the University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14642; email: Sean Dobbin, Sean_Dobbin@URMC.Rochester.edu.
• Mary Jo Messito, MD, can be reached at the New York University School of Medicine, 550 1st Ave., New York, NY 10016; email: Mary.Messito@nyumc.org.
• Lloyd Werk, MD, MPH, can be reached at Nemours Healthy Choices Clinic, Nemours Children’s Hospital, 13535 Nemours Parkway, Orlando, FL 32827; email: Yusila Ramirez, Yusila.Ramirez@nemours.org.
• Jennifer Woo Baidal, MD, MPH, can be reached at the NewYork-Presbyterian Morgan Stanley Children’s Hospital, 3959 Broadway, New York, NY 10032; email: Alexandra Simpson, ajs9044@nyp.org.

Disclosures: Cook reports being on a data-safety monitoring board with Novo Nordisk that is testing a drug intervention for obesity. Armstrong, Messito, Werk and Woo Baidel report no relevant financial disclosures.