To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child’s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient’s age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.

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Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report

Obesity is becoming a global epidemic in both children and adults. It is associated with numerous comorbidities such as cardiovascular diseases (CVD), type 2 diabetes, hypertension, certain cancers, and sleep apnea/sleep-disordered breathing. In fact, obesity is an independent risk factor for CVD, and CVD risks have also been documented in obese children. Obesity is associated with an increased risk of morbidity and mortality as well as reduced life expectancy. Health service use and medical costs associated with obesity and related diseases have risen dramatically and are expected to continue to rise. Besides an altered metabolic profile, a variety of adaptations/alterations in cardiac structure and function occur in the individual as adipose tissue accumulates in excess amounts, even in the absence of comorbidities. Hence, obesity may affect the heart through its influence on known risk factors such as dyslipidemia, hypertension, glucose intolerance, inflammatory markers, obstructive sleep apnea/hypoventilation, and the prothrombotic state, in addition to as-yet-unrecognized mechanisms. On the whole, overweight and obesity predispose to or are associated with numerous cardiac complications such as coronary heart disease, heart failure, and sudden death because of their impact on the cardiovascular system. The pathophysiology of these entities that are linked to obesity will be discussed. However, the cardiovascular clinical evaluation of obese patients may be limited because of the morphology of the individual. In this statement, we review the available evidence of the impact of obesity on CVD with emphasis on the evaluation of cardiac structure and function in obese patients and the effect of weight loss on the cardiovascular system.

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Obesity and Cardiovascular Disease: Pathophysiology, Evaluation, and Effect of Weight Loss

Despite recent declines in mortality, cardiovascular diseases are the leading cause of death in the United States today. It appears that many of the major risk factors for coronary disease have been identified. Researchers are still learning about different modifiable factors that may influence cardiovascular diseases. Socioeconomic status may provide a new focus. The principal measures of SES have been education, occupation, and income or combinations of these. Education has been the most frequent measure because it does not usually change (as occupation or income might) after young adulthood, information about education can be obtained easily, and it is unlikely that poor health in adulthood influences level of education. However, other measures of SES have merit, and the most informative strategy would incorporate multiple indicators of SES. A variety of psychosocial measures--for example, certain aspects of occupational status--may be important mediators of SES and disease. The hypothesis that high job strain may adversely affect health status has a rational basis and is supported by evidence from a limited number of studies. There is a considerable body of evidence for a relation between socioeconomic factors and all-cause mortality. These findings have been replicated repeatedly for 80 years across measures of socioeconomic level and in geographically diverse populations. During 40 years of study there has been a consistent inverse relation between cardiovascular disease, primarily coronary heart disease, and many of the indicators of SES. Evidence for this relation has been derived from prevalence, prospective, and retrospective cohort studies. Of particular importance to the hypothesis that SES is a risk factor for cardiovascular disease was the finding by several investigators that the patterns of association of SES with coronary disease had changed in men during the past 30 to 40 years and that SES has been associated with the decline of coronary mortality since the mid-1960s. However, the declines in coronary mortality of the last few decades have not affected all segments of society equally. There is some evidence that areas with the poorest socioenvironmental conditions experience later onset in the decline in cardiovascular mortality. A number of studies suggest that poor living conditions in childhood and adolescence contribute to increased risk of arteriosclerosis. Some of these studies have been criticized because of their nature, and others for inadequate control of confounding factors.(ABSTRACT TRUNCATED AT 400 WORDS)

Socioeconomic factors and cardiovascular disease: a review of the literature.

Objectives. The development of recommendations for physicians, nurse practitioners, and nutritionists to guide the evaluation and treatment of overweight children and adolescents. Methods. The Maternal and Child Health Bureau, Health Resources and Services Administration, the Department of Health and Human Services convened a committee of pediatric obesity experts to develop the recommendations. Results. The Committee recommended that children with a body mass index (BMI) greater than or equal to the 85th percentile with complications of obesity or with a BMI greater than or equal to the 95th percentile, with or without complications, undergo evaluation and possible treatment. Clinicians should be aware of signs of the rare exogenous causes of obesity, including genetic syndromes, endocrinologic diseases, and psychologic disorders. They should screen for complications of obesity, including hypertension, dyslipidemias, orthopedic disorders, sleep disorders, gall bladder disease, and insulin resistance. Conditions that indicate consultation with a pediatric obesity specialist include pseudotumor cerebri, obesity-related sleep disorders, orthopedic problems, massive obesity, and obesity in children younger than 2 years of age. Recommendations for treatment evaluation included an assessment of patient and family readiness to engage in a weight-management program and a focused assessment of diet and physical activity habits. The primary goal of obesity therapy should be healthy eating and activity. The use of weight maintenance versus weight loss to achieve weight goals depends on each patient9s age, baseline BMI percentile, and presence of medical complications. The Committee recommended treatment that begins early, involves the family, and institutes permanent changes in a stepwise manner. Parenting skills are the foundation for successful intervention that puts in place gradual, targeted increases in activity and targeted reductions in high-fat, high-calorie foods. Ongoing support for families after the initial weight-management program will help families maintain their new behaviors. Conclusions. These recommendations provide practical guidance to pediatric clinicians who evaluate and treat overweight children.

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Obesity Evaluation and Treatment: Expert Committee Recommendations

judgment of the author In this review, we combine the two approaches We systematically review the literature, include all articles that meet pre­ determined minimal requirements, and present a summary of the results of the studies We also examine the methods used in the studies and provide our assessment of the quality of each study

https://www.annualreviews.org/doi/pdf/10.1146/annurev.pu.08.050187.001345

Physical activity and the incidence of coronary heart disease

This study is concerned with blood pressure behavior in young adults (aged 15 to 29 years) in the biracial community of Evans County, Ga., on two occasions 7 years apart. On the basis of casual blood pressure recordings the prevalence of systolic pressure equal to or greater than 140 mm Hg or diastolic pressure equal to or greater than 90 mm Hg, or both, showed race/sex differences as follows: white males 19.0 percent, white females 12.7 percent, black males 34.0 percent, black females 31.6 percent. Similar differences were noted in the incidence during the 7 year interval. The problem presented by the variability of the casual blood pressure recording is apparent in this interval study. Of particular interest is the association of weight with blood pressure in this youthful group, particularly among white males and females and black females, in relation to both initial and subsequent pressure levels. The data suggest that in this population under 30 years, weight is a risk factor for hypertension, and that maintenance of ideal weight, instituted in youth, may be a preventive measure.

Influence of race, sex and weight on blood pressure behavior in young adults.

Analysis of serum uric acid (SUA) data obtained during the second examination of 2,530 persons in Evans County, Georgia, revealed a mean SUA level of 5.7 and 5.6 mg/100 ml for white and black males, respectively, and 4.8 and 4.9 mg/100 ml for white and black females, respectively. The SUA level and ponderal index were negatively correlated in all four race-sex groups. The prevalence of hypertension was greater in hyperuricemics as compared to normouricemics in all race-sex groups. Increased prevalence of coronary heart disease in hyperuricemics was secondary to increased body size. We review hypotheses concerning the relationships between SUA and coronary risk factors, hypertension, and coronary heart disease.

Serum Uric Acid: Its Relationship to Coronary Heart Disease Risk Factors and Cardiovascular Disease, Evans County, Georgia

In a seven-year follow-up study of a total county population, the incidence of coronary heart disease (CHD) was found to be lower in black than in white men in every occupational category except sharecroppers. Among nonfarming occupations the occupational gradient in CHD observed in the 1960 prevalence study was no longer present when incident cases were the basis for comparison. The lower prevalence rate in white farmers compared to nonfarmers, however, was confirmed in the incidence study. The most likely explanation for these findings was that sustained physical activity above a certain critical threshold value was protective against CHD. This explanation received some circumstantial support from the relationship discovered between leisure time and onthe-job physical activity and the prevalence of CHD. Hypotheses concerning the possible pathogenic processes through which physical activity might operate are briefly reviewed.

Occupation and Physical Activity and Coronary Heart Disease

Elevations of systolic blood pressure, diastolic blood pressure, and serum cholesterol level were accompanied by an increased risk of developing coronary heart disease (CHD) in Evans County, Georgia. This was true for white men, black men, and white women. Black women did not exhibit an increase in incidence with the rise in risk factor levels. The white male excess in CHD incidence persisted over that of the black male at each categorical level of blood pressure and cholesterol studied. White women appeared to have CHD incidence rates generally similar to those of black women at lower levels of risk factors; at higher levels of risk factors, the white female CHD incidence rate was larger than the black female.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=intemed&articleId=578750&pdfFileName=archinte_128_6_007.pdf

Blood pressure and cholesterol as coronary heart disease risk factors.

In a seven-year follow-up of 3,102 Evans County, Georgia, residents examined in the prevalence survey of 1960 through 1962, 143 new cases of coronary heart disease (CHD) occurred, 56 of which resulted in death during the interval. Ethnic differences in CHD among males discovered during 1960 through 1962 were again confirmed. Excess of white males could not be explained by differences in case fatality, diagnostic criteria, missed cases, or by a competing cause of death. In contrast to ethnic differences, differences by social class found in the prevalence survey among white males were not found in the incidence study. Various analyses suggested that the excess prevalence found in the high social class was a reflection of prior high incidence rates in this class. Over time these class differences are disappearing, particularly among younger men.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=intemed&articleId=578747&pdfFileName=archinte_128_6_006.pdf

Joan C. Cornoni

Papers

Influence of race, sex and weight on blood pressure behavior in young adults.

Serum Uric Acid: Its Relationship to Coronary Heart Disease Risk Factors and Cardiovascular Disease, Evans County, Georgia

Occupation and Physical Activity and Coronary Heart Disease

Blood pressure and cholesterol as coronary heart disease risk factors.

Incidence of Coronary Heart Disease by Ethnic Group, Social Class, and Sex