Management of Childhood Obesity: Comparison
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Please note this is a comparison between Version 2 by Karina Chen and Version 1 by Clemens Drenowatz.

The examination of the etiology of childhood obesity is a growing area of research aiming to yield important insights for public health. Given the rising prevalence of childhood obesity in most developed and developing countries, it is now considered a global pandemic . Worldwide, an estimated 170 million children are considered overweight or obese currently, and approximately more than half of them are predicted to become obese adults. These trends in excess body weight may also contribute to an increase in chronic cardio-metabolic disorders, typically observed only in adults (e.g., hypertension, hyperglycemia, and dyslipidemia), but are becoming increasingly common in children and adolescents with obesity . Additionally, pediatric populations with obesity are known to have several psychosocial problems including discrimination, social isolation, and low self-esteem, which affect their health, education, and quality of life. Furthermore, the crosstalk between obesity and many viral pandemics, such as the 2009 swine flu or the current COVID-19 pandemic, has provided new insights into mortal characteristics of this chronic syndrome.

  • children
  • adolescents
  • overweight
  • obesity
  • weight management
  • lifestyle
  • body composition

1. Weight-Related Behaviors in Children

Comprehensive clinical guidelines and recommendations to diagnose, prevent, and treat childhood obesity have been well documented for pediatric specialists to implement at different stages in obesity prevention and treatment programs [20,21].

Comprehensive clinical guidelines and recommendations to diagnose, prevent, and treat childhood obesity have been well documented for pediatric specialists to implement at different stages in obesity prevention and treatment programs [1][2].

Nutrition and dietary pattern not only affect anthropometry and body composition in children and adolescents, but they also influence neurocognitive and psychomotor development [22,23]. Evidence indicates that when compared to adults, children and adolescents are at a higher risk of insufficient intake of certain food groups (e.g., whole grains and/or unprocessed foods) [7,24], which may contribute to the increased risk of obesity [7]. Calorically restricted diets are widely used to target childhood obesity [22], but potentially contribute to nutrient deficiencies, which may impair growth and development [22,25]. The importance of adequate nutrient consumption for growth and development also emphasizes the need for targeting energy expenditure by ensuring sufficient PA. Even though detrimental effects of insufficient PA on various health and weight outcomes are well-documented, results from a comprehensive analysis including 1.6 million adolescents from a pooled number of 298 school-based studies from 146 countries show that 80% of adolescents do not meet PA recommendations of at least 60 min of PA with moderate to vigorous intensity over 5 d/w, which puts their current and future health at risk [26].

Nutrition and dietary pattern not only affect anthropometry and body composition in children and adolescents, but they also influence neurocognitive and psychomotor development [3][4]. Evidence indicates that when compared to adults, children and adolescents are at a higher risk of insufficient intake of certain food groups (e.g., whole grains and/or unprocessed foods) [5][6], which may contribute to the increased risk of obesity [5]. Calorically restricted diets are widely used to target childhood obesity [3], but potentially contribute to nutrient deficiencies, which may impair growth and development [3][7]. The importance of adequate nutrient consumption for growth and development also emphasizes the need for targeting energy expenditure by ensuring sufficient PA. Even though detrimental effects of insufficient PA on various health and weight outcomes are well-documented, results from a comprehensive analysis including 1.6 million adolescents from a pooled number of 298 school-based studies from 146 countries show that 80% of adolescents do not meet PA recommendations of at least 60 min of PA with moderate to vigorous intensity over 5 d/w, which puts their current and future health at risk [8].

In addition to poor nutrition and low PA, results from different studies show that most children and adolescents do not meet obesity-associated lifestyle guidelines, such as recommendations for sleep and screen time [27,28]. According to the Centers for Disease Control and Prevention (CDC), 60% to 70% of the American pediatric population does not meet the American Academy of Pediatrics (AAP) sleep recommendations [1,27] of 10–13 h for 3- to 5-year-olds, 9–12 h for 6- to 12-year-olds, and 8–10 h for 13- to 18-year-olds [29]. Short duration and late sleep timing can contribute to the onset and development of childhood obesity [30], particularly by altering appetite-regulating hormones and consequential eating disorders [31]. Parents can play an important role in fostering healthy sleep patterns by arranging sleep time, providing a calm atmosphere, and keeping screens away before bedtime [32]. Higher amounts of daily screen time contribute to obesity due to their association with a reduced feeling of satiety, increased consumption of unhealthy and energy-dense snacks [33], and poor sleep patterns [34]. The AAP recommends that daily nonacademic screen time (TV, video games, and mobile phone) should not exceed one hour for 2- to 5-year-olds, and two hours for ≥6-year-old children, and there should be parental supervision of content watched [1]. Available data, however, indicates that the majority of children has an extraordinarily high daily screen time [28,35], up to an average of 6 h/day among 13- to 18-year-olds [36] and 7 h/day among 8- to 18-year-olds [37] when TV, computer, mobile devices, and web-based sources are combined. Sedentary behaviors, screen time, and sleep abnormalities can be even higher during annual vacation due to the absence of a regular schedule [38].

In addition to poor nutrition and low PA, results from different studies show that most children and adolescents do not meet obesity-associated lifestyle guidelines, such as recommendations for sleep and screen time [9][10]. According to the Centers for Disease Control and Prevention (CDC), 60% to 70% of the American pediatric population does not meet the American Academy of Pediatrics (AAP) sleep recommendations [11][9] of 10–13 h for 3- to 5-year-olds, 9–12 h for 6- to 12-year-olds, and 8–10 h for 13- to 18-year-olds [12]. Short duration and late sleep timing can contribute to the onset and development of childhood obesity [13], particularly by altering appetite-regulating hormones and consequential eating disorders [14]. Parents can play an important role in fostering healthy sleep patterns by arranging sleep time, providing a calm atmosphere, and keeping screens away before bedtime [15]. Higher amounts of daily screen time contribute to obesity due to their association with a reduced feeling of satiety, increased consumption of unhealthy and energy-dense snacks [16], and poor sleep patterns [17]. The AAP recommends that daily nonacademic screen time (TV, video games, and mobile phone) should not exceed one hour for 2- to 5-year-olds, and two hours for ≥6-year-old children, and there should be parental supervision of content watched [11]. Available data, however, indicates that the majority of children has an extraordinarily high daily screen time [10][18], up to an average of 6 h/day among 13- to 18-year-olds [19] and 7 h/day among 8- to 18-year-olds [20] when TV, computer, mobile devices, and web-based sources are combined. Sedentary behaviors, screen time, and sleep abnormalities can be even higher during annual vacation due to the absence of a regular schedule [21].

2. Strategies for the Prevention and Treatment of Childhood Obesity

To date, the safety and efficacy of various approaches on the management of childhood obesity have been reported by numerous experimental and cross-sectional studies as well as reviews and meta-analyses [2,6,15,39,40]. Nevertheless, pediatric clinicians and researchers are often encountering several challenges when applying preventative and therapeutic programs and the characteristics of an optimal and comprehensive weight management strategy remain controversial [1,41]. Evidence suggests that the management of childhood obesity requires consideration of genetic, biological, behavioral, psychological, interpersonal, and environmental factors to induce sustainable lifestyle changes along with an in-depth understanding of these interactions to identify opportunities for intervention strategies [39].

To date, the safety and efficacy of various approaches on the management of childhood obesity have been reported by numerous experimental and cross-sectional studies as well as reviews and meta-analyses [22][23][24][25][26]. Nevertheless, pediatric clinicians and researchers are often encountering several challenges when applying preventative and therapeutic programs and the characteristics of an optimal and comprehensive weight management strategy remain controversial [11][27]. Evidence suggests that the management of childhood obesity requires consideration of genetic, biological, behavioral, psychological, interpersonal, and environmental factors to induce sustainable lifestyle changes along with an in-depth understanding of these interactions to identify opportunities for intervention strategies [25].

2.1. Intervention Components

The most common preventative and therapeutic interventions applied and suggested by investigations are nutritional, PA, lifestyle, and educational methods. In adolescents with a high degree of obesity or advanced metabolic disease, clinical treatments including pharmacological and surgical strategies have also been suggested [20][1]. Due to the potential side effects of medical interventions, a careful evaluation and comparison of risks and benefits are necessary before implementing such interventions for pediatric patients with obesity [42][28]. It has been emphasized that pharmacotherapy and bariatric surgery should never be implemented in adolescents with obesity (and those with other vital untreated disorders) who have not engaged in healthy dietary and PA practices [20][1].

2.1.1. Diet

It should be considered that nutritional approaches targeting childhood obesity are not limited to restricted energy intake but rather, the most appropriate nutrition strategy for long-term weight reduction and the promotion of metabolic and mental health is shifting to healthy food choices [43][29] that include predominantly whole food plant-based sources [44,45][30][31]. This dietary pattern restricts added sugars, refined grains, sweetened beverages, fast foods, calorie-dense snacks, and high-fat processed foods and includes fruits, vegetables, nuts, and whole-grains along with well-structured meal frequencies [6,44,46][23][30][32]. The weight-related benefits rising from plant-based diets are attributable to a reduced caloric intake and an increase in postprandial energy expenditure by a higher thermogenic response [47,48][33][34]. Additionally, whole food plant-based diets lead to favorable changes in cardio-metabolic and digestive health, which are both associated with further weight-related advantages as well [49,50][35][36]. Increasing nutritional literacy of children and their parents (regarding agriculture, food industries, food safety, cooking, and theoretical knowledge of energy balance, nutrition, and diets) could further promote sustainable changes that contribute to healthier dietary patterns [51][37]. While these are general principles and recommendations, no single diet should be prescribed or recommended as the best for all children with obesity [43][29]. Researchers believe that the optimal macronutrient composition depends on factors such as appetite, thermogenesis, energy homeostasis, and gut microbiota [52][38]. Furthermore, the ideal diet for treating overweight and obesity should be safe, efficacious, nutritionally adequate, culturally acceptable, and economically affordable [43][29]. To date, however, the majority of nutritional strategies targeting childhood obesity are still based on a “one-size-fits-all” model, which does not take into account the inter-individual variability [53][39], which often results in a reduced adherence rate to dietary changes [54][40].

2.1.2. Physical Activity

On the other side of the energy balance equation, PA has been emphasized as a critical component for healthy body weight. Promoting PA is considered an effective intervention strategy in pediatric weight management [55[41][42],56], which attributes to the concept of energy flux [19][43]. Energy flux represents the rate of energy expenditure and energy intake [19[43][44],57], and a higher energy flux (obtained by increased PA) results in better regulation of energy balance during weight loss [57][44] and/or the prevention of weight gain [58][45]. PA could also result in favorable improvements in mental and physiological health, and both are indirectly associated with further weight-related advantages [59][46]. In children and adolescents with obesity, the most common barriers to engage in regular PA programs are lack of self-discipline, lack of someone to engage in PA with, self-consciousness about appearance [60][47], and decreased level of motivation due to the limited motor abilities and/or being out of shape [61][48]. Daily physical activities of children are not limited to regular physical education classes or sport/exercise engagements. Active travel to school, unstructured active play during school recess, and activities at home or playgrounds can be additional viable PA sources [32][15]. Currently, however, due to the COVID-19 pandemic and social lockdowns, the movement opportunities have been significantly diminished [62][49], and home exercises have been highly recommended [63][50].

2.1.3. Lifestyle and Education

In addition to diet and PA, other lifestyle parameters (e.g., psychological behaviors, modifying sleep patterns) are considered effective interventions in weight management programs. Independently or along with educational interventions, additional lifestyle behaviors could further increase the efficiency of PA and dietary interventions [1][11]. A controlled experimental study showed that a two-year, multi-component obesity intervention focusing on a lifestyle educational curriculum resulted in beneficial changes in Body Mass Index (BMI) percentiles in the intervention groups [64][51]. There is also evidence suggesting that mindfulness interventions [65,66][52][53] and forethoughtfulness (defined as being oriented more towards the future than the present) [67][54] might be advantageous for improving obesity-related eating and behavioral patterns. Mindfulness, defined as the awareness that arises from purposefully paying attention in the present moment with non-judgment [68][55], is suggested as an effective intervention strategy targeting childhood obesity [69][56]. Evidence also indicates that sleep is an important modifiable risk factor for managing childhood obesity, as eating and PA behaviors can be affected by the quality and duration of sleep [70][57]. Modifying sleep patterns in school-age children resulted in healthy dietary patterns via decreased food consumption, in particular, thus promoting favorable weight outcomes [71][58].
In general, it has been well-established that multi-component interventions including PA, nutritional, lifestyle, and educational strategies have been shown to yield better outcomes than single-component strategies [1,41,72][11][27][59]. In a systematic review of the effectiveness of lifestyle interventions targeting children’s weight and cardio-metabolic health, beneficial outcomes were observed only following the multi-component interventions [73][60]. However, due to the complex interaction in these approaches, identifying the degree of effectiveness for each component remains controversial.

2.2. Intervention Settings

Almost all studies in the childhood obesity sector have critically investigated or discussed the environment where interventions are applied and the people who support and/or supervise weight management programs. It has been well-established that home, school, and community can all play important roles independently in shaping and stabilizing children’s lifelong health- and weight-related behaviors [74,75][61][62].

2.2.1. Home

Parental beliefs, attitudes, behaviors, and social support are vital for a child’s health and body composition [76][63]. Available evidence indicates that parents are involved in about half of the interventions targeting childhood obesity, and successful improvements on children’s BMI are in 75% of studies with parental involvement [74][61]. Results show, from a meta-analysis of 22 randomized control trials examining home-based interventions to control childhood obesity, that parents can play a crucial role in managing children’s weight by facilitating, motivating, and coaching the healthy behaviors of their children [77][64]. Due to the close familiarity of parents and their child, parents may better understand and consider the lifestyle parameters contributing to the development of obesity in their child [78][65]. Although parent-only interventions may be more cost-effective compared to school- and community-based programs [79][66], evidence suggests to combine home-based programs with other settings to deliver more favorable effects on anthropometry and BMI in children [80][67]. The effectiveness of grandparental supervision, on the other hand, has been reported to be close to zero with no association between children’s BMI z-scores and grandparental child care (whether as the primary caregiver or co-residence) [81][68].

2.2.2. School

School is an important setting for improving child health behaviors, as children spend a significant part of their daily life in schools [82,83][69][70]. Moreover, the following conditions of the school environment also benefit the setting for implementing overweight/obesity-related interventions: schools offer a structured environment for applying interventions with ease; schools may provide one or two meals per day and, therefore, potentially dictate healthy food choices in their cafeteria; schools usually provide opportunities for PA and active games during recess and daytime; schools produce and expand extracurricular educational resources and wellness policies for both children and parents; schools could run an indirect competitive and encouraging atmosphere to promote children’s motivation and adherence towards interventions; schools could introduce their physical education instructors and/or athletic trainers as role-models; schools benefit from the contribution of staff and teachers to facilitate, deliver, and supervise the interventions [74,84,85][61][71][72]. Interestingly, successful school-based interventions are also highly effective in improving children’s anti-obesogenic behaviors at home [83][70]. However, because of time and budget constraints, many schools are not able to implement health and weight management programs [72][59].

2.2.3. Community and Clinics

In addition to home- and school-based strategies, the community environment and clinical settings are also common areas for managing childhood obesity and prevention [20,75][1][62]. Community interventions targeting obesity incorporate policies and strategies and aim to reduce the population risk of obesity [75][62]. These interventions involve but are not limited to the availability and use of health and fitness facilities, media-based activities, and health-oriented businesses by local and central administrations [1,86][11][73]. The EPODE program (Ensemble Prévenons l’Obésité Des Enfants: together, let us prevent childhood obesity) could be considered a successful example of a community-based intervention, which emphasizes a multifactorial approach targeting childhood obesity at different community levels [87][74]. Interventions using a community-based approach could achieve the long-term goals of reducing the prevalence of childhood obesity [88][75], especially for children who live in low-income societies [75][62]. Clinical or primary-care interventions, on the other hand, include any medical or non-medical strategies implemented by healthcare and pediatric specialists [89][76]. Clinical and community-level interventions can significantly improve lifestyle patterns when applied simultaneously [90][77]. Significant improvements in body weight have been achieved in pre-school children aged 2–5 years following multi-component clinical interventions (e.g., PA, nutrition, education) with parental involvement [91][78]. However, reports from different meta-analytic studies indicate poor effectiveness of primary-care programs on childhood obesity [89[76][79][80],92,93], which might be attributed to a dose-response relationship, where the frequency and duration of treatment contact highly affect the outcomes [1][11]. Additionally, the “sustainability” of intervention effects could be another limitation in clinical approaches, as the time of engagement is limited compared to other settings [94,95][81][82].
 

3. Future Directions for the Prevention and Treatment of Childhood Obesity

In general, it seems that due to the multi-factorial nature of childhood obesity, a maximally efficient strategy to manage childhood obesity requires integrating multiple settings for delivering multi-component interventions. Evidence shows that school-based interventions with family inclusion have the largest effect on weight outcomes when multi-component programs are implemented, including PA and diet [84,96][71][83]. Results from a study comparing the effectiveness of home versus school settings on nutritional habits, PA behaviors, and BMI changes showed that the home environment had a stronger association with health in general compared to the school setting [97][84]. It should be mentioned, however, that parental involvement in many preventive studies can be more effective in pre-school and early-school children, whereas school- and community-based intervention strategies lead to more favorable outcomes in older children and adolescents [1][11], particularly for those who are above twelve [98][85]. Nevertheless, to enhance the effectiveness of strategies, it appears important that parents permanently engage in supporting and reinforcing their children’s health behaviors [99][86].
Some limitations can affect the progress of weight management programs, similar to any preventative and therapeutic strategy. Time and financial resources are major limitations for the implementation of multi-component weight management strategies [100][87]. In addition, poor awareness and lack of self-discipline have been reported as personal barriers when adhering to a healthy lifestyle [60][47]. Furthermore, difficult-to-reach goals set by parents and clinicians are considered a vital but hidden limitation, as it is well-established that strict targets may often lead to failure in weight control programs in children [101][88]. Age also appears to be an important moderator for weight control outcomes as older children displayed larger and more beneficial effects than younger children following weight-management interventions [92,93][79][80]. Beyond these limitations, the obesity prevention strategies seem to follow a dose-effective manner, as more intensive and longer-lasting interventions are associated with better outcomes in children [93][80]. Further, it appears that purposeless and/or unsupervised strategies not based on the individual needs and personal characteristics of the targeted child could minimize intervention effects [54][40].

 

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