Obesity

Childhood and Adolescent Obesity: A National Epidemic

Have you ever wondered if children coming into your dental operatory these days really are fatter, or is it just your imagination? And if they are fatter, how does it relate to what they are eating and what is the approach to treatment? This review article is written for dental health professionals, their own children, and their young patients and families, and will briefly address these issues.

As you have observed in your dental practice and heard on the evening news, children are fatter these days, paralleling what is happening to their role models, adults. Not only are more children obese (greater than 120 percent mean body weight/height), but children in the superobese category (greater than 140 percent mean body weight/height) are making up a larger percentage of the population. The worrisome part is that up to 25 percent of all obese infants become obese adults. Even more impressive, as many as 80 percent of obese adolescents become obese adults.1 At the same time, it is also clear that there are definite health risks associated with being overweight during childhood itself, not just later on in. Overweight children face immediate health risks such as obstructive apnea, cardiomyopathy, pancreatitis, orthopedic disorders, and respiratory disorders, particularly in children already suffering from asthma.2 In addition, overweight children may have abnormal blood glucose levels and glucose tolerance tests, have higher blood pressures, and may have abnormal lipid profiles.3,4 The good news is that if children lose weight, parameters may normalize. For example, both total cholesterol and triglyceride levels significantly decrease in children who lose as little as 10 percent of their total weight in a four-week period. Not only parents, but also many healthcare professionals, are not aware of the health risks during childhood associated with obesity in children,, and only talk about predisposition for chronic diseases associated with aging, such as heart disease and stroke. For example, the prevalence of non-insulin dependent diabetes in children and adolescents is on the increase and seems to be related to the increasing degree of fatness in children.

One approach that may be helpful with the parents of your young, obese dental patients is to facilitate in the parents an understanding of the immediate health risks faced by the overweight child and the importance of seeking medical help. The key is not to raise the parents' anxiety levels, which can lead to negative behavioral interactions between the child and the parents. The answer, rather, is to motivate the parents to seek help and to refer them to appropriate resources in your community. The treatment of childhood obesity needs to involve all family members, not just the obese child.5

Contrary to popular belief, medical causes of childhood obesity are relatively rare, comprising 1-4 percent of all childhood obesity cases. The most common medical causes include endocrine and genetic disturbances. The usual, environmental type of obesity can generally be distinguished from medical obesity by observing the family (family obesity common vs. family obesity rare), the child's stature (tall child vs. a short child), IQ (normal vs. low), bone density (normal vs. retarded), and the presence of physical defects (no defects vs. defects). A "work-up" for obesity in children should include measuring cholesterol and serum lipids, blood pressure, assessing physical activity, smoking, diabetes, psychosocial factors, orthopedic problems, and skin problems. Stretch marks in overweight children and fungal growth in skin folds are a common findings in obese and superobese children.6

Are kids fatter mainly because they are eating more calories and, in particular, eating more fat calories? This is an interesting question with unexpected findings. When comparing the years 1977-1978 and 1987-1988, a 3-5% decrease in the intake of total calories was reported over the age range of 2-19 years. Addressing mean daily fat intake (of females) during this period, there was actually a 4-5% decrease in fat grams and percent dietary fat calories during the 1987-1988 period. These results help us understand the importance of decreasing physical activity in increasing fatness in kids.1

As a review for the dental health professional, it is postulated that there are three critical periods in childhood for obesity development in adults: the perinatal period, the period of adiposity rebound at about 5 years of age, and the adolescent period. For example, we know that infants born during a famine show lower levels of childhood obesity and adult obesity. Infants born to diabetic mothers are born fatter and, generally, are fatter as children, adolescents, and adults. Body mass index increases in the first year of life and then levels off from ages 1-4. At about the age of 5, BMI again increases. This is called the period of adiposity rebound. We know that being overweight as an adolescent and/or adult is greatest in children who have the earliest adiposity rebound.7

Are there ethnic differences in childhood obesity? Certainly. African-American, Mexican-American, Puerto-Rican, Native Hawaiian, and some Native American cultures have the highest rate of childhood obesity. This may be related to mothers gaining greater amounts of weight during pregnancy leading to higher birth weight babies who tend to be fatter infants and children. In addition, gestational diabetes tends to occur at higher rates in these populations. Finally, the earlier introduction of solid foods may also be a contributing factor to childhood obesity in these cultures.8 One role of dental health professionals is to encourage the family to breastfeed for at least a year. This is the current recommendation from The American Academy of Pediatrics.

The influences upon a child's eating behaviors are many, including parental/childcare provider influences, social/environmental influences, and, of course, media influences.9 With respect to parental influences, for example, verbal prompting of children to eat does, indeed, work, increasing the amount of food eaten from 42 percent to 71 percent. However, this may not only increase the amount of food eaten by children, but also increase the amount of fatness in children. Nonverbal influences, such as what foods are purchased, how they are prepared, how they are served, the modeling of eating behavior by the adults, and the emotional rather than nutritional uses of food are additional parental influences. We all are aware of the media influences on eating behaviors in children.

The treatment of childhood obesity can be as evasive as the treatment of adult obesity. Weight loss programs for both children and adults have many goals in common (i.e., preservation of muscle mass, safety, etc.). There is an extra consideration with children, however, that one does not want a decrease in linear growth (height of the child). Weight loss approaches include the use of low calorie diets, family-based behavioral intervention, combined sports and nutrition programs, and inpatient rehabilitation programs.5,6,10 Each of these approaches has been associated with some success, and appear safe and effective. One key is the direct involvement of at least one obese parent, which improves both short-term and long-term weight loss for both the overweight child and parent. Inpatient rehabilitation programs are generally for morbidly obese children and involve a three to four month inpatient regimen. A child is released back into the home environment when he or she can see an observable weight change, when some of the abnormal biochemical parameters have been corrected, when normal eating patterns have been established and when an increase is seen in social skills and self-esteem. A behavior modification program is an important part of any weight loss program for children.11

In summary, what is the significance of this brief overview for a dental health professional? First, there is a relationship between dental caries and risk factors for cardiovascular disease in obese children. Obesity rates and caries rates increase together. Dentists should identify children with these risks and initiate dietary counseling. This is predicted to reduce both caries risk and cardiovascular risk.12 Second, try to make parents aware of the immediate effects of obesity on the child, in terms of abnormal biochemical parameters, such as elevated blood glucose and cholesterol, blood pressure, and the physical effects of being overweight on the developing skeleton. Third, realize that medical obesity is by far the exception, not the rule. Most obesity found in children is of the environmental type. Encourage breast feeding for at least a full year as an important preventive measure, particularly in high-risk populations. Fourth, physical activity and psycho-social evaluations need to be included in the evaluation of an obese child, not just the obvious clinical, dietary, and laboratory findings. Finally, understand that childhood obesity is a serious problem in American children today and effective treatments exist. It may very well be that you, as a dental health professional, are the first person to raise awareness of these issues with the child and parent. You need to know what resources are available in your community or region and refer overweight children and their families to these resources. There is no "plug-in-and-play" solution for obesity in American children, although it would be great if there was.

Author

Dr. Karp, PhD, DMD, is a professor at the Medical College of Georgia in the Medical School, the Dental School, and the School of Graduate Studies. He is a certified nutrition specialist and Director of the Dental School Nutrition Consult Service and a member of the American Institute of Nutrition and the American Society of Clinical Nutrition.

References

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5. Nader, P., The Role of the Family in Obesity Prevention and Treatment. Ann NY Acad of Sciences, 699:147-153, 1993.
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8. Kumanyika, S., Ethnicity and Obesity Development in Children. Ann NY Acad of Sciences, 699:81-92, 1993.
9. Ray, J., Klesges, R. Influences on the Eating Behavior of Children. Ann NY Acad of Sciences, 699:57-69, 1993.
10. Korsten-Reck, U., Bauer, S., Keul, J. Sports and Nutrition-An Out-Patient Program for Adipose Children (Long-Term Experience). Int J Sports Med, 15:242-248, 1994.
11. Boeck, M., Lubin, K., Loy, I., Kasparian, D., Grebin, B., Lombardi, N. Initial Experience with Long-term Inpatient Treatment for Morbidly Obese Children in a Rehabilitation Facility. Ann NY Acad of Sciences, 699:257-259, 1993.
12. Larsson, B., Johansson, I., Hallmans, G., Ericson, T. Relationship Between Dental Caries and Risk Factors for Atherosclerosis in Swedish Adolescents. Comm Dent Oral Epidem, 23:205-210, 1995.

To request a printed copy of this article, please contact / Warren B. Karp, PhD, DMD, The Medical College of Georgia, School of Dentistry, Augusta, GA 30912.