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CHILDHOOD OBESITY

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					                    CHAPTER                         video games and cellular phones, which reduces            to 13.9 percent; for those aged 6-11 years,
                                                    the opportunities for them to explore the outside         prevalence increased from 6.5 percent to
            CHILDHOOD OBESITY                                                                                 18.8 percent; and for those aged 12-19 years,
                                                    as many generations previously did on a daily
              (2 CONTACT HOURS)
                                                    basis. The sedentary lifestyles and unhealthy             prevalence increased from 5.0 percent to 17.4
Learning objectives                                 diets are a few of the culprits contributing to our       percent [24]. See Table 1 below:
Upon completion of this course, the participant
                                                    nationwide epidemic of childhood obesity.             The rate of childhood obesity is very alarming
should be able to do the following:
! Identify the prevalence of childhood obesity      Although a child may enjoy the opportunities          as it has doubled in the past few decades for
   in the United States.                            life has to offer today, it typically comes with a    the preschool age and tripled for school age to
   Identify the most common trends of               price. Unfortunately, our industrialized societies    adolescent children in America. According to
   childhood obesity in the United States.          stigmatize children based upon their body size        Bibbins, 2007, there are more than 9 million
! Define and differentiate between the terms        and appearance. Over the past few years, research     children and adolescents (17 percent) that are
   overweight and obesity.                          has demonstrated that children as young as 5          now considered to be overweight in the U.S.
! Define and interpret the meaning of body          years of age are aware of their own body type         [12]. At this time, approximately 30.3 percent of
   mass index (BMI).                                in comparison to their friends and peers. This        children 6 to 11 years of age are overweight, and
! Identify the difference of the various growth     certainly can impact their perceptions pertaining     15.3 percent are considered obese [60].
   charts constructed by the Center for Disease     to their appearance, athletic ability, social         According to the International Obesity Task
   Control and Prevention (CDC).                    competence, and self-worth. Our youth should          Force and the World Health Organization
! Identify and differentiate between the            not have to endure the potential stress inflicted     (WHO), there are an estimated 155 million
   most common long term complications of           upon them by the stigmas of society, nor should       children worldwide that are deemed overweight
   childhood obesity.                               their lives be cut short by the complications that    or obese [37]. Therefore, to put it in perspective,
! Identify and recognize the significant impact     may arise from obesity.                               the U.S encompasses 17 percent of the total
   of obesity and cardiovascular disease.           As health care professionals, it is imperative        number of obese children worldwide.
! Identify and recognize the significant impact     to unite with patients and families, the medical
   of obesity and diabetes.                                                                               In addition, another growing subset of overweight
                                                    community and school boards to defeat obesity         children are children under the age of 5 years of
! Discuss childhood obesity and depression.         among our youth. As a nation, we need to equip
! Discuss the correlation of childhood obesity                                                            age. The WHO has estimated that out of the 155
                                                    our youth with the appropriate tools to eliminate     million overweight/obese children worldwide, 7
   and reproduction issues among females.           childhood obesity. Our goal is to reduce or
! Identify the costs of obesity.                                                                          percent of them, 22 million, are overweight under
                                                    prevent the risks of co-morbid health conditions      the age of 5 [77]. In 2000, 22 percent of the U.S.
! Identify and differentiate between the            and even death from the complications of obesity.
   contributing factors of obesity.                                                                       preschool age children were overweight and 10
! Discuss the impact of the American schools        Prevalence                                            percent were considered obese [72]. In essence,
   influencing the epidemic of childhood          Childhood obesity has reached epidemic                  one in four preschool age children are overweight
   obesity.                                       proportions over the past few decades, as it has        or obese.
! Discuss the history required to properly        increased rapidly in many regions of the world,         Hay et al (2007), notes that the rates are
   screen for obesity among children.             especially in the United States (U.S.). At this         even higher today among the minority and
! Identify and differentiate between the various  time, childhood obesity is considered the most          economically disadvantaged children [35]. The
   diagnostic tests for childhood obesity.        prevalent nutritional disorder in the U.S. [60].        results within the U.S. are as follows:
! Identify and discuss the various treatment      In November 2007, the CDC released results                  In the United States, the prevalence of
   modalities of childhood obesity.               from two studies compiled by data utilizing                 overweight children among children 2 to 5
! Discuss the ways nurses can educate families    the National Health and Nutrition Examination               years of age was 8.6 percent in non-Hispanic
   to prevent childhood obesity.                  Survey (NHANES) [24]. The NHANES                            children, 8.8 percent in non-Hispanic black
                                                  compared the rate and incidence of childhood                children, and 13.1 percent in Mexican
Introduction                                      obesity within the U.S. from the mid-1970s to
Over the past few decades, our youth, who are the the rate of childhood obesity in 2003-2004. The             American children. In the adolescent range,
future of tomorrow, have been enduring serious                                                                12-to 19-year-olds, there is a significant
                                                  results comparing the difference in childhood               number of more non-Hispanic black and
health conditions related to being overweight or  obesity over the past thirty years demonstrated
obese. Over the past decade, Healthy People 2010 the following:                                               Mexican American adolescents that are
has attempted to reduce the number of children                                                                overweight (23.6 percent and 23.4 percent
                                                      For children aged 2-5 years, the prevalence             respectively) compared with non-Hispanic
diagnosed with obesity. However, according to         of overweight increased from 5.0 percent
the Centers for Disease Control and Prevention
(CDC), the United States has made little progress
in attaining the 2010 goal of increasing physical
activity and reducing childhood obesity.
Researchers and scientists have found many
contributors to the global obesity epidemic.
According to the World Health Organization
(WHO), many of the profound changes over the
past few decades within each of the modernized
societies has been contributed to the economic
growth, urbanization, and globalization of the
food markets [79]. In addition, the behaviors
and attitudes of our youth have changed over
the past few decades. The American Obesity
Association, reiterated in 2005 that the youth of
today are considered the most inactive generation
in all of history [9]. Our youth today have the
convenience of the Internet, television (TV),

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    white adolescents (12.7 percent) [34].             adipose tissue varies by the gender and age of the     for diagnostic purposes. When assessing body
The prevalence of a child being overweight is          individual. It is greater in post pubertal females     mass in the pediatric patient, it is based upon the
slightly higher in girls in comparison with boys,      than males, and normally encompasses 12 percent        percentiles for that particular age group, opposed
as the following NHANES 2003-2004 data                 of body tissue at birth, increasing to 25 percent      to adults, who are diagnosed and classified based
demonstrates [24]:                                     at 5 months, then decreasing to 15 to 18 percent       upon the actual BMI score (weight/kg divided
 Girls. In females, non-Hispanic black                during puberty [33].                                   by the height) and is not gender specific [79]. In
    girls had the highest prevalence of being                                                                 adults, overweight is classified as a BMI >25 and
                                                       The American Heart Association has
    overweight (25.4 percent) compared to                                                                     obesity is classified with a BMI > 30 [30]. It is
                                                       recommended that a child be considered obese if
    that of non-Hispanic whites (15.4 percent)                                                                important to note that a child could potentially be
                                                       the following criteria are met:
    and Hispanic Americans (14.1 percent).                                                                    considered overweight without being obese; for
                                                        Children who display a height or weight
    Therefore, in girls, the highest prevalence is                                                            example, in a child who going through a growth
                                                           greater than the 75th percentile for their age
    among African Americans.                                                                                  spurt or puberty [30]. The child’s percentile may
                                                           and gender.
 Boys. Childhood obesity is slightly higher                                                                  indicate he or she is overweight based upon the
                                                        Children who have significantly increased
    among adolescent non-Hispanic white boys                                                                  percentile, but in all actuality the child is not. An
                                                           their weight for their height percentile and
    (19.1 percent) than among non-Hispanic                                                                    athletic child may have excess muscle, which
                                                           one who suffer from a morbidity that would
    black boys (18.5 percent) and Hispanic                                                                    weighs more than fat, which can skew the data
                                                           be worsened by obesity (e.g., dyslipidemia,
    American boys (18.3 percent). Therefore, in                                                               if one only looks at the percentile. Therefore,
                                                           diabetes mellitus, or hypertension) [33].
    boys, the highest prevalence is among non-                                                                as health care professionals, we need to obtain
    Hispanic white. In addition, up to 24 percent      However, if a child under the age of 2 falls           a thorough history because, the BMI alone may
    of African-American and Hispanic children          in a category greater than the 75th percentile,        potentially skew the data for an athletic child
    are above the 95th percentile [39].                the child should not be considered obese or            or one going through a growth spurt whose
                                                       overweight because the child’s weight varies           weight is outside the 75th percentile, due to
There are numerous data sources supporting the
                                                       during that time period [35]. During this time         their muscular build. See table 2 which analyzes
epidemic, prevalence, and trend of childhood
                                                       period, the child is going through various rapid       different percentiles of a 10-year-old boy based
obesity based upon the prestigious NHANES data
                                                       growth spurts, and the data can be skewed based        upon his weight.
from the past 30 years. Since the prevalence of
                                                       upon the percentile alone. Therefore, if a child
childhood obesity is staggering, it is important                                                              Table 2
                                                       under the age of 2 is apparently overweight,
to understand that the majority of obese children
                                                       the health care professional needs to assess the
grow up to be obese adults. According to
                                                       current diet and trends in order to recommend
Schwarz, a child has an increased risk of obesity
                                                       minor alterations if needed. For instance, if
as an adult the older their onset age of obesity is
                                                       the child is 7 months old drinking six ounces
as child, such that 26-41 percent of preschoolers
                                                       of formula every two hours, the parents can
with obesity are obese as adults, compared with
                                                       be encouraged to decrease the frequency of
42-63 percent of school-aged children. [60].
                                                       the formula and encourage appropriate foods
Therefore, the higher the degree of obesity during
                                                       of a puree consistency. During this time, it is
childhood, the higher incidence of adult obesity.
                                                       imperative that the child has a diet with a certain
Individuals aged 18 years with a BMI at or above
                                                       percentage of fat, such as formula or breast milk
the 95th percentile have a 66-78 percent risk of
                                                       prior to the first birthday. In addition, whole milk
being overweight at age 35 years [60].
                                                       is recommended at 1 year of age as it stimulates
At this time, the National Institute of Health         brain growth.
(NIH) has said that more than 65 percent of
adults living within the U.S. are considered
                                                       Definition of body mass index to
overweight or obese. Nearly 31 percent of              differentiate between overweight and
adults, an estimated 61 million people, meet the       obesity
criteria for a diagnosis of obesity [65]. To put the   In order to differentiate between being
numbers in prospective, there are more than 1.1        overweight and obese, one must understand the
billion adults worldwide who are overweight,           body mass index (BMI) one screening tools to
and 312 million of them are considered obese.          identify the risks imposed upon an individual
According to the New England Journal of                based upon weight. The BMI is calculated by
                                                                                                              The CDC has classified a pediatric patient’s
Medicine, if the numbers of adults are combined        utilizing one of the following formulas:
                                                                                                              weight based upon the average weight for their
with the number of children currently overweight,       BMI= weight (kg)
                                                                                                              individualized age and gender. Once the nurse or
the WHO estimates that there are 1.7 billion                Height (m2) [35].
                                                                                                              practitioner plots the weight, based upon the age
people worldwide who are overweight [37].               BMI= weight (pounds) x 703
                                                                                                              and gender a percentile will match the plot on
                                                            Height squared (inches2 ) [72].
Definition of obesity                                                                                         the right column of the BMI form. The patient is
Childhood obesity is defined as the presence           Health care professionals have utilized the            diagnosed as being underweight, healthy, at risk
of excess adipose tissue. Adipose tissue is a          body mass index (BMI) screening tool to                of becoming overweight or overweight based
form of connective tissue that stores fat, which       calculate a percentile number based upon the           upon the CDC’s following percentile ranges:
provides insulation and protection for the body        height and weight that indicates the risk of           [15].
[45]. A certain percentage of adipose tissue is        being underweight, overweight or obese. The
                                                                                                               Weight status      Percentile ranges
important during childhood and adolescence             routine plotting of the BMI based upon age and
                                                                                                               category
because the excess fat promotes brain and growth       gender can be located at http://www.cdc.gov/
                                                       growthcharts. Although it does not measure the          Underweight        Less than the 5th percentile
development. The adipose tissue accumulates
when the total energy intake exceeds the total         amount or percentage of fat in the body, research       Healthy weight     5th percentile to less than the
energy expenditure [60]. However, excessive            does correlate that it has a direct measure of body                        85th percentile
adipose tissue weight may come from muscle,            fat when utilized appropriately [16].                   At risk of         85th to less than the 95th
bone, fat, or body water [45]. Normally, the           The BMI is a sensitive screening tool that is           overweight         percentile
percentage of body tissue that is composed of          readily available and reliably quantified in
                                                       clinical settings, but it should not solely be used
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                                                             following charts:                                The IOM’s 2005 report said that, approximately
 Overweight         Equal to or greater than the
                                                             Š Length-for-age and weight-for-age.             60 percent of obese children 5 to 10 years of age
                    95th percentile
                                                             Š Head circumference-for-age and weight-         had at least one cardiovascular disease (CVD)
The CDC and the American Academy of
                                                                 for-length.                                  risk factor, such as elevated total cholesterol,
Pediatrics (AAP) recommends that health care
                                                            Toddlers and preschoolers, 2 to 5 years of age   triglycerides, insulin or blood pressure, and 25
professionals begin to screen for the BMI on all
                                                             are measured by:                                 percent of the children had two or more CVD risk
children over the age of 2 years old to assess their
                                                             Š Weight-for-stature.                            factors [39].
weight category [16]. Although the BMI provides
                                                            Then children and adolescents, 2 to 20 years
a percentile range based upon the patient’s                                                                   In addition, according to the American Obesity
                                                             of age, are placed on the growth chart graph
weight, age and gender, it should not be utilized                                                             Association, pediatricians and childhood obesity
                                                             to measure:
as a sole diagnostic tool.                                                                                    researchers have reported an increased incidence
                                                             Š Stature-for-age and weight-for-age.
    If a child’s BMI is between the 85th and                                                                  of type II diabetes and asthma due to the excess
                                                             Š BMI-for-age.
    95th percentile for his or her age and                                                                    fat in children [7]. Another potential problem
    gender, he or she is considered overweight           It should be noted that there are four charts        with childhood obesity is mental health problems,
    and should be evaluated for hypertension             available for birth to 36 months, separated by       such as low self-esteem and depression among
    (HTN), dyslipidemia, and diabetes. If the            gender. The chart compares the length and weight     youth. It is imperative to reduce or prevent
    child’s BMI is greater than, or equal to, the        for age, then a second graph compares the head       childhood obesity because it can persist into
    95th percentile for his or her age and sex,          circumference and weight for length. There are       adulthood. The probability of obesity persisting
    he or she should be further evaluated for the        also four charts for 2 to 20 years of age based      into adulthood increases from 20 percent at 4
    potential exogenous causes of obesity and for        upon gender, then one for the stature for age        years of age to 80 percent by adolescence [35].
    complications caused by overweight status.           and weight. The second graph in each gender          Another interesting factor, speculated by the New
                                                         is the BMI for specific age. The most prevalent      England Journal of Medicine, is that when these
According to Schwarz, 2007, the most recent
                                                         graphs utilized are based upon the 5th and 95th      children reach adulthood, they are less likely than
surveys nationally have demonstrated that 21 to
                                                         percentiles. However, a few specialists, such as     their thinner counterparts to complete college and
24 percent of American children and adolescents
                                                         endocrinologists, may utilize the 3rd and 97th       are more likely to live in poverty [43].
are overweight and that nearly 16 to 18 percent
                                                         percentiles [21].
are obese based upon the BMI criteria [60]. Since                                                             In addition to the various disease processes,
childhood obesity has doubled and tripled over           Similar to the BMI, the growth charts should         obesity is also associated with complications of
the past few decades with one in four children           not be used as a solo diagnostic instrument,         pregnancy, menstrual irregularities, hirsutism
being identified as obese, it is time that health        but should contribute to the overall clinical        (presence of excess body and facial hair),
care professionals properly screen children to           impression for the child being measured [21].        stress incontinence, increased surgical risk and
ensure the proper treatment is implemented               The growth chart provides a quick glance at the      mortality [79].
within families.                                         overall growth pattern based upon the average
                                                         percentiles with other children nationwide. It       Obesity and cardiovascular disease
Growth charts                                            allows the practitioner to assess whether the        Obesity and cardiovascular disease often occur
In addition to the BMI, the growth charts are            child is growing appropriately based upon            together. The increased demands of the body that
another tool utilized to measure and plot the            average growth or if the child is at risk for        is overweight or obese puts a strain on the cardiac
height and weight of the child each time he or she       being underweight, less than 5th percentile;         muscle, thus exacerbating the risks of an enlarged
visits the pediatrician. It is imperative to correlate   overweight, greater than 85th percentile; or         left ventricle (LV), cardiomegaly, hypertension
the growth charts with the BMI to assess a better        obese, greater than 95th percentile.                 (HTN) and atherosclerosis. According to the
analysis of the child, since body fat differs in age                                                          CDC, 2007, there are an estimated 61 percent
and gender [21]. The Centers for Disease Control         Morbidity and mortality                              of overweight young people who have at least
and Prevention (CDC) and the National Center             Individuals who are obese have a 10 to 50 percent    one risk factor for heart disease, such as high
for Health Statistics (NCHS) have collaborated to        increased risk from all causes of death compared     cholesterol (dyslipidemia) or high blood pressure
create the pediatric growth charts for a universal       to healthy individuals. Most of the increased        (HTN) [19]. There are multiple research studies
clinical impression nationwide [21]. The growth          risk is due to cardiovascular causes [79]. At this   that have implied atherosclerosis, hardening of
charts consist of a series of percentile curves          time, obesity is considered the second largest       the arteries, is prevalent in children as young
that illustrate the distribution of selected body        behavioral contributor to death after smoking,       as 3 years of age [32]. Atherosclerotic damage
measurements in U.S. children. [21]. During each         with 300,000 deaths occurring every year [30].       to the arteries is exacerbated by smoking, low
well-baby/child visit, the practitioner can easily       Throughout history, obesity has existed, but,        high-density lipoprotein and HTN [32]. HDL is
assess the average percentiles of their patient          it has not been as prevalent in our youth until      the healthy component of cholesterol required in
based upon the growth chart and measuring the            recently as it has reached epidemic proportions.     our bodies to reduce the risk of cardiovascular
age appropriate chart:                                   Failure to control the epidemic of obesity will      disease. However, HDL is decreased with a
     Initially, the growth charts were constructed       lead to children and adolescents decreasing their    high-fat diet. In order to increase the HDL, and
     by the National Center for Health Statistics        life expectancy and an increasing early mortality    decrease the risk of cardiovascular disease, one
     (NCHS) as a clinical tool for health                rate over the course of their lives [30].            needs to have a low-fat, nutritious diet and an
     professionals to determine if the growth of                                                              active lifestyle.
                                                         Long term complications of obesity
     a child is adequate. However, in 2000, the
                                                         According to the CDC, childhood obesity              Research has demonstrated that children 9 to
     CDC reconstructed the charts based upon
                                                         imposes a plethora of various health risks,          18 years of age had a higher risk of developing
     the research collected over the past few
                                                         complications and potential co-morbidities, such     HTN by being overweight and having a family
     decades from NHANES [21]. For the novice
                                                         as hypertension (HTN), dyslipidemia, type II         history of HTN [32]. Research has demonstrated
     nurse or practitioner, the growth charts can
                                                         diabetes, coronary heart disease, stroke (CVA),      that sleep apnea is a contributing factor for HTN
     be confusing because there are a total of 16
                                                         gallbladder disease, osteoarthritis, sleep apnea,    in adults; however, there are limited studies
     charts to date; eight for boys and eight for
                                                         respiratory problems, and some cancers such          completed in children [32]. Sleep apnea is
     girls.
                                                         as endometrial, brain and colon [23]. Obese          usually a less common complication of obesity
However, the health care professional will only          children are at significant risk of coronary heart   for children and adolescents. It is defined by a
utilize the appropriate charts based upon the age        disease (CHD) because most exhibit high blood        cessation of breathing for more than 10 seconds,
and gender of the child as follows: [21].                pressure (HTN), dyslipidemia, impaired glucose       in which the patient exhibits loud snoring and
 Infants, birth to 36 months, are to utilize the        tolerance (IGT) and vascular abnormalities [10].     labored breathing [17]. This phenomenon occurs
Elite CME                                                                                                                                                 Page 3
due to the release of a combination of a few key      becoming a developing world problem. In 1995,             with boys with a normal weight. Another
chemicals released during an apneic episode [71]:     the emerging market economies had the highest             complication of childhood obesity assessed
 During apnea, the carbon dioxide in the blood       number of diabetics. If current trends continue,          during the study was a 2.5 times risk of
    increases and oxygen levels drop. This effect     India and the Middle Eastern crescents will have          oppositional defiant disorder among boys
    triggers a cascade of physical and chemical       taken over the diabetic trend by 2025 [77].               and girls. An oppositional defiant disorder is
    events that can then increase risk for heart                                                                defined as a consistent uncooperative, defiant,
                                                      Type II diabetes is correlated with excess adipose
    problems.                                                                                                   hostile behavior to authoritive figures [13].
                                                      tissue and the term insulin resistance, also known
 Apnea also causes decreased levels of the
                                                      as metabolic syndrome. In addition, insulin           Among severely obese adolescents, 48 percent
    gas nitric oxide (NO), a potent substance that
                                                      resistance and adiposity increases the risk of        have moderate to severe depressive symptoms,
    causes blood vessels to be elastic and expand.
                                                      cardiovascular disease [53]. Therefore, many          and 35 percent report high levels of anxiety [13].
    NO plays a crucial role in blood pressure
                                                      patients battling obesity have insulin resistance     Obese girls are more likely to have attempted
    control and heart health.
                                                      and cardiovascular disease. Insulin resistance is     suicide than non-obese girls. Overweight
 Apnea may also increase levels of a
                                                      a prevalent term that develops from both genetic      adolescents reported engaging in significantly
    substance called angio tensin-converting
                                                      and environmental factors that coincides with         more unhealthy behaviors and experienced more
    enzyme (ACE), this has a significant role
                                                      obesity [34].                                         psychosocial distress than their non-overweight
    in exacerbating HTN and congestive heart
                                                      Normally, once an individual ingests a food,          peers. In addition, overweight adolescents are
    failure (CHF).
                                                      the item is broken into glucose, a simple sugar,      typically more isolated to their social networks
Dyslipidemia has been seen in children as young                                                             than to their normal-weight peers.
                                                      which is the main source of energy for the cells.
as 8 years of age who are overweight or obese
                                                      However, the body cannot use glucose without          Unfortunately our society places stigmas on
[71]. Dyslipidemia is demonstrated by having
                                                      the help of insulin breaking it down to convert       individuals for their outside appearance. A child
a fasting lipid profile that is compiled of the
                                                      it into energy. If the pancreas is not working        who is obese may be ridiculed or bullied by
total cholesterol and low-density lipoprotein
                                                      properly or there is an excessive amount of           peers and may exhibit signs of being withdrawn
cholesterol (LDL-C), triglycerides (TGs), and
                                                      adipose tissue in the body, the insulin is not        or depressed. It is important for health care
high-density lipoprotein cholesterol (HDL-C).
                                                      stimulated in a normal manner. Therefore, an          providers to screen each child for depression,
The AHA recommends the averaged results
                                                      excessive amount of glucose builds up in the          objectively and subjectively. One question a
of three fasting lipid profiles as the baseline
                                                      blood stream, setting the stage for metabolic         health care provider may ask the school age
for guiding treatment modalities. Enclosed are
                                                      syndrome and diabetes [50].                           and adolescent child is, “How do you generally
the normal cholesterol levels per the NCG and
                                                      In essence, insulin resistance is defined as the      feel on a daily basis?” In addition, if the health
American Heart Association (AHA) [53]:
                                                      body being unable to recognize and respond            care professional diagnoses obesity, the patient
Cholesterol levels for 2- to 19- year-olds                                                                  should be referred to psychological counseling
                                                      appropriately to the demands of insulin in the
 Levels         Total cholesterol,      LDL-C,        body, so, the body responds by making more            to help deal with behavior that exacerbates the
                mg/dL                   mg/dL         insulin, which predisposes the risk of diabetes       obesity issue and find ways to deal with the
                                                      and atherosclerosis. The most prevalent type of       psychological aspects.
 Acceptable     <170                    <110
                                                      diabetes is the adult onset, type II that comprises   Obesity and reproduction
 Borderline     170-199                 110-129
                                                      more than 85 to 90 percent of all cases [37]. The     At this time, researchers have limited data
 High           >200                    >130          most attributable factor for developing type II       correlating the effects of obesity and menarche.
Overall, children with an excessive amount            diabetes is weight gain, due to the excess adipose    However, researchers are assessing the potential
of adipose tissue are at a greater risk of            tissue. At this time, there are approximately 197     affect of leptin, a hormone that has a direct effect
cardiovascular disease and mortality as an            million people worldwide who have impaired            on fat, metabolism, and reproduction [46]. At this
adult [53]. There are numerous cardiovascular         glucose tolerance, most commonly because of           time, researchers have noted that females who are
complications that arise with excessive adipose       obesity and the associated metabolic syndrome         obese typically have an earlier onset or later onset
tissue. In order to eliminate the risk, health care   [37]. This number is expected to increase to 420      of puberty and menarche [63].
professionals are required to screen all children     million by 2025 [37].
                                                                                                             In the next few years, researchers will be
for obesity to reduce the risk of cardiovascular      It is important to eradicate the onset of diabetes    exploring the potential effects of leptin as the
damage and potential mortality as a young adult.      in children because it can result in advanced         etiology and correlation remains unclear at this
Obesity and diabetes                                  complications of cardiovascular disease and           time [72]. In general, the average female typically
Over the past few years, type II diabetes/non         kidney failure [17]. Researchers have seen an         begins puberty around 12 years of age; however,
insulin dependent diabetes (NIDDM), the typical       increased in Type II diabetics over the past two      it can be before or after, depending upon the girl’s
adult onset diabetes, has been on the rampage         decades that correlates to the rising obesity         genetic history, weight, activity, and stress.
among our youth. It has been surprising to many       numbers. The majority of the time, it can be
                                                      eliminated with proper exercise to decrease the       In addition, many females develop polycystic
health care professionals, because one usually                                                              ovarian syndrome (PCOS) due to obesity. In a
does not correlate type II with children; type        amount of adipose tissue stored in the abdomen.
                                                      In addition, fatty liver associated with excessive    U.S. study, scientists reported that the prevalence
I is the most common juvenile diabetes. Type                                                                of PCOS might be as high as 11.2 percent in
I diabetes is an inherited form of the disease        weight, unrecognized in the pediatric literature
                                                      before 1980, today occurs in about one in three       women of reproductive years. Of that group,
process in which the individual is unable to                                                                adolescent girls make up a large part, perhaps as
produce enough insulin. According to the Centers      obese children [43].
                                                                                                            high as 50 percent because the symptoms usually
for Diseases Control (CDC) in 2005, more than         Obesity and depression                                manifest during menarche. [38]. PCOS is a
13,000 young people are diagnosed with Type           According to a study at Duke University, chronic      classification of a female exhibiting the following
1 diabetes each year [18], as opposed to type II      childhood obesity was associated with a higher        signs [81]:
diabetes, which has been typically considered         incidence of depression in boys and hostile            Oligomenorrhea is a menstrual cycle that is
adult-onset and usually arises after the age of       defiant behavior in both boys and girls [13]. The         irregular and occurs greater than every 35
40, and has shown a dramatic rise among youth.        study said:                                               days. In addition, the female may have oligo-
Approximately 85 percent of individuals with              Boys who remained obese during their                  ovulation (irregular ovulation) or anovulation
diabetes are type II, and of these individuals, 90        childhood and adolescence were four times as          (not ovulating).
percent of them are obese or overweight [77].             likely to endure clinical depression compared      Hirsute/hirsutism is having fine, coarse hair
In 2007, the WHO has implied that type II is
Page 4                                                                                                                                               Elite CME
    on the face, chin, and abdomen; it is similar    follows [6]:                                              caloric foods has contributed significantly
    to male patterns.                                 Lack of physical activity – The American                to the obesity epidemic. In addition, many
   Obese, classified by the BMI.                        Heart Association recommends that all                 children do not have fruits and vegetables
   Infertile                                            children as young as 2 years of age begin to          in their diet. According to the CDC, 80
   Insulin resistance. Therefore, metabolic             participate in moderate, intense activities for       percent of high school students do not eat
    syndrome may coexist with PCOS, thus                 a minimum of 30 minutes every day. Children           fruits and vegetables five or more times per
    predisposing the woman to NIDDM, HTN,                and adolescents should be exercising at least         day [20]. Many children indulge in eating
    and heart disease.                                   60 minutes a day to reduce the risk of obesity        while participating in sedentary behaviors.
                                                         and cardiovascular disease [5].                       Research has also demonstrated that one
Impact of costs                                       Sedentary behavior – Watching television                in four toddlers exceeds estimated energy
As previously implied, the prevalence of
                                                         (TV), using the computer, playing video               requirements compared to their counterparts
obesity has doubled or tripled depending upon
                                                         games, listening to music or talking on               20 to 30 years ago by eating candy, pizza,
the age group, in the past 20 years. In lieu of
                                                         the phone are all examples of sedentary               chicken nuggets, soda, sweet tea and salty
the prevalence, it is important to recognize the
                                                         behaviors that increase the likelihood of             snacks [76]. The majority of the food they
billions of dollars spent in America every year
                                                         obesity. The American Academy of Pediatrics           eat is high-caloric, high-fat and high sugar,
related to obesity. The research or data that
                                                         (AAP) has estimated that children watch an            which all increase the risk of adipose tissue
provides the cost of obesity in America does not
                                                         estimated four hours of TV a day; however,            causing hypertrophy of the cells, and which
break it down between children and adults, but,
                                                         they should be limited to one to two hours            have no nutritional value to enhance growth
it implies the general costs of obesity. The cost
                                                         a day once they are over the age of 2 years           and development. In addition, the energy
of obesity in the United Sates was approximately
                                                         [3]. In addition, this does not include the           intake needs to be equal or less than the
$117 billion in 2000 [6]. However, 20 years ago,
                                                         amount of time a child is on the computer             energy expenditure in order to reduce the
the annual cost of childhood obesity was $35
                                                         or playing video games, which also results            risk of obesity [39]. It should be noted that
million a year [74].
                                                         in a sedentary lifestyle. In 2000, the CDC            coincidentally, the amount of sugar in many
At this time, the enormous costs of obesity in           found that older children, blacks and boys            products has increased over the past 30 years,
America is broken down into the following;               tend to watch more TV [14]. The AAP has               especially high-fructose corn syrup. For
    $61 billion was spent on direct health               also integrated a study compiled in 1999,             example, each 12-ounce can of soft drink
    costs, including preventive, diagnostic, and         which found children spend six hours and 32           provides the equivalence of 10 teaspoons
    treatment services, and $56 billion was spent        minutes a day combining TV and computer               of sugar and 150 calories per serving [76].
    on indirect costs, including income lost by          use together [2]. Based upon that data, the           Research has demonstrated that on average,
    individuals who were unable to work due              AAP has estimated that by the time people             more than half of school children consume
    to morbidity or injury, and future income            reach the age of 70, they have spent the              more than one can a day while at school,
    lost due to premature death [74]. The cost of        equivalent of 7 to 10 years of their lives            while adolescents average four soft drinks a
    lost productivity related to obese Americans         watching television [2]. It should be noted           day [76].
    between 17 to 64 years of age is $3.9 billion,       that with excessive TV viewing, computer             Environment – An environment that
    based upon data in 1994 [79].                        use, or insufficient physical activity, there         overexposes high-calorie foods and lack of
                                                         is an increase in adipose tissue because              recreational activities will exacerbate the
The amount of money being spent on obesity
                                                         there is an increase in the energy intake             risk of childhood obesity. Children need to
is astonishing. As noted, the majority of data
                                                         and a decrease in the energy expenditure,             be exposed to an environment that fosters
that demonstrates the current costs pertains to
                                                         thus exacerbating the adipose tissue [35].            growth and development through nurturing;
the obese adult. There is no current research
                                                         The majority of the time when children and            addresses hunger with nutritional foods;
or literature reflecting the psychological costs
                                                         adults are watching TV, they are snacking             communication; participation in sports or
impacted by childhood obesity. In addition, the
                                                         on foods that only exacerbate the potential           recreational activities as a family to reduce
costs provided do not include the additional
                                                         obesity problem. During this vicious cycle of         the risk of childhood obesity. Unfortunately,
amounts spent on co-morbidities related
                                                         watching TV and snacking on foods, children           this may not be feasible for some families
to obesity. If we do not collaborate with
                                                         are also exposed to marketing techniques that         with two working parents or a single family
patients, families, schools and other health
                                                         encourage children to snack on high caloric           home in which there is no parent with the
care professionals, the potential health and
                                                         foods with little or no nutritional value. The        child the majority of the day. The IOM’s fact
detrimental effects of obesity will continue to
                                                         average child will see an estimated 30,000            sheet of 2005 implied that the environment
cost astronomical amounts every year.
                                                         TV commercials a year, advertising foods              could be influenced by the following
Contributing factors                                     high in sugar, saturated fats, salts, and soft        variables:
There is a multiple array of variables that              drinks [76]. See additional comments under            Š Urban and suburban designs that
contribute to childhood obesity that will be             Marketing.                                                 discourage walking.
explored. It should be noted that there is an         Socioeconomic status – Low family                       Š Pressure on families to minimize food
abundance of data correlating the following              incomes and non-working parents have                       costs.
potential variables to increasing the incidence of       a higher incidence of children that are               Š Reduced access and affordability of
one being overweight or obese. However, many             obese. There was a longitudinal study                      fruits, vegetables and other nutritious
cannot agree on the exact cause of the diagnosis         complied in the 1990s that assessed over                   foods for some communities.
for each individual child. The CDC says being            2,900 children during a six-year time                 Š Decreased opportunities for physical
overweight is the result of caloric imbalance,           frame that noted the following results                     activity at school and after school. [39]
and it is mediated by one’s genetic makeup               suggested home environment may influence
                                                                                                           Another modifiable factor that is not implied
and overall health [19]. The variables can be            childhood obesity: Children who lived
                                                                                                           by the American Obesity Association, but is an
classified as modifiable, one having the ability         with single mothers were significantly
                                                                                                           important variable contributing to the epidemic
to control or change the behavior, and non-              more likely to become obese by the 6-year
                                                                                                           is family dynamics. Over the past few decades,
modifiable, which is one that cannot be changed,         followup, as were black children, children
                                                                                                           there have been enormous changes within the
such as genetics.                                        with nonworking parents, children with
                                                                                                           family. Many families have required two working
                                                         nonprofessional parents, and children whose
According to the American Obesity Association,                                                             parents to meet the financial obligations to
                                                         mothers did not complete high school [68].
the modifiable causes of childhood obesity are as                                                          sustain a certain lifestyle. However, by the end
                                                      Eating habits – Overconsumption of high-
                                                                                                           of the day, both parents are extremely exhausted
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after working all day, and it is more convenient      foods were marketed to youth might influence           sending to students.
to purchase fast food or processed dinners that       the consumption of extra calories or bad food
                                                                                                             Although combating childhood obesity is a major
are high in fat and sodium and low in nutritional     choices. The result from the new Institute of
                                                                                                             goal of Healthy People 2010, there have been
value. In addition, throughout the day, many of       Medicine (IOM) study, Food Marketing to
                                                                                                             limited programs implemented in the fight. Many
these children have access to watch television,       Children and Youth: Threat or Opportunity,
                                                                                                             researchers have various opinions on the reasons,
play video games, or search the Internet after        provided astonishing details reiterating the impact
                                                                                                             blaming the media and marketing and budgeting
school, leading to a sedentary lifestyle. Research    of the way youth are targeted. Food marketing,
                                                                                                             in the school systems. There is also limited
has demonstrated that over the years, combining       the IOM implied, intentionally targeted children
                                                                                                             data on changes that have been implemented in
a high calorie diet and a sedentary lifestyle         who were too young to distinguish advertising
                                                                                                             each state. Arkansas was the first state to enact
increases the incidence of obesity [44].              from truth and it encouraged them to eat high-
                                                                                                             legislation in 2003, which was implemented
                                                      calorie, low-nutrient (but highly profitable)
Sometimes in life, individuals are predisposed                                                               during the 2003/2004 school year. It says each
                                                      “junk” foods. [54].
to certain disease states based upon their genetic                                                           school district shall:
makeup. Therefore, a non-modifiable variable          It should be noted that American children spend         Prohibit in-school access by elementary
that influences the risk of a child being obese is    nearly $30 billion of their own money annually              school students to vending machines offering
the following:                                        on “junk” foods. Since 1994, U.S. companies                 food and beverage, 2) disclose to parents the
    Family history – A child with neither parent      have introduced about 600 new children’s food               financial relationship between the school and
    being obese has less than a 10 percent chance     products; half of them have been candies or                 competitive food and beverage companies;
    of becoming obese, whereas overweight             chewing gums, and another fourth are other types            3) require schools to disclose to parents an
    adolescents with at least one parent obese        of sweets or salty snacks. Only one fourth are              annual body mass index (BMI) percentile
    have an 80 percent chance of becoming             more healthful items, such as baby foods, bread             by age for each student; 4) require schools
    obese [76]. Parental obesity doubles the          products, and bottled waters. Companies support             to explain annually to parents the health
    risk of adult obesity in obese and non-obese      sales of “kids’ foods,” with marketing budgets              implications of BMI, nutrition and physical
    children under the age of 10. In addition,        totaling an estimated $10 billion annually.                 activity [66].
    obese children under the age of 3 years           Kellogg spent $22.2 million just on media
                                                                                                             There is limited data available for other schools
    without obese parents are at a low risk           advertising to promote $139.8 million worth
                                                                                                             across the nation, according to the American
    for obesity as adults, but older children,        of Cheez-It crackers in 2004, but these figures
                                                                                                             Academy of Pediatrics (AAP), NIH, and the
    regardless of the parent’s weight status,         are dwarfed by McDonald’s $528.8 million
                                                                                                             United States Department of Agriculture (USDA)
    are an increasing predictor of adult obesity      expenditure to support $24.4 billion in sales [54].
                                                                                                             which regulates food programs offered within
    [75]. A study on modifiable variables,
                                                      Influence of our American schools                      the schools. The USDA has data from 2002 that
    including socioeconomic status found that
                                                      Children spend an enormous amount of their             mentions the foods offered within schools, based
    maternal obesity was the most significant
                                                      childhood in school. Therefore, our schools            upon the state.
    predictor of childhood obesity [75]. Due to
                                                      have a role in either exacerbating or eradicating      In addition, school systems have limited the
    genetics, children are at an increased risk of
                                                      childhood obesity nationwide. There are a few          access students have to exercising. In May 2006,
    developing co-morbidities similar to their
                                                      general, repetitive factors in which the school        the AAP assessed the physical activity aspect
    parents’ including obesity as a child.
                                                      systems may participate that can worsen the            and influence in childhood obesity, as well as
In addition, children are predisposed to the          obesity epidemic; a) the food and drink choices        incorporating the influence of the schools. It said
potential risk of obesity based upon behaviors        that are offered to the children on a daily basis at   research has demonstrated the following results:
implemented by their birth mother before and          school, b) the amount of time each child has to            Only 8 percent of elementary schools, 6.4
after delivery. Research has demonstrated that        engage in physical activity, and c) the educational        percent of middle schools, and 5.8 percent
maternal smoking is associated with a higher          information provided to children and their                 of high schools have an existing physical
BMI in children [53]. It has been speculated that     families about nutrition and healthy living.               education (PE) program for all grades
women who smoke during pregnancy typically
                                                      According to the National Academies, there                 nationwide. However, 80 percent of the
limit the amount of fruits and vegetables that they
                                                      was a 2000 report from the General Accounting              schools require a PE program in their schools,
consume in their diet, thus potentially increasing
                                                      Office that found competitive foods were sold              but 40 percent of the elementary, 52 percent
the risk of obesity later in life. Children learn
                                                      in 98 percent of secondary schools, 74 percent             of the middle schools, and 60 percent of the
by example, so if their parents do not consume
                                                      of middle schools, and 43 percent of elementary            high schools are exempt from PE. The AAP
a healthy diet, they will more than likely eat the
                                                      schools nationwide [49]. While the U.S.                    provided two reasons for this: disabilities
same types of foods and participate in the same
                                                      Department of Agriculture requires school meals            and religious preferences. In addition,
behaviors as their parents. On a positive note,
                                                      to follow the Dietary Guidelines for Americans,            the percentage of students with daily PE
women who breast-feed their children typically
                                                      federal restrictions on competitive foods and              attendance was down from 41.6 percent in
reduce the risk of their children becoming obese.
                                                      beverages are limited to prohibiting the sale of           1991 to 25.4 percent in 1994, and the data has
Influence of our society                              any soft drinks and certain types of candy in              remained the same for over the past 10 years
There is another enormous outside variable that is    cafeterias while meals are being served [49].              with 25.4 to 28.4 percent respectively [1].
impacting our child and adult obesity epidemic,       However, a study in 2007 noted that the majority           Unfortunately, the opportunities have not
marketing strategies throughout America.              of middle schools, 67 percent, and 83 percent              changed for the older age children, as the
Although some products being sold are unhealthy       of high schools continue to have contracts with            average number of minutes students spend
to the consumers, many companies are driven by        a soft drink company [61]. In addition, 32.7               in physical education (PE) each week drops
power and revenue as they continue to market          percent of elementary schools, 71.3 percent of             from 172 minutes in 8th grade to 89 minutes
and advertise certain foods in an enticing manner.    middle schools and 89.4 percent of high schools            in 12th grade, by which time only a third of
                                                      had either a vending machine or a school store             students have even taken a gym class at some
In 2006, the New England Journal of Medicine
                                                      or snack bar where students could purchase                 time during the school year [61].
published an article on an initiative implemented
                                                      these high-fat, high calorie items in school. [27].
in 2004 by Congress. During 2004, Congress                                                                   It is amazing how limited opportunities there
                                                      According to the CDC, ironically, only 4 percent
requested that the CDC examine another                                                                       are for our youth while they attend school,
                                                      of states mandate that schools make fruits or
potential cause that may be influencing the                                                                  especially with the childhood obesity epidemic.
                                                      vegetables available to the students. It is alarming
staggering cases of childhood obesity in our                                                                 It is imperative for health care providers, parents,
                                                      to think about the message our school boards are
country. The Congress speculated that the way                                                                and individuals within a community to unite and
Page 6                                                                                                                                                 Elite CME
work with legislators for each state to bring about                                                                   because the left ventricle is normally
changes for youth. Although the school district         Table 3                                                       weaker in a pediatric patient. As the child
may only be one influence on youth, the majority              Recommended daily amounts from each                     grows, the heart will enlarge and develop
of the children within the U.S. attend school                 group [36].                                             steadily which is demonstrated in the normal
every day. Children, if they have the opportunity                                                                     increase in the blood pressure curve as
to choose water, juice or a soda, will choose the             Food        1000 1200         1400      1600            follows [31]:
soda. In addition, if a child has the opportunity to          group       cal  cal          cal       cal
                                                                                                                            Age             BP
choose between a salad and pizza, the majority                Fruits      1c      1c        1 1/2 c   1 1/2 c
will choose the high-fat options.                                                                                           3               90/56
                                                              Vege-       1c      1 1/2 c   1 1/2 c   2c
Clinical assessment and findings                              tables                                                        4               92/56
Ideally, nurses and practitioners need to screen              Grains      3 oz.   4 oz.     5 oz.     5 oz.                 6               96/57
each patient for weight gain and the high-risk                                                                              8               99/59
patterns and behaviors that lead to obesity before            Meat        2 oz.   3 oz.     4 oz.     5 oz.
the weight gain becomes severe [35]. Research                 and                                                           10              102/62
has demonstrated that if it is caught early, the              legumes                                                       12              107/66
long-term complications and consequences                      Milk        2c      2c        2c        3c                    14              110/67
may be eradicated. Once weight gain has been                  Oils        3 tsp   3 tsp     3 tsp     4 tsp
established, it is recommended to screen for                                                                                16              112/67
modifiable and non-modifiable risk factors that         6.  Exercise pattern. It is recommended that             2.   Height and weight, plotted on a graph at
increase the patient’s chance for becoming obese.           children 2 years of age should exercise at                each visit, that is based upon the average
In addition, one should not stereotype or label             least 30 minutes a day, whereas a child over              percentile for the individual child’s age and
someone as obese based upon those factors alone.            the age of 2 should engage in at least 60                 gender. In addition, include the BMI.
It is imperative to first begin with a thorough             minutes of physical activity each day of the         3. Skin for acanthosis nigricans. The
history, assessing the patterns of eating and               week [5].                                                 practitioner may note that the skin over the
exercise for the patient and family, which include      7. Time of onset of weight gain or obesity. It                neck may appear hyperpigmented, a thicker/
the following [14]:                                         is important to note the trend of the weight              darker color, and have a velvet appearance
1. Dietary intake. It is important to assess the            gain to screen for additional complications               [72].
       entire dietary intake for the child. One can         or other contributing factors.                       4. Perform the Tanner staging. It is important
       assess the dietary intake by encouraging the     8. Family history of diabetes. As previously                  to assess the sexual maturity rating for male
       parents to monitor a diary of the diet over          implied, if there is a family history of                  and female children as they develop into
       a few days. In addition, inquire about the           diabetes and the patient is obese, it increases           adulthood. [72] It is important to assess
       usual number of meals per day and the type           the risk to the child.                                    the normal growth and development of the
       and number of snacks consumed [72].              9. Episodes of sleep apnea. Apnea is defined as               school age and adolescent child as they
2. Total caloric intake. The individual child’s             a cessation of oxygen while asleep, greater               go through puberty to assess that they are
       energy needs vary depending on his or her            than 10 to 20 seconds.                                    properly developing. See Table 4 for the
       age, growth, and physical activity. As a rule    10. Social adjustment, peer group and friends.                difference in the Tanner stages for the male
       of thumb, a 1-year-old requires 800 calories         It is important to assess the peers and the               and female patient [11].
       a day; at 6 the child requires 1600 calories,        individuals who may be contributing to the           Table 4
       and at 10 the child requires, 2000 calories a        weight gain because their issues may be an                   Tanner Staging [55]
       day [76].                                            influence.                                                   Girls
3. Fat intake as a percentage of total calories.        11. Family readiness to participate in a weight
                                                            management program. In order to elicit a              Tanner    Stage of       Pubic       Breasts
       At this time, a child should be limited to a                                                               stage     develop        hair
       total fat intake of 30 to 40 percent of energy       change in the behavior of one individual,
       for children 1 to 3 years of age and 25 to           especially a child, the parents and family            Stage 1   Early          Pre-        Pre-
       35 percent for children 4 to 18 years [76].          need to collaborate. Otherwise, the child                       adolescence    adoles-     adolescent
       Younger children require additional fat              may feel isolated and lack the motivation                       (10-13         cent
       intake in their diet because it fosters brain        to continue changing his or her lifestyle                       years)
       and growth development.                              choices.                                              Stage 2                  Sparse,     Small
4. Carbohydrate intake as a percentage of total         The physical assessment needs to include a                                         straight    mound
       calories. Carbohydrates are based upon the       thorough head-to-toe assessment. It should be             Stage 3   Middle         Dark,       Bigger, no
       glucose utilized by the brain. After 1 year of   noted that the heart tones may appear distant or                    adolescence    curl        contour
       age, brain glucose is consistent with an adult   be displaced from the normal placement if it is                     (12-14                     separation
       level [76]. According to the Recommended         enlarged. For a child under the age of 7 point of                   years)
       Dietary Allowances (RDA), before age             maximal impulse (PMI), is normally at the 4th
       1, the carbohydrate intake should be 60;                                                                   Stage 4                  Coarse,     Secondary
                                                        intercostals space, rather than the fifth intercostals
       whereas after age 1, it more than doubles to                                                                                        curly,      mound of
                                                        space (ICS) of a child older than 7. However,
       130 [76].                                                                                                                           abundant    areola
                                                        with any heart disease, it may be displaced. In
5. Nutrient adequacy of diet. Children should           addition, the following components need to be             Stage 5   Late           Triangle,   Nipple
       be provided meals with food from each            addressed in the assessment process:                                adolescence    medial      projects;
       of the food groups based on their age and        1. Vital signs. All of the vital signs should                       (14-17         thigh       areola part
       required calories a day. (See Table 3)                be assessed routinely on the pediatric                         years)                     of breast
                                                             patient, temperature, pulse and respirations.
                                                             The blood pressure of the child should be
                                                             assessed beginning at the age of 3 years old
                                                             [31]. The normal blood pressure for a child
                                                             differs more than the normal adult, <120/80


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                                                       health care professional must order and                     factors of the obesity or coincide with the
                                                       review certain diagnostic tests based upon the              obesity. Many times obesity and diabetes
Table 4 (continued)                                    National Guideline Clearinghouse (NGC),                     go hand in hand. The goal of the Hgb
        Boys                                           Clinical Guidelines in Family Practice, and                 AIC is to maintain at less than 6 percent
 Tanner Stage   Pubic           Penis      Testes      the Current Medical Diagnosis and Treatment                 to reduce the risk of heart disease and
 stage  of      hair                                   in pediatrics (CMDT) recommendations. It                    kidney damage. See Table 5.
        develop                                        should be noted that the NGC is a prestigious         Hgb A1C Blood sugar conversions [20]
                                                       organization that is a subsidiary of the Agency
 Stage 1   Early      None      Pre-       Pre-        for Healthcare Research and Quality (AHRQ)
           adoles-              adoles-    adoles-     and the United States Department of Health and
           cence                cent       cent        Human Services, that offers evidence-based
           (10.5-                                      clinical practice guidelines [51]. The purposes
           14                                          of the diagnostic tests are to rule in or out the
           years)                                      contributing factor toward the obesity and rule in
 Stage 2              Scanty    Slight   Larger        or out the potential complications that may arise
                                increase               due to obesity.
 Stage 3   Middle     Darker, Longer       Larger      In addition to previously mentioned
           adoles-    curls                            complications from obesity, there are other
           cence                                       medical conditions that may manifest with
           (12.5-                                      obesity, such as the following endocrine disorders
           15                                          [72]:
           years                                        Pituitary and adrenal dysfunction.
 Stage 4              Adult,    Larger     Scro-        Thyroid disease.
                      coarse,              tum          PCOS.
                      curly                dark         Hypothalamic disease.
 Stage 5   Late       Adult-    Adult      Adult       Therefore, obesity is diagnosed based upon
           adoles-    thighs                           the BMI percentiles for the height, weight and           Thyroid stimulating hormone (TSH). The
           cence                                       gender:                                                   TSH measures the function of the thyroid. In
           (14-16                                       If > 85th percentile, screen for HTN,                   May 2005, a research study was conducted
           years)                                          dyslipidemia, and diabetes.                           with 4,600 participants that demonstrated
                                                        If > 95th percentile, screen for exogenous              a direct correlation in the TSH and BMI.
Due to the complexity of obesity, one must be              causes and complications that are exacerbated
diligent in proficiently assessing the pediatric                                                                 Overall, researchers concluded that the
                                                           by obesity. Exogenous causes are contributed          thyroid function, even when within normal
patient in a professional demeanor placing a               to overeating [80].
potential stigma on him or her. The BMI is an                                                                    range, is a factor that helps determine body
important source in screening and predicting           If the BMI demonstrates a patient is overweight           weight, and even slightly elevated TSH
potential complications and co-morbidities             or obese, then the practitioner is encouraged to          levels are associated with an increase in
related to obesity. Therefore, key diagnostic          adhere to ordering the following diagnostic tests         the occurrence of obesity. Interestingly,
factors are the result of the BMI, the growth          [72]:                                                     thyroid function has the same impact on
chart, and the physical assessment. Due to              Assess the following lab values, once                   BMI as physical activity. [62]. There was
modifiable and non-modifiable risk factors and              overweight or obesity has been established.          another study in 2000 in Germany that
other medical conditions that may be contributing           Š Hemoglobin A1C. The glycosylated                   demonstrated the medians of the TSH and T3
to the obesity, one must be very thorough in                   hemoglobin A1C(Hgb A1C) is a                      concentrations were normal, but significantly
history and assessment techniques.                             direct correlation of the percentage of           higher in the obese group than in the controls,
                                                               glucose that attaches to the hemoglobin           while the T4 levels did not differ. In addition,
The American Obesity Association encourages                    A over a course of five to 12 weeks               in order to effectively treat the thyroid, one
nurses and practitioners to assess for additional              [29]. Hemoglobin transports oxygen                must first control the weight [67].
signs and co-morbidities that the patient may                  throughout the bloodstream. If there is          The normal adult TSH level is 0.5 and 4.0m
exhibit [7].                                                   an accumulation of excess glucose, it will        U/L, whereas the normal pediatric level is as
 Modifiable:                                                  be demonstrated in the Hgb A1C blood              follows [41]:
    Š Cardiac risk factors with a higher than                  test by a percentage. The percentage of             Age              Male            Female
         average blood pressure, heart rate, or                the Hgb A1C has a direct correlation to                            (μIU/mL)         (μIU/mL)
         cardiac output.                                       the average blood glucose level over the
    Š Type 2 diabetes risk factors, such as                                                                      1 mo - 5 y      0.550-7.100      0.460-8.100
                                                               duration of the average life of a red blood
         glucose intolerance and insulin levels that           cell (RBC). The average red blood cell             6-18 y         0.370-6.000     0.360-5.800
         are higher than normal.                               lives for 90-120, days depending on the
    Š Orthopedic problems, which include                                                                        Lipid panel. The lipid panel is composed of
                                                               health of the individual. The results of          three types of cholesterol to rule out cardiac
         weight stress in the joints of the lower              the Hgb A1C are an average of 1 percent
         limbs, tibial torsion, bowed legs and                                                                   disease: low density lipo proteins (LDL),
                                                               change in the A1C result which reflects a         high-density lipoproteins (HDL) and total
         slipped capital femoral epiphysis.                    change of about 30 mg/dL (1.67 mmol/L)
         According to the American Obesity                                                                       cholesterol. There is limited data correlating
                                                               in the average blood glucose. Therefore,          normal lipid panel results for the pediatric
         Association, this is more common in                   an Hgb A1C of 6 percent corresponds to
         males.                                                                                                  patient. However, according to Diabetes
                                                               an average glucose of 135 mg/dL (7.5              Care, the total cholesterol is usually 40 points
    Š Patterns of sedentary behavior, such as                  mmol/L), while an A1C of 9 percent
         too much television and low physical                                                                    higher in the adult than in the child [4]. The
                                                               corresponds to an average glucose of 240          following are the normal adult levels [42]:
         activity level.                                       mg/dL (13.5 mmol/L) [40]. The Hgb A1C             Š LDL < 100 mg/dl; the bad cholesterol.
Diagnostic procedures                                          is an important test to assess for obesity        Š HDL > 35 mg/dl; recently the AHA
To properly treat childhood obesity, the                       because it can be one of the contributing
Page 8                                                                                                                                                 Elite CME
        raised the recommended results to >60 to      family and health care providers. Failure for the          Š   If the child is > 7 years of age with
        reduce the risk of cardiovascular disease.    parents to comply or collaborate in a family/team              a BMI between 85-95 percent, with
        The HDL is the good cholesterol.              approach could be detrimental to the child, who                complications, the primary goal is weight
    Š Triglycerides < 150 mg/dl.                      may feel isolated and alone as he or she battles               loss. The appropriate goal is one-pound
   Complete metabolic panel (CMP). The CMP           obesity. It should be conveyed to the parents                  weight loss a month until a BMI less than
    assesses for normal electrolytes and to screen    that although being overweight and obese is a                  85 percent is met.
    for diabetes and liver function.                  complex medical problem, it is treatable and it is
                                                                                                             In order for parents and children to meet their
   Urinalysis. The urinalysis assesses for           imperative that they verbalize understanding of
                                                                                                             personal goals of weight maintenance or loss
    ketones, which demonstrate the potential for      this concept [72]. In addition, each child should
                                                                                                             based upon their age, percentile, and co-
    diabetes. In addition, frequent urinary tract     be referred for behavioral therapy to assist them
                                                                                                             morbidities, the following is recommended [72]:
    infections, demonstrated by leukocytes or         in making lifestyle modifications and changes
                                                                                                              Between 2 and 7 years of age:
    ketones in the urine, may also be correlated      within their lives. As a practitioner or nurse
                                                                                                                 Š Gradually reduce the amount of fat in the
    with underlying diabetes.                         caring for the patient and family, one should
                                                                                                                     diet; however, some fats, such as linoleic
                                                      display a professional, caring, compassionate
In addition, based upon the physical assessment                                                                      and linolenic acid, are vital for growth.
                                                      demeanor at all times to promote a trusting
finding, family history, and the results of the                                                                      Linoleic acid (Omega 6 family) is found
                                                      relationship.
laboratory values, the following additional tests                                                                    in vegetables, fruits, nuts, grains and
may be ordered:                                       If the child is under the age of 2 years, he or she            seeds. Linolenic acid (Omega 3 family)
 12-lead electrocardiogram (EKG) and/                should be referred to a pediatric obesity center               is composed of flaxseed, fish, green leafy
    or echocardiogram. The EKG and echo               for appropriate management and treatment. If this              vegetables, grains, and soybeans [73].
    can assess for any underlying cardiac             referral is not feasible, then the primary caregiver       Š The majority of their calories must be
    abnormalities.                                    should at least consult the center. In addition, the           consumed by grains, fruits, vegetables
 Complete blood count (CBC). The CBC can             following recommendations are encouraged in                    and reduced fat dairy products.
    assess for underlying infections, which may       the Clinical Guidelines in Family Practice for the         Š Encourage parents to limit the amount of
    be exacerbated with undiagnosed diabetes.         child less than 2 years of age [72]:                           TV to less than one hour a day.
    In addition, the CBC can assess for anemia,        Discourage feeding the infant or toddler high            Š Refer to a nutritionist.
    which may be complicated by an underlying              calorie foods.                                     Older than 7 years of age
    cardiac disorder due to the obesity.               Limit juices to two to four ounces a day. As             Š The dietary guidelines are similar to that
 Urine microalbumin. Microalbuminurea                     parents and health care professionals, we                 of adolescents and adults. It is important
    assesses for the daily excretion of albumin,           should encourage water for our toddlers,                  to focus on consuming healthy meals.
    which can be detected per a urine dipstick.            school age and adolescent children. In
                                                                                                             Although there are limited research studies
    Microalbuminurea is an important indicator             addition, Motts for Tots offers juices with 40
                                                                                                             correlating the long-term effects of weight
    of nephropathy, which is a complication of             percent less sugar today.
                                                                                                             control programs for children, treatment focused
    the diabetes [29].                                 Advise the parent to offer a pacifier between
                                                                                                             on behavioral changes integrating the family have
 Pulmonary function test (PFT). PFTs                      feedings to limit the urge to eat.
                                                                                                             been associated with weight loss and a decrease
    are completed to assess for asthma, a              Never put a child under the age of 2 on
                                                                                                             in the BMI [35]. Therefore, strongly urge the
    complication of obesity.                               reduced fat milk, as the high fat in the milk
                                                                                                             family to be proactive and positive because
 Chest x-ray (CXR). A CXR is completed to                 promotes brain development and growth.
                                                                                                             negative attitudes and demeanors will prevent the
    assess for consolidation in the lung fields        Refer the child to a nutritionist to provide
                                                                                                             child from making a lifestyle change. In addition,
    and the structures of the heart to rule out            additional education for the parents and
                                                                                                             set goals with the patient and family to ensure a
    cardiomegaly, an enlarged heart that can be            to customize a thorough diet plan for the
                                                                                                             collaboration and partnership within the family.
    exacerbated by obesity.                                patient.
 Skin-fold measurements. Skin-fold                    Reassess the child monthly.                          In addition to dietary modifications, it is
    measurements are a more accurate, diagnostic                                                             imperative to exercise. The AHA recommends
                                                      Below are recommendations to treat childhood
    screening tool to assess for obesity. However,                                                           at least 60 minutes of activity for all children,
                                                      obesity per the 2007 current diagnosis and
    many clinicians do not incorporate them into                                                             adolescents and adults [72]. However, it should
                                                      treatment guidelines if the child is over the age
    their routine screening because it is costly                                                             be reiterated that the AHA recommends that
                                                      of 2 [35].
    and time-consuming.                                                                                      2-year-olds should participate in 30 minutes of
                                                       If uncomplicated obesity, the primary goal
 Sleep studies. Sleep studies are completed to                                                              exercise. In addition, during the initial treatments,
                                                          is to achieve healthy eating and activity
    assess for sleep apnea.                                                                                  the patient and family should begin gradually,
                                                          patterns.
                                                                                                             slowly building up to their exercise goal.
Treatment of childhood obesity                            Š If the child is between 2-7 years of
After the diagnosis of obesity has been                        age with a BMI > 95 percent and no            Prescription medications to help eliminate the
established, it is imperative to initiate treatment            complications, the primary goal should        weight, should be initiated only as an adjunct to
to manage any acute or chronic complications                   be to maintain the child’s current weight     dietary, activity, and behavioral treatment. There
exacerbated by obesity. The therapy should be                  to promote them to “grow into” their          are limited options for prescription medications
based on the child’s risk factors, age, severity               height.                                       for the pediatric patient diagnosed with obesity.
of obesity, comorbidities, family history and             Š If the child is > 7 years of age with a          And, medications should be the last resort for
support [35]. The therapy is always customized                 BMI between 85 to 95 percent, without         children. Typically, children diagnosed with being
for the individual patient. In addition, the                   complications, the primary goal is weight     overweight or obese, without any contributing
recommendations for children battling obesity                  maintenance.                                  factors and co-morbidities, can be treated with
differ from that of an adult because the child is      If the child is enduring secondary                   diet, exercise, and behavioral lifestyle changes.
still growing; the treatment needs to be gradual          complications, the primary goal is to              At the time of this writing Orlistat is approved for
and safe. If a child loses excess weight, that can        eradicate or improve the complication arisen       treating obesity in adolescents. [35].
contribute to nutritional deficiencies and could          from obesity.                                      However, if the contributing factor is related
stunt growth [35].                                        Š If the child is between 2-7 years of             to an endocrine disorder, such as diabetes
                                                               age with a BMI > 95 percent and               or hypothyroidism, then the appropriate
In order for the treatment to be successful, the
                                                               complications, the primary goal is weight     pharmacotherapy will be implemented in
child needs to have support from his or her
                                                               loss.                                         conjunction with the obesity treatment.
Elite CME                                                                                                                                                  Page 9
   If the pediatric patient has been diagnosed         The key with education is to begin with the                   and dancing.
    with obesity, metabolic syndrome or Type            parents, because they are the most important role         Š   In addition, parents need to discourage
    II diabetes, the child can be prescribed            models for their children. Children learn by the              sedentary lifestyle behaviors of their
    metformin (glucophage) 500 mg twice a day           examples set by their parents at an early age.                children. Children whose parents
    (BID) to reduce the insulin resistance, thus        Parents can be effective by ensuring that they                are home or participate in activities
    decreasing the weight [59].                         choose healthy foods and exercise. The American               with them are less likely to indulge
   If the pediatric patient has an underlying          Obesity Association conducted a study that                    in sedentary behaviors [28]. Regular
    hypothyroidism, the patient will be referred        demonstrated the following results:                           physical activity is one of the key
    to an endocrinologist for proper treatment              Almost 30 percent of parents said they are                factors helping children and adults
    and monitoring of the hypothyroidism.                   “somewhat” or “very” concerned about their                to achieve and maintain a healthy
                                                            child’s weight, and 12 percent of parents                 weight, thus reducing their risk of co-
If the pediatric patient has a co-morbidity, such as
                                                            considered their child overweight [8].                    morbidities related to obesity. The CDC
dyslipidemia, the first choice of treatment is a bile
                                                        The other key aspect to promote healthy eating                has recognized a vast array of benefits
acid sequestrants, such as Colestid or Questran
                                                        and to prevent childhood obesity is for public                for those who participate in physical
[47]. Sequestrants bind to the bile acids in the
                                                        and private schools to ensure children have                   activity, as it helps to build and maintain
intestine to prevent them from being reabsorbed
                                                        healthy, nutritious meals while they are in the               healthy bones and muscles, helps reduce
into the bloodstream. The liver then produces
                                                        school and have opportunities to exercise. In                 the risk of developing obesity and
more bile to replace the lost bile. However, for
                                                        addition, healthy living should be integrated into            co-morbidities, and reduces feelings
cholesterol to increase, it needs to make bile that
                                                        the educational curriculum in the school. Our                 of depression and anxiety because it
is found in the blood, reduces the LDL [48]. If
                                                        school systems need to promote healthy living by              enhances a psychological well-being
the LDL does not improve, the second choice
                                                        eliminating vending machines that sell sodas and              [26]. If time is a constraint, set aside the
is a statin, with the lowest available dose [47].
                                                        chips and cookies. All children should participate            time or participate in shorter increments
If the pediatric patient has elevated triglyceride
                                                        in a form of exercise for 30 to 60 minutes a day,             of activities throughout the day.
levels, it is best treated with blood glucose and
weight control, unless the levels are greater than      depending on their grade and abilities. If there      In addition, the AAP recommends parents
1,000mg/dl. At that time, it would be treated with      are conflicting variables, the child can experience   participate in all activities with their child and
a fibric acid to prevent pancreatitis [47].             alternative experiences related to health and         to lead by example as a role model. To elicit
                                                        exercise. We need to change our current module        a change in behavior, children need to have
In rare instances, surgical intervention has been
                                                        to elicit a change in our youth’s behavior and        powerful role models who participate in activities
implemented to reduce the weight loss; one of the
                                                        food choices.                                         and healthy behaviors. Although there are many
bariatric procedures may be a solution if the child
                                                        All children should be encouraged to develop          tempting foods to indulge in on a daily basis, we
meets the criteria. According to Schwarz, 2007,
                                                        healthy eating habits by their parents as they        need to be in control of our bodies and future,
the bariatric surgery has been used primarily in
                                                        adhere to the following CDC guidelines:               and we cannot let the food control our behaviors.
adults, but also in some children 15 years of age
or greater [60].                                         Diet. Children should participate in their          Another aspect to incorporate into our prevention
    The most common procedure is a gastric                  healthy food choices, instead of parents          education is to encourage parents to be positive
    reduction, in which a pouch is constructed              dictating their daily diet to them. Children      with their children, regardless of their weight.
    that has a capacity of 15 to 30 milliliters             who participate in their choices are more apt     Negative attitudes, comments, and behaviors
    (ml) of food at one time. In the gastric                to change their behavior, as this is a lifelong   verbalized by parents will not elicit a change
    bypass surgery, a larger pouch that empties             journey. Children should be encouraged to         in child’s behavior. Unfortunately, it could
    into the jejunum is created; this induces a             consume the following foods in their diet,        potentially lead to other complications, such
    dumping syndrome as the nutrients pass the              based upon their dietary recommendations          as depression or anxiety, or other nutritional
    duodenum and most of the stomach. The                   [24]:                                             behaviors, such as anorexia or bulimia and binge
    individual who has battled obesity for a                Š Provide plenty of vegetables, fruits and        eating. According to the CDC, a large number
    large portion of his or her life without much               whole grains. Parents should serve and        of high school students use unhealthy methods
    success, may be tempted to proceed with                     recommend a variety of colors.                to lose or maintain their weight; 12.3 percent of
    one of the bariatric procedures. However,                    Examples of low-fat and low-sugar           students went without eating for more than 24
    complications may arise from the surgery,                       foods:                                    hours, 4.5 percent had vomited or taken laxatives,
    such as encephalopathy, nephrolithiasis,                        Š A medium apple or banana.               and 6.3 percent had taken diet pills, powders, or
    cholelithiasis, protein-losing enteropathy, and                 Š One cup of blueberries, grapes,         liquids without the knowledge of their health care
    other nutritional deficiencies.                                      carrots or bell peppers.             professional [20]. Neither the parents nor health
                                                            Š Include a low-fat or non-fat milk, or dairy     care professionals want our youth to endure any
A child who is enduring obesity should be                       products.                                     more heartache. Children need to be loved and
referred to counseling and support-groups within            Š Choose lean meats, poultry, fish, lentils       nurtured, regardless of their weight. Parents and
the community, depending upon the severity,                     and beans for protein.                        health care providers need to be supportive of
co-morbidities, and support system at home.                 Š Serve reasonable sized portions. Most           the child at all times to build a positive, trusting
There are a vast array of organizations locally                 Americans indulge in oversized portions       rapport. The surgeon general recommends that
and globally to help educate children and families              for each meal, thus leading to obesity.       parents focus on their child’s strengths and
about obesity. In addition, there are nonprofit             Š Encourage your family to drink lots of          positive qualities, instead of their weight [69].
organizations, such as the American Obesity                     water.
Association, that offer support for the patient             Š Limit sugar-sweetened beverages.                Governmental influence
and family. It can be very beneficial for a child           Š Limit the consumption of sugar and              The government has realized that childhood
to talk with therapists or other children that are              saturated fat. See Table 3 (earlier in this   obesity has become an epidemic with staggering
encountering obesity.                                           chapter) for a breakdown of the amounts       numbers that needs to be eliminated. Therefore,
                                                                based upon the diet.                          there are a few programs implemented by
Prevention
                                                         Exercise.                                           agencies within the government to encourage the
It is imperative as health care providers to
                                                            Š Encourage at least 60 minutes of                recommended daily exercise for the entire family.
prevent childhood obesity for all children,
regardless of their weight and risk factors through             moderate exercise a day. Examples             In 1999 Hearts N’ Parks, a national community-
education, screening, and well-children checkups.               include; brisk walking, playing tag,          based program, supported by the American
                                                                jumping rope, playing soccer, swimming
Page 10                                                                                                                                                 Elite CME
Dietetic Association, the National Heart, Lung       to incorporate the family, children cannot be                                                   medscape.com/viewarticle/566056?src=mp
                                                                                                                                                   31. Engel, J. (2002) Pediatric Assessment. 4th edition. Mosby: St. Louis.
and Blood Institute (NHLBI) of the National          expected to defeat obesity on their own. We                                                   32. Festschrift, B. Obesity in Childhood and Cardiovascular Risk. Clinical and
                                                                                                                                                     Experimental Pharmacology and Physiology (2006) 33, 831-837.
Institute of Health (NIH) and the National           should not look at obesity as a solo incidence; we                                            33. Gidding, S. Leibel, R., Daniels, S., Rosenbaum, M., VanHorn, L., & Marx, G.
                                                                                                                                                     Understanding obesity in youth: A statement for healthcare professional from the
Recreation and Park Association (NRPA) [55].         need to lead by example as a family. The family                                                 committee on atherosclerosis and hypertension in the young of the council on
Hearts N’ Parks has made tremendous efforts to       has to work as a unit to change the behaviors                                                   cardiovascular disease. Circ: American Heart Association 1996; 94:3383-3387.)
                                                                                                                                                     Retrieved online December 6, 2007 at http://circ.ahajournals.org/cgi/content/
increase the number of participants since opening    of diet and exercise, the two major contributing                                                full/94/12/3383
                                                                                                                                                   34. Hannon, T., Gontham Rao, & Arslanian, S.A. (2005) Childhood Obesity and Type 2
in 1999. According to data published in 2004,        factors of obesity. Each member of the family                                                   Diabetes Mellitus. Pediatrics Vol 116. No 2. 473-480. Retrieved online December 13,
                                                                                                                                                     2007 at http://pediatrics.aappublications.org/cgi/content/full/116/2/473
the number of participants (1,200 in 2003) and       needs to demonstrate a positive, genuine, team                                                35. Hay, W., Levin, M.J., Sondheimer, J.M., & Deterding, R.R. (2007). Current diagnosis
                                                                                                                                                     and treatment in pediatrics (18th ed). Lange: New York.
programs (142 in 2003, compared to 68 in 2002)       approach to ensure each individual lives a                                                    36. Hgb A1C Blood Sugar Conversions. Retrieved online December 5, 2007 at http://
had doubled from 2002 to 2003 [57]. The goal of      healthier, longer life.                                                                         www.diabetes-blood-sugar-solutions.com/hgb-a1c.html
                                                                                                                                                   37. Hossain, P., Kavar, B., Nahas, M. (2007) Obesity and Diabetes in the Developing
the Hearts N’ Parks is to foster lifestyle choices                                                                                                   World- A growing challenge. New England Journal of Medicine. Vol 356: 213-215,
                                                     As health care professionals, it is recognized                                                  January 18, 2007. Number 3. Retrieved online December 20, 2007 at http://content.
that will change and reduce the risk of heart                                                                                                        nejm.org/cgi/content/full/356/3/213
                                                     that there are numerous programs and a wealth                                                 38. Insulite Laboratories. PCOS and Adolescents. Retrieved online December 20, 2007
disease and obesity. The program encourages                                                                                                          at http://www.pcos.insulitelabs.com/PCOS-and-Adolescents.php
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                                                     obesity; however, the number of individuals
the entire family to elicit change. In addition,                                                                                                   40. Lab Tests Online: A1C (2005). Retrieved online December 10, 2007 at http://www.
                                                     affected speaks louder than words. Therefore, it is                                             labtestsonline.org/understanding/analytes/a1c/test.html
the program has expanded to 50 new magnet                                                                                                          41. Laboratory Corporation of America (2007). Thyroid Stimulating Hormone. Retrieved
                                                     time that we step up and do more for our youth.                                                 online December 21, 2007 at http://www.labcorp.com/datasets/labcorp/html/chapter/
centers in 11 states nationwide: Arizona, Florida,                                                                                                   mono/ri010700.htm
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Georgia, Illinois, Indiana, Ohio, Maryland,                                                                                                          Kwa-Men/Lipid-Profile.html
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Michigan, Missouri, New Mexico, and Nevada.                                                                                                          of Medicine 2007. 357: 2325-2327. Retrieved December 6, 2007 at http://content.nejm.
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The Indiana-Ohio sites were combined as one                                                                                                          org/cgi/content/full/357/23/2325
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                                                     living long, healthy lives.                                                                   45. McCance, K.L., Huether, S.E. (1994). Pathophysiology: The biologic basis for
N’ Parks programs in the state of Florida [56].                                                                                                      disease in adults and children. 2nd ed. Mosby: Missouri.
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the CDC has begun to fund a new website,                Number 23 2329-2337 Retrieved December 12, 2007 at http://content.nejm.org/cgi/
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Healthy Dining, to allow consumers to look for          ions&excludeflag=TWEEK_element&searchid=1&FIRSTINDEX=0&resourcetype
                                                        =HWCIT
                                                                                                                                                     hnp_ab.htm
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restaurants within their local area to find the      11. Benjamin, J.T. (2004). Continuity Clinical Notebook: Tanner Staging. Retrieved              Retrieved online November 29, 2007 at http://www.nhlib.nih.gov/health/prof/heart/
                                                                                                                                                     obesity/hrt_n_pk/hnp_map_04.htm
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healthiest options. It can be accessed at www.          chapter3/tanner.htm                                                                        57. National Institute of Health News. May 27, 2004. Hearts N Parks Program Continues
                                                                                                                                                     to Help Participants of All Ages Adopt Heart-Healthy Behaviors. Retrieved online
healthydiningfinder.com [78].                        12. Bibbins-Domingo, K., Coxson, P., Pletcher, M.J., Lightwood, J., & Goldman, L.
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Conclusion                                              nejm.org/cgi/content/full/357/23/2371?query=TOC
                                                     13. Boyles, S. Mental illness common in childhood obesity. WebMD Medical News                   nrpa
Childhood obesity is an extremely complex               2003. Retrieved online November 29, 2007 at http://www.webmd.com/mental-health/
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                                                                                                                                                   59. Rx List: Glucophage. 2006. Retrieved online December 21, 2007 at http://www.
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disease process that affects the entire body         14. Burns, C., Dunn, A., Brady, M., Starr, N., Blosser, C. (2004). Pediatric primary care:    60. Schwarz, S.M. (2007). Obesity. Retrieved online December 5, 2007 at http://www.
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                                                        A handbook for nurse practitioners (246-261). (3rd edition). Saunders: Missouri.
system. It is imperative to properly understand      15. CDC (2007). About BMI for Children and Teens. Retrieved online December 27,               61. Science News. Childhood Obesity Due to a Host of Unhealthy Pressures, Study
                                                        2007 at http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.               Shows. Sept 26, 2007. Retrieved online December 20, 2007 at http://www.sciencedaily.
the disease and potential co-morbidities to ensure      htm                                                                                          com/releases/2007/09/070925160626.htm
                                                                                                                                                   62. Shomon, M. (2007). Slight Fluctuations in TSH: Can they affect your
that all children are thoroughly screened. Failure   16. CDC (2007). BMI- About BMI for Children and Teens. Retrieved online December
                                                        5, 2007 at http://cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm             weight? Retrieved online December 10, 2007 at http://thyroid.about.com/od/
to recognize or screen for the potential causes      17. CDC (2007). Childhood Overweight: Consequences. Retrieved online December 27,
                                                        2007 at http://www.cdc.gov/print.do?url=http percent3A percent2F percent2Fwww.cdc.
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and the potential co-morbidities may exacerbate         gov percent2Fncedphp percent2Fdnpa..                                                         Practitioner. Pedriatics Vol. 102 No. 1 July 1998, p. e4. Retrieved online December 11,
                                                                                                                                                     2007 at http://pediatrics.aappublications.org/cgi/content/abstract/102/1/e4
                                                     18. CDC (2005). Diabetes Projects. Retrieved online November 29, 2007 at http://www.
the complexity of properly treating childhood           cdc.gov/diabetes/projects/cda2.htm                                                         64. Speiser, Phyllis W. et al. (2005). Childhood Obesity. The Journal of Clinical
                                                     19. CDC (December 2007). Healthy Weight: Childhood Obesity. Retrieved online                    Endocrinology & Metabolism (90), 3 :1871-1887. Retrieved online December 21, 2007
obesity.                                                December 21, 2007 at http://www.cdc.gov/HealthyYouth/overweight/index.htm                    at http://jcem.endojournals.org/cgi/content/full/90/3/1871
                                                     20. CDC Healthy Youth and Nutrition. Retrieved online November 29, 2007 at www.               65. Spiegel, A., & Alving, B.M Science based solutions to obesity: What are the Roles of
                                                                                                                                                     Academia, Government, Industry and Health care? Executive summary of the Strategic
As implied, many variables may induce the               cdc.gov/HealthyYouth/Nutrition
                                                     21. CDC (2007). National Center for Health Statistics. The Growth Charts: US.                   Plan for National Institutes of Health Obesity Research. American Journal of Clinical
risk of a child becoming obese. Many of the             Retrieved online December 27, 2007 at http://www.cdc.gov/nchs/about/major/nhanes/
                                                        growthcharts/background.htm
                                                                                                                                                     Nutrition, Vol. 82, No. 1, 211S-214S, July 2005. Retrieved online December 1, 2007 at
                                                                                                                                                     http://www.ajcn.org/cgi/content/full/82/1/211S
contributing factors are integrated, which           22. CDC (May 2007). Nutrition Resources for Healthcare professionals. Retrieved               66. State Government Affairs Issue Brief: Legislative Strategies to Address
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exacerbates the problem of obesity. However,            professionals/practice/index.htm                                                             aapkansas.org/content/chapterFocus/obesity/legislativeStrategies.htm
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morbidity or death for our youth. It is imperative   25. CDC (2007). Physical Activity and Good Nutrition: Essential Elements to Prevent
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that the proper changes be implemented to               gov/nccdphp/publications/aag/dnpa.htm                                                      69. Surgeon General. (2007). The problem of overweight in children and adolescents.
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To elicit behavioral changes in the way our             childhood/tips_for_parents.htm
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youth care for their bodies, it is imperative           approach. Lexi-Comp: Hudson                                                                  Barmarrae: Gainesville.
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74. Wellesley-Cole Morgan, C. (2004). Underage and overweight: America’s childhood
  obesity crisis-What every family needs to know. Prev Chronic Dis. 2004 October; 1(4):
                                                                                                   CHILDHOOD OBESITY                        10. The glycosylated Hemoglobin A1C
  A21. Published online 2004 September 15. Retrieved online December 14, 2007 at
  http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1277961
                                                                                                   Self Evaluation Exercises                    (Hgb A1C) is a direct correlation of the
75. Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K., Dietz, W. (1997). Predicting
  obesity in young adulthood from childhood and parental obesity. New England Journal      Choose True or False for questions 1 through         percentage of glucose that attaches to the
  of Medicine. Vol 337: 869-873. Number 13. Retrieved December 12, 2007 at http://
  content.nejm.org/cgi/content/full/337/13/869?hits=20&fulltext=childhood+obesity&s        10 and check your answers at the bottom of           hemoglobin A over a course of five to 12
  earch_tab=collections&excludeflag=TWEEK_element&searchid=1&FIRSTINDEX=
  0&resourcetype=HWCIT                                                                                      the page.                           weeks.
76. Whitney, E., & Rolfes, S.R. (2008). Understanding nutrition. 11th ed. Thomson:
  California.                                                                                                                                         True                False
77. World Health Organization: Obesity and Overweight. (2007). Retrieved online
  December 9, 2007 at http://www.who.int/dietphysicalactivity/publications/facts/
  obesity/en/                                                                             1. According to the Centers for Disease
78. Weight Control Information Network-Publication. WIN Notes Winter 2007.
  Retrieved online November 29, 2007 at http://win.niddk.nih.gov/notes/winter07/             Control and Prevention (CDC), the United
  winnotes_winter07.htm
79. Weight Control Information Network-Statistics. Statistics Related to Overweight and      States has made little progress in attaining
  Obesity. Retrieved online November 29, 2007 at http://win.niddk.nih.gov/statistics/
  index.htm
                                                                                             the 2010 goal of increasing physical
80. World Web Online. Exogenous Obesity. Retrieved online December 21, 2007 at               activity and reducing childhood obesity.
  http://www.wordwebonline.com/en/EXOGENOUSOBESITY
81. Youngkin, E. Q. & Davis, M.S. (2004). Women’s health: A primary care clinical
  guide. 3rd ed. Pearson: New Jersey.                                                               True                False

                                                                                          2. Childhood obesity is considered the most
                                                                                             prevalent nutritional disorder in the U.S.
                                                                                                    True                False

                                                                                          3. Obesity is defined as the presence of
                                                                                             minimal adipose tissue.
                                                                                                    True                False

                                                                                          4. Obesity is considered the fourth largest
                                                                                             behavioral contributor to death after
                                                                                             smoking.
                                                                                                    True                False

                                                                                          5. Over the past few years, type II diabetes/
                                                                                             non insulin dependent diabetes, the typical
                                                                                             adult onset diabetes, has been on the
                                                                                             rampage among our youth.
                                                                                                    True                False

                                                                                          6. Insulin resistance is defined as the body
                                                                                             being unable to recognize glucose.
                                                                                                    True                False

                                                                                          7. Childhood obesity is associated with a
                                                                                             higher incidence of depression in girls.
                                                                                                    True                False

                                                                                          8. The American Heart Association
                                                                                             recommends that all children as young
                                                                                             as 2 years of age begin to participate in
                                                                                             moderate, intense activities for a minimum
                                                                                             of 30 minutes a day.
                                                                                                    True                False

                                                                                          9. Research has demonstrated that on average,
                                                                                             more than half of school age children
                                                                                             consume more than one can of soda a day
                                                                                             while at school, and adolescents drink an
                                                                                             average of four a day.
                                                                                                    True                False


                                                                                                                                            Answers:
                                                                                                                                                             8.T 9.T 10.7
                                                                                                                                                             1.T 2.T 3.F 4.F 5.T 6.F 7.F




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