The Journal for Nurse Practitioners
Volume 3, Issue 8 , Pages 549-554, September 2007

Childhood Overweight: Early Detection of Risk Factors

  • Lynn E. Shay, MSN, CPM, CRNP, NP-C

      Affiliations

    • Lynn E. Shay, MSN, CPM, CRNP, NP-C, is currently working in a private family practice in Berks County, PA.

Article Outline

Abstract 

Childhood overweight is a public health crisis that warrants intensified primary prevention efforts. Currently, prevention efforts made during the second year fall short of efficacy because of the late initiation of intervention. A review of the literature indicates that primary prevention should begin during preconception counseling and continue through infancy and childhood. The review of risk factors will alert the practitioner to incorporate this surveillance at every acute and well-child visit.

Keywords:  Childhood overweight , early detection of risk factors

 

Childhood overweight is a public health crisis in the United States. Data indicate that since the 1970s the incidence of overweight in preschoolers and adolescents has doubled and that it has tripled in children aged 6 to 11 years.1 Long-term effects on individual health and health care costs on a societal level are monumental. These long-term costs related to childhood overweight can only be extrapolated from figures about adult overweight and obesity, which was estimated at $117 billion in the year 2000.2 A focus on primary prevention necessitates that practitioners assess all pediatric patients for overweight. Overweight in children, defined as equal to the 95th percentile or greater on the body mass index (BMI) sex-based chart, is a multifactorial problem, ranging from preconception and intrauterine factors to dynamic childhood aspects. Childhood overweight that is the result of unavoidable genetic factors occurs only rarely in a small segment of the population, whereas other children may have genetic predisposition that are only realized in obesogenic environments.3

Current research has provided primary care providers with documented categories of risk factors for childhood overweight that can be referenced during preconception counseling, prenatal care, and subsequent health care of the pediatric population. Information about these risk factors can be elicited retrospectively by parental self-report and sensitive history taking on the part of the clinician. The necessity of addressing risk factors with parents is determined by the long-term effects of pediatric overweight and by the distressing implications that current efforts are not decreasing the prevalence of this problem. In a retrospective data comparison, collective data for 1963-1970 from the National Health and Nutrition Examination Survey reported approximately 4% to 5% of children aged 6 y through 19 y were overweight. By the 1999-2002 survey, 16% of this same age group was now overweight, despite attempts by health care practitioners and schools to stem this burgeoning growth.4 The effects of overweight in children are delineated in Table 1. These childhood health issues are likely to carry over into adulthood and necessitate the use of numerous and costly health resources.

Table 1. Morbidities related to childhood overweight26, 30
Cardiovascular
Hypercholesteremia

Dyslipidemia

Hypertension

Left ventricular hypertrophy

Atherosclerosis


Endocrine
Hyperinsulinism

Insulin resistance

Impaired glucose tolerance

Metabolic syndrome

Type 2 diabetes mellitus

Menstrual irregularity

Polycystic ovarian syndrome

Early sexual maturation in females


Neurologic
Pseudotumor cerebri


Pulmonary
Asthma exacerbations

Obstructive sleep apnea syndrome

Pickwickian syndrome


Orthopedic
Blount disease

Genu varum

Slipped capital femoral epiphysis


Renal
Proteinuria


Gastrointestinal
Nonalcoholic fatty liver disease

Nonalcoholic steatohepatitis

Gallstones


Psychiatric
Depression

Behavioral disorders

Low self-esteem

Diminished activities of daily living

Decreased social interaction

Higher rates of suicidal ideation


Cruz et al, 2005; Eremis et al, 2004; Schumann, Nichols, & Livingston, 2002; Wang, 2002

Primary preventive efforts require practitioners to be aware of the risk factors for the development of overweight and obese children in each stage of life, including preconceptional concerns. Theoretically, preventive efforts are best served by applying investigative efforts as early as possible in the life cycle. These risk factors are delineated in Table 2 according to the developmental stage of the child. Many of these factors develop before the standard concerns about BMI measurements starting at age 2 y, thus highlighting the need for screening during family planning visits, preconception counseling, prenatal visits, and infant health checks.

Table 2. Childhood Overweight Risk List
Childbearing
Maternal BMI preconception > 30

Maternal weight gain during pregnancy > 35 pounds

Poor maternal diet: high in sugar, low in vegetables and fruit

Maternal smoking during pregnancy

Paternal BMI at birth > 30

Gestational diabetes or glucose intolerance during pregnancy


Infancy
Birth weight < 1500 g

Intrauterine growth retardation

Birth weight > 4500 g or large for gestational age

Weight gain of > 2 pounds per month from birth to 4 months

Introduction of solids before 4 months of age


Toddlerhood and Preschool
Prolonged bottle-feeding > 19 months

Child without siblings

Ethnicity: Latino, African American, or Native American

Early BMI rebound < 43 months

Less than 10.5 hours of sleep per day at age 3 years

Weight gain of 5 pounds per inch of growth


Childhood
Activity
Media viewing time > 2 hours per day or > 8 hours per week

Television in child's bedroom

Meals consumed during television viewing

Lack of safe exercise areas

Physical activity < 30 minutes per day

Nutrition

Poor parental food choices

Absence of family meals

Poor access to adequate nutrient-rich food sources

Low intake of magnesium-containing foods or vitamin supplements


Environment
Family of low socioeconomic group

Low level of maternal education

Controlling parental style in regard to child's food choices

Chronic environmental stressors



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Preconception and Pregnancy Counseling 

Ideally, prevention of pediatric overweight begins before conception. Studies indicate that mothers who are obese in early pregnancy are more likely to have children with weight issues. There are genetic implications as mentioned before, but the effects of maternal overweight (BMI, 25-29.9) or obesity (BMI ≥ 30) on the intrauterine environment are separate issues. Maternal overweight or obesity with accompanying insulin resistance and higher insulin concentrations directly affects the fetus. Maternal overweight or obesity, even without the additional diagnosis of gestational diabetes, was shown to increase the likelihood of having an infant with a birth weight outside median values and therefore at increased risk of developing metabolic syndrome later in life.5, 6, 7 Women thinking of becoming pregnant should strive for a BMI less than 25, maintain balanced diets, take prenatal vitamins daily, and commit to nicotine abstinence.

Maternal smoking during pregnancy is also linked to higher BMIs in children later in life, perhaps because of insults on the appetite regulation system in the fetal hypothalamus.8 There is also some indication that the more women smoked, the higher the risk for overweight, especially for intakes of 20 or more cigarettes per day.9 Data showed that smoking at the first prenatal visit was associated with overweight in the offspring by the age of 3 years.10 Malnutrition and undernutrition in the first trimester are also linked with rebound overweight when children reach adulthood.7, 11 Pregnant women in the first trimester should be encouraged to maintain a high-quality diet with vitamin supplementation, commit to smoking cessation, and monitor their weight gain.12

Fathers are not exempt from responsibility to prevent childhood overweight. Studies indicate that increased paternal BMIs are also risk factors. In one study, children were studied over time from prebirth until 14 years of age. Results showed that 36% of children were overweight by age 14 years when fathers were overweight compared with a 20% rate with normal weight fathers, 50% of children were obese with overweight mothers compared with 21% with normal weight mothers, and 59% of children were obese when both parents were obese or overweight compared with 17% when parents had a BMI in normal range.13 Clinicians should encourage a baby's father to maintain a normal weight and also commit to nicotine abstinence to prevent secondary exposure to his pregnant partner.

During pregnancy, practitioners should counsel patients to target a pregnancy weight gain of no more than 35 pounds. Gestational weight gain of approximately 35 pounds are positively correlated with the birth of large-for-gestational age infants, who are in turn predisposed to childhood overweight.9, 14, 15 Women who develop gestational diabetes or even glucose intolerance during pregnancy increase the risk that their children will develop overweight and metabolic syndrome later in life. Maternal diet considerations become even more important in these conditions of impaired glucose metabolism so that the fetus is not exposed to uncontrolled high concentrations of maternal blood glucose with concomitant maternal hyperinsulinemia in the second and third trimesters.5, 16

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Infancy 

It has long been established that breastfeeding provides a protective effect against concerns of later childhood overweight. Breastfeeding offers optimal nutrition for the infant along with an educational mechanism that links hunger with food intake.17, 18 Infants are also exposed to different flavors and nutrient sources according to the mother's diet. If a mother's diet incorporates a variety of fruit and vegetables, later introduction of these new foods seems to be less offensive to toddlers. An elevated acceptance level of new healthy foods promotes a protective effect against future overweight.16 Mothers who have chosen to bottle-feed their babies should be counseled to transition their children to cup feedings before age 19 months. Prolonged bottle-feeding beyond this time can predispose children to overweight.19

During infancy, practitioners can use growth charts to monitor the rate of growth by comparison to initial birth weights. Low birth weight infants up to 1500 g (especially with a diagnosis of intrauterine growth retardation) or large for gestational age infants weighing 4500 g or more must be monitored for catch-up growth or excessive growth patterns.20, 21, 22 If an infant gains more than 2 pounds per month in the first 4 months of life, additional concerns about the development of overweight should be noted.23 The introduction of solids before the age of 4 months can contribute to abnormal weight gain in infants and is an independent risk factor for childhood overweight.16

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Toddlers and Preschoolers 

Practitioners who are serving the Latino, African American, or Native American populations should be on high alert for overweight trends in young children. Multiple studies show these ethnic groups to have a high prevalence and predilection toward childhood overweight.1, 10, 11, 14, 24 Children without siblings in the household are also more likely to be overweight.7, 16, 25

Normal BMI patterns in this age group show a J-shaped curve with a nadir around age 5 years. When plotting BMIs at office visits, practitioners should make note of the BMI rebound that occurs before 43 months of age. Data indicates that a gain of 5 pounds or more per inch of growth predicts overweight in the elementary school years.26 Beyond surveillance of growth and nutrition history, sleep patterns may also provide clues to overweight risks. Monitoring sleep patterns are significant because the risk of overweight is raised when toddlers sleep less than 10.5 hours per day.9 Another environmental concern with toddlers and preschoolers is the common use of childcare. Interestingly, children who attend part-time preschool childcare have a decreased risk of overweight than do children who attend full-time childcare or never attend childcare.27

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General Childhood Concerns 

Other useful assessments during pediatric visits can include information gathering about nutrition, activity level, and other environmental factors. Large amounts of time devoted to television viewing and other screen time activities have become common in most households and negatively affect activity levels of children. Children at risk of overweight are those who spend more than 2 hours per day, or more than 8 hours per week, occupied with media viewing. If the television is in the child's bedroom, this is also a bona fide risk factor for overweight as well as watching television while eating meals.15, 26, 28, 29 Physical activity of less than 30 minutes per day should alert the practitioner to the need for counseling about appropriate levels of activity and whether there are safe areas around the home for activity.9, 30

Nutritional aspects related to childhood overweight include poor food choices on the part of parents, especially in terms of fast-food consumption and inadequate magnesium sources such as fruit and vegetables.31 Serum magnesium concentrations are inversely correlated with fasting insulin.32 Families that have limited access to nutritious foods for their children will increase their probability of adult weight problems.33 Meals taken together as a family are indicative of better weight control.30

Environmental features of childhood overweight risk include the socioeconomic levels of the child's family of origin. Low levels of maternal education and socioeconomic circumstances were shown to be associated with the highest intake of dietary fat and with increased childhood overweight.14, 16, 21 Parental styles of food control should be examined during office calls. Parents who monitor food and variety intake have a more positive influence on the child's food intake than parents who exercise a controlling attitude and restrict food choices to a large degree.34 Families that are barraged by situations that provoke the stress response also have children more prone to being overweight.35

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Conclusion 

Efforts to prevent childhood overweight should begin before conception and continue during pregnancy, infancy, and young childhood. Every opportunity should be used to assess for risk factors that contribute to this health problem in an additive progression (Table 3). Studies indicate that underweight children are more aggressively evaluated, treated, and referred than are children who are overweight.36 This approach must change on the part of practitioners. It was noted that opportunities are being lost at well-child visits to discuss the basics of overweight prevention: diet and exercise, especially among groups at highest risk.37 Although some investigators recommend an “earlier” primary prevention effort in elementary school, this indeed is too late.38 Primary prevention of childhood overweight begins with prospective parents.

Table 3. Policy Recommendations for Clinical Practice
1.Focused preconception planning about healthy parental BMI and smoking cessation

2.Prenatal care that includes quality nutritional assessment and weight gain monitoring at every visit

3.Infant nutrition counseling during the prenatal period with written reinforcement

4.Sequential monitoring of weight gain and growth in the first 2 years of life with targeted nutritional guidance to caretakers

5.Identify parents of higher risk children and provide them with succinct nutritional messages

6.Query all families on time spent on television and media viewing

7.Complete a short recall of food intake and activity at every clinical opportunity

8.Identify family resources for meal planning

Further research is needed in terms of the identification of risk factors for childhood overweight and the quantification of such risks. The Institute of Medicine39 commented that “É the current level of investments by the public and private sectors still does not match the extent of the problem.” Health care costs specifically attributable to childhood overweight must be delineated, and this information must be used to implement the best and most timely prevention efforts possible. There are many possible venues to change the course of this trend in the United States through industry, communities at large, and government. Clinicians, however, have the most direct opportunity to educate parents, prospective parents, and pediatric patients on lifestyle modification. Although there are data gaps about certain aspects of childhood overweight issues, it is clear that this public health crisis needs to be addressed initially with prospective parents with the use of multimodal messages.

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References 

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 In conjunction with national ethical standards, this author reports no relationship with business or industry that represents a conflict of interest.

PII: S1555-4155(07)00466-7

doi:10.1016/j.nurpra.2007.06.003

The Journal for Nurse Practitioners
Volume 3, Issue 8 , Pages 549-554, September 2007

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