The Journal of Pediatrics
Volume 157, Issue 1 , Pages 3-4, July 2010

Obesity at the Extremes: The Eyes Only See What the Mind is Prepared to Comprehend

  • Thomas Inge, MD, PhD

      Affiliations

    • Corresponding Author InformationReprint requests: Dr Thomas Inge, Cincinnati Children's Hospital Medical Center Surgery, 3333 Burnet Avenue, Cincinnati, OH 45229.
    • ,
  • Stavra Xanthakos, MS, MD

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

published online 19 April 2010.

Article Outline

BMI, Body mass index

 

See related articles, p 15 and p 26

In clinical practice, we sometimes remark that “the eyes only see what the mind is prepared to comprehend” (Henri Bergson, French Philosopher, 1859-1941). Two articles in this issue of The Journal remind us that this quote is also relevant to the pediatric obesity problem. In the first, McCormick et al1 analyzed medical records from “well-child” visits of thousands of children <5 years of age. They found that as many as 16% of infants in the Galveston area are obese, a prevalence higher than the 10% recently cited in nationally representative data.2 Despite their obesity, only a third were diagnosed as obese by their pediatricians during these visits.

Although this study did not identify the reasons for not making the diagnosis, several potential factors may play a role. There may be a reluctance to label infants as obese and to delay this diagnosis in the hope that they will outgrow their baby fat as they become toddlers. Even though this may be a realistic expectation in some children, it may not be in others.3 Even if the topic is raised, parents of overweight/obese preschoolers may not perceive their child's overweight status as a problem or health concern and may not be receptive to the discussion.4, 5 Compounding the issue is the fact that there is little time to address multiple other health care maintenance issues at well child visits. Finally, many providers feel that they cannot make a substantial impact on treatment of childhood obesity in the office, although some authors still hope that ongoing intervention studies will demonstrate an impact in preschool children.6

Complementing this work, Koebrick et al7 provide new, sobering estimates of the prevalence of extreme pediatric obesity. Analyzing records of over 700 000 patients ages 2 to19 years in southern California, these authors found that 6.4% met criteria for extreme obesity, defined as 120% of the 95th percentile or body mass index (BMI) >35 kg/m2. Strikingly, the prevalence in Hispanic boys and Black girls was 11 and 12%, respectively. For boys, prevalence peaked at 8% at age 10, and in girls there was a bimodal distribution with peaks at 12 and 18 years. For perspective, extreme pediatric obesity prevalence may now be equal to or greater that in adults, as only 5.7% of US adults have BMI values >40 kg/m2.8 Although recent national estimates of obesity prevalence in children and adolescents suggested no significant increasing trend in pediatric obesity between 1999 to 2000 and 2007 to 2008, except for BMI ≥97%ile for boys,2 the analysis did not isolate those with BMI ≥99th percentile and therefore may mask an ominous skew toward the greatest extremes of pediatric obesity.

Taken together, these reports raise considerable concerns about the health and well-being of our youth and portend major health consequences over time. Although neither report addressed long-term health consequences of being obese as an infant, or being extremely obese as an adolescent, others have done so. Type 2 diabetes in native American adolescents can double mortality risk in adulthood and increases the risk of end-stage renal disease by 5-fold.9 Indeed, glucose intolerance alone in these youth increases the risk of premature death (before age 55) by 73%, and a BMI in the highest quartile more than doubles the premature mortality risk.10 Models predict that adolescent obesity could be responsible for up to 1.5 million life-years lost in the United States alone, with total costs of $254 billion when lost productivity and medical costs are taken into account.11 Sadly, even if all obesity-related comorbidities were treated, only modest reductions in excess mortality, and no reduction in costs would be predicted.11

Aside from these more obvious obesity-related health problems, more subtle signs of metabolic distress have also been linked to pediatric obesity. Before the development of comorbidities, obese 9-year-olds already demonstrate alarming elevations of inflammatory and prothrombotic factors that correlate with body fat mass.12 We also know from long-term (60-year) follow-up that being overweight as an adolescent is a more powerful predictor of development of multiple obesity-related diseases than being overweight in adulthood, and the risk persists, even if the weight is lost during the adult years.13

We can hypothesize that if we are unable to reverse the trend of increasing obesity severity, children who are affected today will acquire greater “pound-years” and thus face even greater risks of adverse health effects and reduced life expectancy compared with the obese or overweight child from a generation ago. Examining the results of interventions targeting the problem is eye-opening. The US Preventive Services Task Force recently reviewed effectiveness of weight management interventions for obese children.14 Comprehensive behavioral interventions with frequent visits result in a 1.9 to 3.3 kg/m2 reduction in BMI at 12 months. Medications (orlistat or sibutramine) add a small but significant reduction in BMI for obese adolescents during active use of the medication. However, the cardiovascular risks of sibutramine in some people may be greater than the benefits, leading the European Medicines Agency to recently suspend marketing of the drug. Also, there is little evidence that drugs or behavior modification result in sustained long-term improvements in BMI beyond the intervention period and this is particularly true for children with extreme obesity.15

A growing number of short- to intermediate-term studies do suggest that bariatric surgery provides safe and effective weight loss and comorbidity improvement for severely affected adolescents.16, 17, 18 Adult data have reproducibly indicated that bariatric surgery reverses comorbidities and this translates into improved life expectancy.19 However, surgery has limitations: it can be costly, invasive, and is not without risk. Today's procedures are generally contraindicated for pre-adolescent age groups, and long-term health effects, durability of the weight loss, and life expectancy for teens who undergo operations remain largely unknown at present. Therefore, although bariatric procedures could be our most promising intervention for pediatric extreme obesity, there remain knowledge gaps regarding safety and effectiveness of specific procedures. Surgery, as we know it today, is certainly not a viable option for all ages, nor is it a population-based solution. One important goal therefore is to discover mechanism(s) by which successful procedures achieve sustained BMI reduction and health improvement. The second goal will be exploiting this knowledge to refine and improve interventions, which may take a surgical or nonsurgical form to target obesity or specific comorbidities.

Our increased awareness of the problems associated with pediatric obesity in this issue of The Journal coincides with a national call to action, the “Let's Move” campaign, led by Michelle Obama and supported by numerous health advocacy groups, medical professional societies, and industry.20 This initiative should focus greater attention on the problem and encourage parents and schools to create more appropriate food choices and fun physical activity programs for kids.

Certainly the root causes of, and therefore the prevention and treatment of pediatric obesity extend beyond the sole reach of the dietitian, psychologist, pediatrician, and surgeon. We applaud and encourage efforts to promote multifaceted approaches uniting family-, school-, and community-based interventions, with support from public and private sectors to help turn the tide and reduce the burden of infant and childhood obesity as well as the spread of extreme pediatric obesity. We must keep our eyes and our minds wide open to all reasonable prevention and treatment approaches. The health and well-being of our population, and the productivity and standing of our country in the world community will depend on realistic and practical solutions to this ever evolving problem of childhood obesity.

Back to Article Outline

References 

  1. McCormick DP, Sarpong K, Jordan L, Ray LA, Jain S. Infant obesity: are we ready to make this diagnosis?. J Pediatr. 2010;157:15–19
  2. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303:242–249
  3. Lee JM, Lim S, Zoellner J, Burt BA, Sandretto AM, Sohn W, et al. Don't children grow out of their obesity? Weight transitions in early childhood. Clin Pediatr (Phila). 2010;
  4. Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don't low-income mothers worry about their preschoolers being overweight?. Pediatrics. 2001;107:1138–1146
  5. Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of overweight preschool children. Pediatrics. 2000;106:1380–1386
  6. Hesketh KD, Campbell KJ. Interventions to prevent obesity in 0-5 year olds: an updated systematic review of the literature. Obesity (Silver Spring). 2010;18(Suppl 1):S27–S35
  7. Koebnick C, Smith N, Coleman KJ, Getahun D, Reynolds K, Quinn VP, et al. Prevalence of extreme obesity in a multiethnic cohort of children and adolescents. J Pediatr. 2010;157:26–31
  8. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303:235–241
  9. Pavkov ME, Bennett PH, Knowler WC, Krakoff J, Sievers ML, Nelson RG. Effect of youth-onset type 2 diabetes mellitus on incidence of end-stage renal disease and mortality in young and middle-aged Pima Indians. JAMA. 2006;296:421–426
  10. Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC. Childhood obesity, other cardiovascular risk factors, and premature death. N Engl J Med. 2010;362:485–493
  11. Lightwood J, Bibbins-Domingo K, Coxson P, Wang YC, Williams L, Goldman L. Forecasting the future economic burden of current adolescent overweight: an estimate of the coronary heart disease policy model. Am J Public Health. 2009;99:2230–2237
  12. Mauras N, Delgiorno C, Kollman C, Bird K, Morgan M, Sweeten S, et al. Obesity without established comorbidities of the metabolic syndrome is associated with a proinflammatory and prothrombotic state, even before the onset of puberty in children. J Clin Endocrinol Metab. 2010;95:1060–1068
  13. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents: a follow-up of the Harvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327:1350–1355
  14. Whitlock EP, O'Connor EA, Williams SB, Beil TL, Lutz KW. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. In: Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2010.
  15. Levine MD, Ringham RM, Kalarchian MA, Wisniewski L, Marcus MD. Is family-based behavioral weight control appropriate for severe pediatric obesity?. Int J Eat Disord. 2001;30:318–328
  16. Inge TH, Miyano G, Bean J, Helmrath M, Courcoulas A, Harmon CM, et al. Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents. Pediatrics. 2009;123:214–222
  17. Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ, Daniels SR, et al. One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. J Pediatr Surg. 2006;41:137–143
  18. O'Brien PE, Sawyer SM, Laurie C, Brown WA, Skinner S, Veit F, et al. Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial. JAMA. 2010;303:519–526
  19. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–752
  20. Obama B. Presidential Memorandum: Establishing a Task Force on Childhood Obesity. In: Office of the Press Secretary, The White House; 2010.

PII: S0022-3476(10)00212-X

doi:10.1016/j.jpeds.2010.02.068

Refers to article:

  • Infant Obesity: Are We Ready to Make this Diagnosis? , 25 March 2010

    David P. McCormick, Kwabena Sarpong, Lindsay Jordan, Laura A. Ray, Sunil Jain
    The Journal of Pediatrics July 2010 (Vol. 157, Issue 1, Pages 15-19)

  • Prevalence of Extreme Obesity in a Multiethnic Cohort of Children and Adolescents , 22 March 2010

    Corinna Koebnick, Ning Smith, Karen J. Coleman, Darios Getahun, Kristi Reynolds, Virginia P. Quinn, Amy H. Porter, Jack K. Der-Sarkissian, Steven J. Jacobsen
    The Journal of Pediatrics July 2010 (Vol. 157, Issue 1, Pages 26-31.e2)

The Journal of Pediatrics
Volume 157, Issue 1 , Pages 3-4, July 2010

Article Tools