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Severe obesity in children: a growing problem.

Severe obesity in children is defined as greater than or equal to the 99th percentile of body mass index (BMI) for the child's age and gender. BMI is calculated by taking a person's weight in kilograms and dividing it by the height in meters squared.

Your pediatrician and major healthcare societies and organizations now use BMI to classify children who are at least two years old as "normal weight," "overweight," "obese," or "severely obese," rather than using height and weight charts, which used to be the practice. For assessing overweight and obesity in children younger than two years old, however, the latter charts are still used (specifically, the weight-for-height percentile).

The proportion of severely obese children in the United States has increased by more than 300%, skyrocketing from only 1% in 1976-1980 to 4% from 19992004. This is very worrisome for the health and well-being of our children and our nation. Severe childhood obesity is associated with multiple cardiovascular risk factors, including elevated cholesterol, triglycerides, blood sugar, and blood pressure, and low levels of the good cholesterol, HDL. Severely obese children have school absenteeism rates 11% greater than healthy-weight children! The famous Bogalusa Heart Study revealed that all severely obese children become obese adults.

Prior to our research, however, little was known about the predictors of future severe childhood obesity in infants, toddlers, and young children, and no studies had examined the risk and protective factors for severe kindergarten obesity. This is a particularly important issue, given that there is research documenting that the higher number of fat cells in obese adults is set during childhood.

What the Research Tells Us

In a recent article published in the International Journal of Obesity, our research team reported the findings of research aimed at identifying the predictors of severe obesity in kindergarten students using data from a nationally representative study. The Birth Cohort of the Early Childhood Longitudinal Study, also known as ECLS-B, is a nationally representative longitudinal study (i.e., participants were studied over a long period of time) which followed 14,000 children from birth in 2001 through kindergarten entry through 2008. ECLS-B is an outstanding data source for this work because it conducted interviews across the U.S. of children, parents, childcare and early-education providers, and teachers.

The study questions addressed children's early development, healthcare, nutrition, physical well-being, and kindergarten experiences. Our analyses for this study examined the associations of 32 parental, 21 prenatal/pregnancy, 32 infant, and 46 early childhood characteristics, both alone and in combination, with severe obesity at kindergarten entry.

There were several important study findings. The overall rate of severe obesity in kindergarteners was 6%. An infant or young child crossing the 85th percentile of weight-for-height at nine months old and/or having a BMI > 85th percentile prior to kindergarten age is an especially powerful predictor of severe obesity in kindergarten. Children crossing the 85th percentile of weight-for-height at nine months old are twice as likely to be severely obese in kindergarten, and those with a BMI > 85th percentile at two years old and preschool age each are eight times more likely to become a severely obese kindergartener!

Severe maternal obesity, drinking tea or coffee between meals or before bedtime at two years old, and maternal gestational diabetes were associated with three times the likelihood of severe obesity in kindergarten. Latino and multiracial race/ethnicity, drinking sugary beverages at kindergarten age at least once weekly, the number of adults in the household, and a middle upper-arm circumference at nine months old also were associated with severe obesity.

Certain protective factors also were identified. Older maternal age at having the first child is associated with reduced odds of severe obesity. Ever attending a daycare center, eating fruit at least once weekly at kindergarten age, and a maternal history of a prior newborn birth weight of at least 8.8 pounds are associated with a substantially reduced risk of severe obesity in kindergarten.

A special statistical technique called recursive partitioning analysis was also used, and it identified clusters (i.e., combinations) of parental, prenatal/pregnancy, infant, and early childhood characteristics associated with an especially high and low risk of severe kindergarten obesity.

Although the overall rate of severe kindergarten obesity was 6%, this analysis revealed a 2% future severe obesity rate in preschoolers whose BMI was < 85th percentile, and also yielded four groups in which more than 50% of children were severely obese, including three groups with a 7180% severe obesity rate.

For example, among children with a BMI [greater than or equal to] 85th percentile at preschool age and crossing the 85th percentile of weight-for-height at nine months old with lower parental educational attainment and older maternal age, the severe obesity prevalence was 79% for those without preschooler bedtime rules, vs. 35% for those with rules. For the latter group, the severe obesity prevalence was 14% in those with non-vaginal deliveries vs. 46% for vaginal deliveries. For the latter group, taking the child outside to walk or play a few times monthly or less at nine months old predicted a severe obesity prevalence of 80%, vs. 33% for those with outside walk/play sessions at least a few times weekly.

How to Prevent Childhood Obesity

The research indicates several things that you, as a parent, can do to help prevent your infant or young child from becoming a severely obese kindergartner:

* Take your child outside to walk or play at least a few times a week at nine months old

* Establish clear bedtime rules for preschoolers

* Have your child eat fruit at least weekly

* Avoid having your child consume sugary beverages; the evidence suggests that consuming sugary beverages a couple of times of month is not a risk factor, but at least regular weekly consumption is

* Don't let your child drink tea (including iced tea) or coffee between meals or before bedtime at two years old


There are several key take-home messages from this research:

* Crossing the 85th percentile of weight-for-height at nine months old and/or having a BMI [greater than or equal to] 85th percentile at an earlier age (two years old or preschool age) are powerful predictors of future severe obesity at kindergarten entry.

* For mothers, being severely obese just prior to pregnancy and having gestational diabetes are major risk factors for having your child become a severely obese kindergartener.

* Parents should work with their child's healthcare providers to identify early on those young children at high risk for later severe obesity. They should carefully monitor the child's BMI and growth curve starting at nine months old. Potentially effective interventions for these high-risk children might include frequently taking young children outside to walk or play, having bedtime rules, encouraging frequent consumption of fruit, and avoiding sugary beverages.

By Glenn Flores, MD, FAAP

Glenn Flores, MD, is professor of Pediatrics, Clinical Sciences, and Public Health, Director of the Division of General Pediatrics, and the Judith and Charles Ginsburg Endowed Chair in Pediatrics at the University of Texas Southwestern and Children's Medical Center Dallas. He has published 197 articles and book chapters on pediatric issues, is a former member of the U.S. Preventive Services Task Force, and has provided U.S. Senate and Congressional testimony. He has consulted for the U.S. Surgeon General, National Institutes of Health, and the Sesame Street Workshop. His work has won awards from the American Academy of Pediatrics, American Public Health Association, and Academic Pediatric Association.
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Author:Flores, Glenn
Publication:Pediatrics for Parents
Geographic Code:1USA
Date:Jan 1, 2014
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