Natalie Lutz, CPNP

For many decades, pediatric obesity has been a complex and perplexing problem for children, families and health care providers worldwide. Maintaining a healthy weight and lifestyle have challenged people for decades, but the COVID-19 pandemic has adversely affected numerous health conditions including obesity while highlighting societal disparities that contribute to it. Indeed, the pandemic has had a significant negative impact on families most at risk for obesity.

That’s because when families struggle to obtain nutritious food, stable housing and economic security, the impacts are noticed in many areas – including growth charts.

Many children rapidly gain weight over summer break due to a decrease in activity, irregular sleep schedules and increased snacking on low-nutrient foods. The pandemic has compounded the issue well beyond summer break, interrupting normal routines and support systems, pulling kids away from common outlets for physical exercise and increasing stress levels. Even as more children have returned to in-person school, unhealthy habits adopted early in the pandemic persist. Children have become more sedentary, isolated, and are consuming nutrient-poor food and drinks.

As a result, children and their family members have experienced rapid increases in their body mass index (BMI) and deterioration of their overall well-being. The issue is so pervasive that The American Academy of Pediatrics (AAP) published interim recommendations to address obesity during the pandemic.

To help providers navigate this complex situation, this article will review genetic and individual factors leading to obesity, share screening and treatment recommendations, and detail motivational strategies to help families improve self-efficacy and incorporate lasting changes. Additional discussion includes ways that healthcare providers can advocate for change to make healthy lifestyle choices more accessible for everyone.

Genetics play a key role in the development of obesity. Certain genes influence weight regulation by increasing hunger and food intake.

Genetic factors can be monogenic or multifactorial:

 involves a specific variant of a single gene and is seen in rare cases of inherited obesity. It is associated with more severe, early-onset obesity with distinctive phenotypes. Early-onset obesity beginning prior to age 5 with extreme hyperphagia is more likely to be associated with a genetic origin, such as with syndromes that include obesity as a feature. Examples of monogenic forms of obesity include Prader-Willi Syndrome, Bardet-Biedl Syndrome or Leptin (satiety hormone) deficiency.

 is more commonly seen and involves complex interactions with multiple genes and environmental factors, which can affect genetic associations with BMI.

Environmental influences include global dietary changes over the last few decades with a leaning toward sugary food and drinks and more sedentary lifestyles.

Some families are at higher risk for obesity due to barriers to accessing healthy foods, financial limitations, food insecurity and increased marketing of unhealthy food and drinks. As a result, many families gravitate toward foods that are low-cost, high-calorie and, in many cases, nutrient-poor. Many of these foods are highly processed, which is associated with a lower-quality nutrient content.4 Therefore, despite consuming an excessive number of calories, individuals with obesity have high rates of micronutrient (vitamin and mineral) deficiencies.

Malnutrition is often associated with undernutrition (underweight). However, malnutrition can take many different forms including undernutrition, inadequate micronutrients, overweight, obesity and associated diet-related noncommunicable diseases.

Overweight and obesity result when a person consumes too much energy (calorically dense food) without enough energy expenditure (sedentary lifestyle).

In addition, sugary drinks (ie, juice, soda, energy drinks, sports drinks, sweet tea, coffee drinks) are a leading source of added sugar in the American diet and are associated with weight gain, obesity and related comorbidities.

 Conditions related to weight gain include an increased risk for type 2 diabetes, fatty liver disease, hypertension, sleep apnea, atherogenic cardiovascular disease, metabolic syndrome, precocious puberty and polycystic ovary syndrome. Limiting sugar-sweetened beverages can improve weight management and help to reduce risks of comorbidities

Many primary care providers hesitate to speak with patients about an elevated BMI or weight gain because it can be time consuming and uncomfortable. However, it is important to broach the subject and order lab screening when indicated to monitor for conditions associated with weight gain. Lab screening is recommended for patients in overweight or obese categories if health risk factors are present to assess for comorbidities of obesity.

Screening for patients with abnormal weight gain and an elevated BMI are outlined as follows:

 A BMI in the 85th to 94th percentile is considered overweight, a BMI >95th percentile is considered obese, a BMI ≥120% of the 95th percentile or ≥35 kg/m2 is considered extremely obese.

based on family history, genetic predisposition, review of systems and physical exam. Quality sleep is another important factor and patients should be assessed for symptoms of sleep apnea.

 should include a screen for acanthosis nigricans (AN), hirsutism and intertrigo.

AN is a skin abnormality often associated with insulin resistance that manifests as a thickening of the epidermis with velvety, hyperpigmented plaques in areas such as the neck fold, axillae, flexor skin surfaces and umbilicus.

Hirsutism is excessive hair growth in females commonly seen on the face, chest, back, and lower abdomen. It is associated with polycystic ovary syndrome.

Intertrigo is inflammation caused by skin-to-skin friction and may be seen in skin folds of obese individuals.

The AAP recommends lab screening for patients with abnormal weight gain and an elevated BMI:

Elevated liver function studies (AST/ALT) can be associated with nonalcoholic fatty liver disease.

High cholesterol is associated with an increased risk of atherogenic cardiovascular disease.

HA1C and fasting glucose are included to screen for diabetes or prediabetes. HA1C <5.7% is normal, 5.7% - 6.4% indicates prediabetes and >6.5% indicates diabetes.

may be warranted by the patient’s clinical condition or lab results, including, but not limited to:

Thyroid function tests (TSH/FT4) help rule out thyroid dysfunction, as weight gain is a common symptom of hypothyroidism. Conversely, TSH levels at the upper limit of normal range or slightly increased in obese individuals may be secondary to obesity.

 Insulin level can be included if symptoms of insulin resistance or acanthosis nigricans are noted. However, it does not offer diagnostic value.

Although not routinely recommended by the AAP for screening,low Vitamin D (25-[OH]D) is common in children with obesity. Compared with normal-weight adolescents, those with obesity require higher doses of vitamin D to maintain a sufficient level of Vitamin D 25-[OH]D concentration (Madhusmita, 2020).

According to the Endocrine Society, 7 guidelines for obesity treatment are as follows:

Providers should promote a decrease in BMI with intensive, age-appropriate lifestyle modifications that are culturally sensitive, and family centered.

Lifestyle modifications should support healthy eating following AAP guidelines and USDA recommendations. The AAP’s Prevention Plus “5210” habits include eating five daily servings of fruits and vegetables, limiting non-academic screen time to 1-2 hours, getting at least one hour daily of exercise or active play and eliminating sugar-sweetened beverages.

Providers should assess for psychosocial comorbidities and prescribe assessment and counseling when indicated.

Pharmacotherapy for obesity can be used only after a formal program of intensive lifestyle modification has failed or to improve comorbidities. Additionally, it should only be used in conjunction with a lifestyle modification program. The medication should be discontinued if patients do not have a >4% BMI reduction after 12 weeks at the medication’s full dosage.

Bariatric surgery is suggested only under specific criteria including a BMI >40 or BMI >35 with extreme comorbidities in a patient with a sexual maturity rating of 4 or 5. Patients must have a psychological evaluation to confirm a stable and competent family unit and ability to adhere to healthy diet and activity habits.

Referral to a multidisciplinary team can also be helpful in managing a patient with comorbidities related to obesity. Many hospitals have programs that include a multidisciplinary team of pediatric specialists (ie, endocrinologists, nurse practitioners, registered dietitians, certified diabetes educators, and a psychologist) who work together to provide comprehensive, family centered care for children diagnosed with diabetes or comorbidities related to obesity.

Motivational interviewing is a communication technique first developed to help individuals struggling to overcome addictions. The technique is also effective for complex medical conditions involving a behavioral component such as obesity. In a systematic review, MI helped parents create healthier environments for their children and improved anthropometric measurements.

 Motivational interviewing is more effective when provided at least every other month when compared to usual care.

 The expansion of telehealth amid the pandemic may facilitate increased use of this technique in regular clinical practice.

Pediatric providers have the opportunity to support families and develop trust over a long period of time, which creates a good opportunity to use MI. Starting at birth, providers can help foster healthy child-caregiver relationships and provide guidance regarding nutrition, physical activity, stress and sleep.

 MI is a good strategy to help families improve healthy habits, stress management skills, or build healthy relationships. Additional topics include sleep habits, family meals and breathing exercises to reduce stress.

The well-established tenets of delivering MI include:

 Providers should approach each encounter in an empathetic, non-judgmental way that excludes personal biases related to weight status and food choices. Weight stigma is perpetuated by many people in our society – including health care providers – due to a belief that fear and shame will motivate people to change. In reality, weight stigma increases binge eating, isolation and avoidance of health services, and can contribute to weight gain.

 Providers should allow parents and patients to explore ambivalence about their motivation to change. In allowing them to talk about the pros and cons of making changes, providers can help families discover their own strengths and solutions. One method to start the conversation is to ask for permission to show and discuss the growth chart. Next, providers may ask families their impression of how things are going with establishing healthy routines at home (ie, what is going well and where they are experiencing difficulties). Providers should validate their efforts and their struggles.

 Providers should recognize that not every individual or family is ready to change or would benefit from the same interventions. Some families may need information and/or encouragement while others benefit from resources to obtain enough healthy food.

 For families ready for change, providers can help them consider new and positive health behaviors based on the family’s strengths while also troubleshooting potential obstacles. Asking families when they would like to follow up to discuss health goals allows them the opportunity to be involved in creating their own personal roadmaps.

For some, obesity is a symptom of a more pressing issue such as disordered eating, anxiety or depression, adverse childhood experiences or a family stressor. To dig deeper, providers may consider universal screenings for these issues to identify key factors impacting a child’s overall health – including their BMI.

The relationship between obesity, health disparities, and mental health is complex. Food insecurity and hunger lead to malnutrition, which may manifest as over or underweight status, while mental health problems can lead to over- or under-eating and sedentary behaviors. Obesity and weight shame can compound mental health problems, creating a cycle that is hard to break. Poverty and health disparities create environments in which healthy lifestyles seem out of reach. By advocating for healthy families and equitable communities, providers can help mitigate this complex web of issues.

First, providers should screen and intervene to address the social determinants of health and improve family well-being. The AAP has developed a universal screen to address food insecurity – the Hunger Vital Sign – along with a toolkit of resources

 to address food insecurity in a sensitive way. Prior to initiating universal screening, practices should develop workflows and resources to link families to national and local programs:

 include the Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants and Children, school breakfast and lunch programs and summer nutrition programs. Additionally, some hospitals, such as Phoenix Children's, offers a CARE program, that includes a multidisciplinary team (registered dieticians, endocrinologists, psychologists, etc.) who work together to provide family-centered care for children diagnosed with diabetes or other comorbidities related to obesity.

may include food banks, mobile produce units and farmers markets. Some hospitals and doctors’ offices may have onsite partnerships with food banks to improve access to healthy food.

Next, practices must develop strategies to support the physical and mental health of their patients and families. The AAP supports numerous psychosocial and mental health screening tools such as the patient health questionnaire 2 (PHQ-2), the Generalized Anxiety Disorder-7 (GAD 7), adverse childhood experiences screens and the pediatric symptom checklist. Providers should help destigmatize mental illness by understanding that many people struggle with mental health obstacles. They can ask how families are coping and have local resources readily available. Providers may benefit from additional training to enhance comfort and confidence in managing mental health conditions. This can be achieved through continuing medical education with local and national programs such as the Reach Institute and by developing partnerships and patient-centered resources to collaborate more effectively with mental health professionals.

There are many opportunities for pediatric providers to advocate for changes that support healthy lifestyles and communities. Pediatricians can teach medical students and residents about social influences of health and collaborate with local learning communities to share ideas and resources. Another opportunity is to reach out to local legislators and share perspectives on potential legislation affecting child and family health and well-being. Many states even have online systems inviting comment on pending legislation. State chapters of the American Academy of Pediatrics often have advocacy groups and task forces that help amplify the voices of healthcare professionals.

Amid many obstacles and limited visit times, it may be hard for pediatric providers to stay optimistic and advocate for changes both in and out of the doctor’s office. Yet, that is exactly what is needed. Genetic factors predispose certain individuals to weight gain, while environmental factors make it harder to maintain a healthy weight. The pandemic has magnified all of these challenges tenfold.

Nevertheless, it is worth the fight: Pediatric obesity is a public health crisis that demands attention and societal resources. To have a true impact in combating pediatric obesity, it is critical to develop team-based, multicomponent strategies that include systems changes, behavioral, pharmacologic and, at times, surgical interventions. Clinical teams should be equipped the necessary time, training, care coordination and counseling in order to best serve families. To have the greatest impact, societal changes must be prioritized across all sectors of daily living with healthy choices incorporated and easily accessible to everyone.

Kristen Samaddar is a pediatrician with Phoenix Children's; Natalie Lutz is a CPNP at Phoenix Children's Endocrinology.

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https://www.who.int/news-room/fact-sheets/detail/malnutrition

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