TAKE-HOME POINTS
■ Primary care PAs have the opportunity to positively affect childhood obesity and reduce long-term risk for disease.
■ Measure BMI in addition to weight, length/height, and head circumference to better assess the appropriateness of growth.
■ Ask pediatric patients and their parents about physical activity and screen time, and reinforce behaviors that reduce risk for overweight.
■ Discuss dietary choices (including sources of empty calories), and reinforce healthy dietary patterns such as those promoted by the USDA at www.choosemyplate.gov.
■ Target reductions in empty calorie intake based on the unique diets of your pediatric patients.
WHO SHOULD READ THIS?
Primary care physician assistants who treat children and their families.
WHY IS THIS IMPORTANT?
The prevalence of childhood obesity is now approaching 20% among US children aged 2 to 19 years, with the prevalence accelerating after age 5 years. While all American youth are affected, Hispanic boys and African American girls are most affected.1
The increased prevalence of obesity in childhood is causing children to develop diseases that were once associated almost exclusively with adults, including hypertension, dyslipidemia, metabolic syndrome, type 2 diabetes mellitus, fatty liver disease (including steatohepatitis and cirrhosis), hyperandrogenism, polycystic ovarian syndrome, sleep disturbances, and orthopedic problems.2 A number of psychological disturbances are also more prevalent in obese children than in their normal-weight peers, including impulsivity and attention-deficit/hyperactivity disorder, depression, anxiety, and uncontrolled eating behavior.3
Fortunately, lifestyle management, which includes dietary modification and physical activity, has been demonstrated in most studies to be effective treatment in children with obesity-related comorbid conditions.4,5 Pharmacotherapy and bariatric surgery have been advocated in cases of extreme obesity with comorbidities; however, these therapies are themselves associated with morbidity and so should only be considered in circumstances such as extreme obesity coupled with significant comorbidities like type 2 diabetes.4,6
WHAT'S NEW?
In 2010, the United States Department of Agriculture (USDA) released its most recent Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans.7 Based on a series of systematic reviews of the literature, the USDA reached several conclusions regarding the factors that contribute most to obesity among American children. Among the factors they found to be related, the largest contributor was sugar-sweetened beverages, followed by increased dietary energy, both total energy (total calories) and dietary energy density (the number of calories in a specific amount of food—foods with high energy density have a relatively high number of calories in a relatively small amount of the food). The specific contribution of dietary fat was less clear than energy, per se. Finally, the committee reported that certain behaviors were linked with increased body fat, including eating one or more meals at fast food restaurants per week, greater screen time (television, video games/computer use), and skipping breakfast.7
Analyzing data from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys (NHANES), Reedy and Krebs-Smith
demonstrated that the top three dietary energy sources for 2- to 18-year-olds were starchy grain-based desserts, pizza, and sugar-sweetened beverages, which together accounted for 447 kcal/day.8 A total of 798 kcal/day—approximately 40% of total
calorie intake among these children—came from "empty" calories; the largest contributor to empty calories was sugar-sweetened beverages, which accounted for 22% of total empty calories. Fully 50% of empty calorie intake (calorie-dense foods with few essential nutrients) came from six foods: sugar-sweetened carbonated beverages, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk (which is recommended only for children younger than 2 years).8��