Publication spotlight: Obesity in children and adolescents: a review of epidemiology, causes, assessment, and management

Publication spotlight: Obesity in children and adolescents: a review of epidemiology, causes, assessment, and management

We are pleased to meet with Dr Grace O’Malley from RCSI University of Medicine and Health Sciences. Grace also leads the paediatric EASO COM in Ireland in Children’s Hospital Ireland at Temple Street. She is co-author of this new publication in Lancet Endocrinology and Diabetes which provides a research update related to child and adolescent obesity.

Grace, thanks for sharing this new publication. Who were your co-authors on the new review?

HI Sheree, thanks for your interest in this. I was delighted to work with esteemed colleagues from Australia (Prof. Louise Baur and Dr HibaJebeile from The University of Sydney and the Children’s Hospital at Westmead, as well as Prof Aaron Kelly from the Center for Pediatric Obesity Medicine at the University of Minnesota in the United States.  We are a multi-disciplinary team of health professionals who work both academically and clinically, and the paper is a ‘must-read’ for anyone interested in the area of childhood obesity.

The focus of the new piece is on childhood obesity aetiology, prevalence, assessment and treatment; can you share some highlights?

Yes. It’s always important to first highlight what we mean by obesity which is defined by WHO as an abnormal or excessive fat accumulation that presents a risk to health. Though measuring the levels of excessive or ectopic adipose (fat) tissue in children is possible, at population levels we estimate this using body mass index centile using sex and age-adjusted child growth references and standards. In addition, a waist-to-height ratio of more than 0.5 can indicate abdominal obesity which is an important predictor of health compilations. Rates of child and adolescent obesity differ across nations and unfortunately rates of severe obesity are rising. Typically, we see strong effects related to social inequality such that in lower-income to middle-income countries, children of higher socioeconomic status have a higher risk of developing obesity compared to the situation in high-income countries where children living in disadvantage are at higher risk.

A bio-socioecological framework is useful in trying to understand how obesity develops and progresses, whereby biological and/or genetic risk coupled with environmental and socioeconomic factors promote the accumulation and ‘growth’ of adipose tissue. Once adipose tissue accumulates excessively or in areas of the body where it is considered ‘ectopic’ (in an area of the body which does not typically store fat tissue like the liver), the body seems to defend that adipose tissue through a feedback loop. So, efforts to reduce the levels of adipose tissue are resisted physiologically by the body, a process described by the bodyweight set point theory.

For developing children, holistic clinical assessment is required to first determine whether the child is of large body size or has the disease of obesity. This can only happen by evaluating whether the child’s health is affected by the level of adipose tissue. Clinical examination needs to include a review of all systems and an awareness of the typical obesity-related complications that arise and how these can affect the health and wellbeing of a child at a given developmental stage. For example, developing obesity at age 2-3 can have a detrimental impact on the child’s physical and motor development, affecting their ability to walk, run and limited their developing of fundamental motor skills which can affect how they play and interact socially with other children. For an adolescent girl, the complications of polycystic ovary syndrome and urinary incontinence can impact their sleep, social interaction and future reproductive health.

After an holistic assessment the child’s obesity is staged to determine the level of severity and a suitable treatment plan is developed in collaboration with the child and family. Treatments encompass nutritional therapy, exercise therapy and rehabilitation, psychological therapy, behavioural support, pharmacotherapy and for adolescents, bariatric surgical procedures. The child’s individual presentation, developmental stage, social support, living circumstances and the health system to which they present will each determine the type of treatment deemed most appropriate. Ideally this is then offered to the family and the child can access it. Unfortunately, many health systems do not consider obesity ‘worthy’ of clinical treatment and many children and adolescents receive minimal or no care. We must remember that this is a contravention of the UN Convention on the Rights of the Child related to accessing healthcare.

Are there elements of the review that may be particularly surprising to or unexpected by the obesity community? 

I think many academics, researchers and clinicians will continue to be surprised regarding the increasing number of health-related complications that are associated with obesity in children and adolescents. In turn, for those who do not work with children or adolescents they may be surprised by the impact of developing such conditions at a young age and how the child’s growth and development can be affected. Remember, one of the main jobs of the child is to play in order to ensure social, cognitive, physical and emotional development. When play and participation are affected and limited due to physical, social or indeed societal barriers (e.g stigma and negative bias), child health and development can be negatively impacted in the longer term.

The obesity community is often asked about the risk of triggering eating disorders with obesity treatment but on the whole evidence in children and adolescents suggests that holistic obesity treatment reduces the symptoms of disordered eating. The key factor for effective childhood obesity treatment is the multi-disciplinary team so that the key drivers of obesity can be identified addressed. These might include mechanical and metabolic factors or factors related to the mental health of the child or parent/s and the social milieu in which the child is developing.

How do you think the review will contribute to childhood obesity management?

The team and I are confident that the review will provide an up-to-date reference for those working in the area already and will help identify areas of their practice which they may need to build additional skill. For health professionals, new to this area of practice who are eager to actively address obesity, the paper will provide a thorough source of guidance to help them initiate obesity care in their clinical practice. Hopefully, readers will be prompted to increase their knowledge, skill and behavior around identifying, assessing and treating obesity and they may even consider developing an EASO paediatric COM in their centre! Being part of the paediatric COM network has been really valuable for our service in Children’s Health Ireland at Temple Street where we have been able to participate in clinical exchange programmes with other health systems and regions.

The paper will be useful to researchers in the field of childhood obesity assisting them to develop relevant novel research questions for impactful translational research.  Together, we can all ACT in solidarity to prevent obesity at the population level and to advocate for the provision of respectful, evidence-informed treatment and care for children affected by obesity.

Read the review: