Physical activity in the treatment of childhood overweight and obesity

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Definition Measurement of Physical Activity Level and Fitness

The measurement of the patient’s physical activity level provides important clues regarding behaviors
that may contribute to the overweight condition. Sedentary behaviors are highly associated
with childhood obesity. There are very accurate laboratory procedures that can be used to determine
physical activity level. These include accelerometry, total energy expenditure by doubly labeled
water, VO2 portable equipment, heart rate monitoring by telemetry, time lapse or video photography,
and others [66]. However, the use of such methods is not feasible or cost-effective in primary care
settings. Likewise, direct observation techniques such as SOFIT and SOPLAY are impractical in
clinical settings. Several self-report questionnaires have been validated in youth 10 years of age or
older and are shown to be good predictors of physical activity level (Table 4.6). Samples of these
questionnaires may be found in Appendix A2.4.1.
Maximal oxygen uptake (VO2 max) is an indicator of physical fitness level in both adult and
youth populations [67–71]. The maximal oxygen uptake indicates the functional capacity of the
heart, lungs, and skeletal muscle and is generally assumed to be the single best indicator of physical
fitness [69]. The VO2 max is determined by exercising a subject and determining O2 intake and O2
and CO2 concentrations in expired air. All VO2 max tests should be supervised by trained and
certified exercise physiologists. Assessing cardiopulmonary fitness in the pediatric population has
become the focus of recent research in pediatric medicine and exercise science [72–76], Cardiovascular
responses to exercise stress can be evaluated by obtaining a value for submaximal steadystate
or peak or max exercise value (Peak or Max VO2). Maximal oxygen consumption (VO2 max)
has been used as an indicator of health related physical fitness [77]. The criteria for achieving a
Peak VO2 response in the pediatric population may not be similar to that of adults [78]. Obtaining
a plateau in oxygen consumption in children can oftentimes be difficult. However, there have been
several protocols that have been used and validated for pediatric exercise testing. In Chapter 10,
Rowland and Loftin detail appropriate fitness testing for overweight youth. Detailed exercise testing
protocols are also located in Appendix A2.4.2.
Psychological Testing
Because overweight children are at increased risk for depression, low self-esteem, and other related
psychological disorders, it is important that they be screened by an appropriate mental health
professional before treatment. Chapter 9 details the appropriate testing procedures for overweight
children. Sample referral forms and detailed psychological testing protocols are located in
Appendix A1 and A2.5.
Tanner Staging
Growth and development are affected by many complex factors. Various outcome measures could
reflect innate physiological factors rather than our proposed intervention outcome. To assess the
effects of nonmodifiable factors such as age and gender on measurement of growth (weight, height),
and body composition (lean body mass, percentage of fat), the sexual maturity rating may be
determined using methods from Falkner and Tanner [79] on all subjects at fixed intervals (baseline,
10 weeks, 6 months, and 12 months). Sexual maturity ratings (Tanner staging) should be performed
during the physical examination by a physician who is specially trained in adolescent medicine
(see Appendix A2.6). Alternatively, a self-report tool is available that allows the patient to selfexamine
his or her level of maturation [80].
The current environmental experience of young children includes few opportunities for physical
activity [81] and an overabundance of high-calorie foods. Sedentary lifestyles and poor nutrition
challenge children who are genetically predisposed to diabetes, heart disease, and other chronic
diseases. Obesity is a logical response to this challenge. Therefore, in predisposed children (e.g.,
those with obese parents and diabetes history), sedentary, nonnutritious environments challenge their
physiologic and metabolic capacity and promote overweight conditions, reduced fitness, further
inactivity, and increased sedentary behaviors (television watching and snacking). This results in a
clinically significant overweight condition (>95th BMI), reduced insulin sensitivity, and an increased
risk of type 2 diabetes and heart disease later in adulthood. Research indicates that increasing
physical activity and improving nutrition may significantly affect this series of events [82–84].
The current childhood overweight epidemic is neither the fault nor the responsibility of any
one single sector of society. All must work together to develop strategies to change public opinion
and behavior concerning healthy nutrition and physical activity across the life span. Because
children who are at risk for overweight at 7 years of age or older become increasingly more
susceptible as they mature, appropriate, targeted family-based dietary and physical activity interventions
should be made available in clinical settings. The economic burden of obesity-associated
illness during childhood in the United States has increased by 43% in the last two decades [85].
Cost-effective individual and group approaches are available and should be both encouraged and
financially supported by the medical community. More funds are needed for programs that work
simultaneously to conduct research and provide ongoing interventions to prevent and treat overweight
children in clinical settings. Physicians play a key role in these efforts to prevent and treat
overweight conditions, as the epidemic of childhood obesity is the most critical challenge facing
the medical community today.

Definition Body Composition Analysis (Estimate of Percentage Body Fat

Skinfold analysis measures the thickness of a double fold of skin and subcutaneous adipose tissue
at various body locations [44]. The use of skinfold calipers is the most widely used method for
determining obesity. The advantages of this method are its relative simplicity, quickness, and
nonevasive nature. In addition, very little space is needed. Various equations have been developed
in the prediction of body composition [45–52]. In overweight children, a two-site formula using triceps
and subscapular developed by Slaughter et al. [53] has been used and shown to be highly correlated
with both underwater weighing and dual-energy x-ray absorptiometry (DEXA) measurements [54].
Bioelectrical impedance may be used to measure the density of lean and adipose tissue in
relation to hydration [49,51,52,55]. Studies have shown total body water (TBW) and electrical
impedance to be related [56,57]. Further studies also report the utility and reliability of body
impedance measurements in the assessment of total body fat [55,58]. Both bioelectrical impedance
and skinfolds provide a reasonably accurate, time- and cost-effective method of assessing body fat
in overweight children [49–51]. However, care should be taken to select a formula specific to the
age, race, and gender of the child, as accuracy varies by study [54,59,60]. More accurate methods
are available but are typically reserved for severe overweight conditions or research studies. These
include underwater weight and DEXA.
For many years, underwater, or hydrostatic, weighing has been the “gold standard” for the
measurement of body fat [44]. The use of underwater weighing is based on Archimedes’ principle.
Simply stated, Archimedes reasoned that an object submerged in water is buoyed up by a counterforce
equaling the weight of the displaced water. An object “loses weight in water.” Therefore, if an object
weighs 50 kg in air and 3 kg when submerged, the loss of weight in water, 47 kg, equals the weight
of displaced water. We can then calculate the volume of water displaced because the density of water
at any temperature is known. More recently, DEXA has been used to determine percentage of fat,
lean body mass, and bone mineral density in overweight children [49,51,52,61]. DEXA uses an
x-ray source to generate photons to scan subjects [62]. Bone-mineral content measurements previously
calibrated against secondary standards with ashed bone sections are used to help calculate fatfree
mass [63,64]. Percentage of fat and fat-free body can be predicted with accuracy by observing
the ratio of absorbance of the different-energy-level photons, which are linearly related to the percentage
of fat in the soft tissues of the body [64]. The coefficient of variation of fat-free tissue measurement
has been calculated at 2%, which is comparable to that obtained by hydrodensitometry [65].

Definition Height and Weight Measurement

The measurement of height or stature is a major indicator of bone length and general body size.
The recommended technique for height measurement includes the use of a vertical board with an
attached metric rule and horizontal headboard, collectively known as a stadiometer. The standard
measure of weight should be recorded using a calibrated electronic scale. The kilograms should
be recorded in the patient’s chart. For both height and weight measures, the patient should remove
shoes and heavy clothing/objects before the measurement.
BMI and CDC Percentiles
The BMI, the calculated number that adjusts weight for height, uses the following formula:
BMI = weight (kilograms)/height (meters2).
The Centers for Disease Control define at risk of overweight as a BMI between the 85th and 95th
percentile for age. Children are considered overweight or obese if the BMI is greater than the 95th
percentile for age. In adults, a BMI value greater than or equal to 25 but less than 30 is considered
overweight, and a BMI value greater than or equal to 30 defines obesity or severe overweight [27].
However, these BMI cutoffs are not appropriate for classifying children’s weight status. First,
childhood mortality is not likely to be related to body composition, so it is not possible to develop
risk-based criteria [28]. Second, BMI typically varies with age, decreasing in the preschool years,
and then increasing after about 6 years of age. Because of these changes in BMI with growth, agespecific
criteria are needed. Gender-specific criteria are also needed as a result of differences in
body composition and timing of growth patterns in adolescence for boys and girls [29]. Revised
growth charts with smoothed age and sex-specific BMI percentile curves were developed by the
National Center for Health Statistics for children aged 2 to 17 years [28]. According to current
standards, youths with a BMI greater than or equal to the 95th percentile for age and sex are
considered overweight, and those with a BMI falling between the 85th and 95th percentiles for age
and sex are considered at risk for overweight [30–32].
It is recommended that children with a BMI at the 85th or higher percentile be further evaluated
for complications associated with overweight and for recent excessive weight gain. Assessments
should include the evaluation of potential genetic, endocrine, or psychological syndromes [30,33–36].
Family medical, diet, and physical activity history should be considered to identify primary risk
factors for overweight, such as parental obesity, sedentary behaviors, early feeding practices,
metabolic or hormonal stress, socioeconomic factors, and ethnicity [5–7,9,34,37–41].
Circumference Measurements
An additional method of assessing body composition is the measurement of girth of various body
sections [42]. From the sum of the measurements, percentage body fat is determined from equations,
tables, or nomograms. A metal or fiberglass measuring tape with a metric scale is used to measure
the circumference of the waist and hip. The waist circumference is a useful indicator for determining
reduction in fat weight after treatment.
Blood Pressure and Heart Rate
Resting blood pressure (BP) measurement is taken as a measure of the force of the heart’s pumping
action. Hypertension in children and adolescents continues to be defined as systolic BP or diastolic
BP that is, on repeated measurement, above the 95th percentile. BP between the 90th and 95th
percentile in childhood had been designated “high normal.” To be consistent with the Seventh
Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure [43], this level of BP will now be termed “prehypertensive” and is an
indication for lifestyle modifications [43]. Pediatric hypertension is often observed in overweight
children, especially those with severe conditions.
Laboratory Blood Work (Baseline, 3 Months and 1 Year)
Biochemical markers, total cholesterol, triglycerides, high-density lipoproteins, and low-density
lipoproteins should be examined by drawing 10 to 20 cc of whole blood in a certified laboratory.
Children should be required to fast for 12 hours before the test.

LEARN TO THE ROLE OF THE PHYSICIAN IN THE TREATMENT OF OVERWEIGHT YOUTH

Initially, physicians are the best source for the diagnosis of pediatric obesity, according to the U.S.
Surgeon General. Doctors and other health care professionals are the best source in determining
whether a child or adolescent’s weight is healthy, and they can help rule out rare medical problems
as the cause of unhealthy weight. A body mass index (BMI) can be calculated from measurements
of height and weight. Health professionals often use a BMI “growth chart” to help them assess
whether a child or adolescent is overweight. A physician will also consider a child or adolescent’s
age and growth patterns to determine whether his or her weight is healthy. Only providers trained
in pediatric medicine possess the level of expertise required to provide an accurate assessment of
pediatric obesity. Regardless, studies indicate that pediatric health care providers diagnosed overweight
in only one half (53%) of overweight children [17]. We found similar poor rates of diagnosis
and referral in a study of Louisiana youth seen in three separate physician’s offices [18]. Physicians
diagnosed obesity in very few of their patients who were classified as greater than 95th percentile
BMI (Table 4.1).
Physicians also provide guidance to parents so that they may best understand the definition of
overweight or at risk for overweight in children. The physicians can then, with the parents’ input,
decide on the best plan of action for the overweight child. Recent studies indicate that at this point,
about 75% of physicians will refer patients initially to registered dieticians [14], and only about
20% of patients will be referred to weight management programs. In another study, in those children
diagnosed as overweight by their physicians, comprehensive treatment programs were not generally
prescribed [17]. In our study, we observed similar low referral rates [18] (Table 4.1). Of more
concern is that between 27% and 42% of pediatricians or pediatric health providers report that
weight management programs are not available in their area [14].
Several clinical observations [19–26] have detailed an interdisciplinary pediatric weight management
intervention in which the physician or pediatric health care provider has an integral role
in treatment. He or she is responsible for the overall medical supervision of the program and
oversees the diagnosis, evaluation, and dietary and physical activity plan of action. In this chapter,
step-by-step details are provided of the medical oversight provided in this approach. Further details
may be found in Chapter 2 by Sothern, Chapter 12 by Schumacher et al., Chapter 14 by Sothern,
Chapter 19 by Carlisle and Gordon, and Chapter 20 by von Almen and Sothern, and in Appendices
A1, A2, and A3.
PERFORMING THE INITIAL MEDICAL EVALUATION (TABLE 4.2)
An initial medical history and a physical examination are performed before enrollment into the
treatment program. This medical information is reviewed with the parents and child before entry
into the program. Assessment and discussion of the child’s growth chart and current weight status
occurs at this time. To determine the child’s goal weight, the physician observes on the BMI growth
chart what weight would match the child’s height percentile (Appendix A1.10). This is the child’s
ideal body weight. The child’s goal weight is this weight plus an additional 20%.
ORDERING AND INTERPRETING LABORATORY BLOOD WORK (TABLE 4.2)
The pediatrician orders an initial battery of blood work that includes a complete blood count, metabolic
panel, and lipid profile (Appendix A2.2). These laboratory tests are repeated 3 months into the program
and at the end of the program. Other tests may be ordered after the initial medical evaluation as needed.
PRESCRIBING AN APPROPRIATE DIET IN COORDINATION WITH THE PROGRAM DIETICIAN
The diet will be for either weight loss or weight maintenance. The child’s medical history, family
health history, age, gender, and current weight status will be considered before prescribing an
appropriate diet. In children at risk for overweight, moderate approaches are best. However, in
children with clinically significant overweight conditions (BMI > 99th percentile), more aggressive
approaches may be necessary. Although the research is limited with respect to such approaches,
several clinical observations and a few randomized controlled trials indicate that the use of very
low calorie diets, low-carbohydrate diets, and low-glycemic diets may result in short-term weight
loss in very overweight youth. In Chapter 11, Sothern and others survey the literature and provide
specific guidelines for low glycemic diets. Sample diets are located in Appendix 3.
PROVIDE ONGOING MEDICAL SUPERVISION (TABLE 4.3)
In group interventions, the pediatrician may choose to attend most of the intervention sessions,
especially during the first 3 months of the program. He may elect to weigh the children and check
vital signs while discussing their progress and answering questions. This helps to ensure medical
safety throughout the course of the program. Whether the physician attends the sessions routinely
or not, he or she should be available by phone to address questions or problems that arise between
weekly sessions. In overweight and normal-weight children with parental obesity frequent monitoring,
reduced television viewing, and increased opportunities for unstructured active play are
typically recommended by the physician (Table 4.4).
FOLLOW-UP (TABLE 4.5)
At the beginning of treatment for pediatric obesity, and every 3 months afterward, patients undergo
a comprehensive evaluation. The results of the evaluations are distributed to the children and parents
and are discussed with the family as necessary. In some cases, the physician may choose to refer
the family to a staff psychologist, if available, or other appropriate mental health professional. A
registered dietician or exercise professional should also be available to assist with interpretation
and to answer questions as well. These evaluations consist of the following 10 items. Appendix 2
contains detailed measurement protocols.

Learn to Medical Aspects of Treatment: The Role of the Physician

What has led to the current epidemic of childhood obesity? When most of today’s parents were growing
up, we had more opportunities for free play. Our neighborhoods tended to be safer, and usually someone
was at home, supervising our activities. These activities typically did not include the increasing
sedentary activities we have today (multiple television stations, computers, Internet, and video games).
We spent more of our time engaging in activities that burned more calories — bike riding, playing
chase, climbing trees. Most families ate a home-cooked meal every night. The rate of childhood obesity
was 5 to 10%. Now, about 15% of children are considered overweight or at risk for overweight.
Environmental factors may contribute as much as 80% to the causes of childhood obesity.
These factors include increased caloric and fat intake (e.g., energy-dense foods and beverages,
irregular meal patterns, snacking and dining out, and sedentary behaviors, such as television viewing
[1,2]) and absence of regular physical activity [3]. Research indicates that obese children demonstrate
decreased levels of physical activity and increased psychosocial problems.
It is well accepted that the environment of the family plays a key role in the development of
obesity in young children at risk for adult obesity and related diseases such as diabetes [4–7].
Research shows that parent inactivity strongly predicts child inactivity [6]. Moreover, the exercise
patterns of parents have a strong influence on the frequency of exercise in their children [8].
Research also shows that parental influences are early determinants of food attitudes and practices
in young children [9]. Furthermore, food preferences greatly influence the consumption patterns
of young children [10]. Therefore, strategies that positively alter the behaviors and environment of
the family may reduce the risk of adult obesity and diabetes by improving physical activity and
nutrition. This may prevent the onset of pediatric obesity and the risk of metabolic disease later in
life, especially in those children with primary risk factors (at risk). Efforts to halt and reverse
obesity and related metabolic disease, therefore, should begin with young children. More important,
educational interventions that target the parents of children at risk for obesity should be an integral
part of standard pediatric and family medical care.
The health consequences of children’s being obese are significant. Obese children are more
likely to develop cardiovascular disease (high cholesterol, hypertension), glucose intolerance (which
may lead to diabetes), gallstones, and psychological problems, to name a few. The most serious
and prevalent long-term consequence of childhood obesity is psychosocial. Obese children are
targets of early and systematic discrimination by peers, family members, and others. Obese children
frequently have low self-esteem and social isolation and can become depressed. One of the best
reasons to treat childhood obesity is to reduce the psychosocial consequences.
The most successful approach to treating childhood obesity is through a multidisciplinary (medical,
nutritional, psychological, physical activity), family-based approach [11]. Such approaches teach
both the overweight child and his or her family how to lead a healthier lifestyle to promote the
achievement of a healthier weight. Interventions are best delivered in a group family setting.
However, the combination of medical supervision, dietary guidance, promoting increased physical
activity, and behavioral counseling should be promoted in the individual medical care of overweight
youth, as well. Unfortunately, although the number of obese pediatric patients seen by physicians
each year is continuously increasing, knowledge of effective treatment techniques is lagging.
Recently, Story and others identified a lack of parent involvement and motivation and lack of
support services as the most frequent barriers to treatment of pediatric obesity in clinical settings [12].
Even though obesity is recognized by the majority of health care professionals as a serious,
chronic disease, they feel unprepared to address the multidimensional aspects of the obesity
problem. Studies indicate that health care professionals believe that childhood obesity requires
immediate medical attention and treatment [12]. However, many of their treatment practices are
not in accordance with current expert recommendations [13]. This was evidenced when a survey
of providers identified perceived low proficiency in the use of behavioral management strategies,
guidance in parenting techniques, and addressing family conflicts [12]. Moreover, providers feel
they lack expertise in motivational skills to promote change in dietary and physical activity patterns
[14]. Despite these findings, behavioral therapy has been shown to be effective, even when done
briefly. The Worcester Area Trial for Counseling in Hyperlipidemia study is an example of how
brief counseling in adults can provide positive results in weight loss [15]. During the study,
physicians were given 8 minutes with each patient. Study patients either received counseling alone
(control) or counseling combined with handouts and questionnaires concerning dieting (treatment)
while in the waiting rooms. A year later, treatment patients were found to have lost 2.3 kg more
than the control and, as a benefit of that loss, lowered their cholesterol by 3.8 mg. Still, physicians
rarely feel that a great difference can be made in the behavior of the families through the use of
individual counseling [15]. This is caused by a lack of both training and experience of physicians
in the area of counseling interventions. Another factor affecting this lack of enthusiasm in physicians
is that many feel “ill-equipped” to handle behavioral issues [15,16], and that such issues are out
of their area of interest [15]. Moreover, because of time constraints, physicians in primary care
especially are conflicted, with heavy workloads combining with a strong work ethic to give the
best care to their patients. Finally, a lack of incentives offered to physicians is another factor that
reduces physician counseling in weight management [15]. However, physicians play a vital role to
the safety and effectiveness of weight loss and maintenance interventions in children.

REFERENCE TO OVERWEIGHT AND OBESITY IN EUROPEAN CHILDREN AND ADOLESCENTS

References

1 Wabitsch M, Kunze D, (eds): Guidelines of the German Working Group on Childhood and
Adolescence Obesity. http://www.a-g-a.de
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and obesity worldwide: International survey. BMJ 2000;320:1240–1243.
3 Wabitsch M: Overweight and obesity in European children and adolescents: Definition and
diagnostic procedures, risk factors and consequences for later health outcome. Eur J Pediatr 2000;
159:S8–S13.
4 Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH: Predicting obesity in young adulthood
from childhood and parental obesity. N Engl J Med 1997;337:869–873.
5 Barlow SE, Dietz WH: Obesity evaluation and treatment: Expert Committee recommendations.
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