Confronting the Epidemic of Childhood Obesity

In a recent policy statement emphasizing early identification and prevention strategies, the American Academy of Pediatrics Committee on Nutrition refers to an “epidemic” of excessive weight and frank obesity in children.1 Similarly, this rather graphic term can be found in a number of recent articles, commentaries, reports from expert consensus conferences, and pronouncements by public officials. “Epidemic” is usually used to describe the spread of an infectious disease. Although not contagious, childhood obesity is spreading like influenza, and we have no vaccine against it. Its prevalence is increasing worldwide, even in less-developed countries. In the United States, childhood obesity is the most common nutritional disorder (1 in 3 are overweight or close to it), with disproportionately high rates in ethnic minorities. American children are on course to grow into the most obese generation of adults in history. The rise in the prevalence of obesity in children and adolescents in the United States is one of the most alarming public health issues facing the nation today.What is the solution? Population-based prevention approaches hold the greatest promise for reducing the onset of obesity among children and adolescents. A new Web portal, Shaping America's Youth (www.shapingamericasyouth.com), lists nearly 1100 multidisciplinary interventions. However, few (<5%) have published quantifiable measures of success. A newly released report from the Institute of Medicine designates prevention of obesity in children and youth as a “national public health priority.” The Institute of Medicine report calls for a comprehensive strategy involving all aspects of American society similar to that which has had at least partial success in promoting automobile safety as well as in reducing tobacco use and smoking-related illness.2It is inevitable that pediatricians and other primary health care professionals play a key role in efforts to combat the epidemic. However, most health care providers have received limited training in nutrition and assessment of excessive weight gain and fail to address it in the pediatric population. A 2002 needs assessment of pediatricians, pediatric nurse practitioners, and dietitians showed that <20% of pediatricians were practicing even the most basic guideline: the assessment of body mass index.3 Early recognition of excessive weight gain relative to linear growth is an essential component of the physical examination and should be integrated during any visit in primary health care.Referrals of children affected by long-lasting obesity to a pediatric endocrinology center have become increasingly common in the past decade. Often, however, the referral to the pediatric endocrinologist occurs late, years after the child has become overweight, as Quattrin et al4 report in their retrospective study published in this issue of Pediatrics. It is notable that the majority of children in that study developed obesity in their preschool years, when preventive measures are likely to be most effective if implemented. Quattrin et al analyzed the outcome of referral to a tertiary care center after an interval of ∼2 years from the first visit, with disappointing results. They logically conclude that this kind of referral is ineffective; instead, efforts should be devoted to developing early family-based behavioral lifestyle intervention programs that could be used by pediatricians and other primary care providers.Because many of these obese children and adolescents will develop one or more metabolic complications,5 there is a role for pediatric endocrinology at a tertiary care referral center, but this is inevitably late in the process and should be part of a multidisciplinary approach to the epidemic. It is essential that both physicians and patients realize that the goal of treatment is not necessarily weight loss alone but also weight management to achieve the best possible weight for improved health. The growing prevalence of childhood obesity indicates an urgent need for the development of effective strategies for both primary and secondary prevention.