Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Obesity now affects one in five children in the United States. Discrimination against overweight children begins early in childhood and becomes progressively institutionalized. Because obese children tend to be taller than their nonoverweight peers, they are apt to be viewed as more mature. The inappropriate expectations that result may have an adverse effect on their socialization. Many of the cardiovascular consequences that characterize adult-onset obesity are preceded by abnormalities that begin in childhood. Hyperlipidemia, hypertension, and abnormal glucose tolerance occur with increased frequency in obese children and adolescents. The relationship of cardiovascular risk factors to visceral fat independent of total body fat remains unclear. Sleep apnea, pseudotumor cerebri, and Blount's disease represent major sources of morbidity for which rapid and sustained weight reduction is essential. Although several periods of increased risk appear in childhood, it is not clear whether obesity with onset early in childhood carries a greater risk of adult morbidity and mortality. Obesity is now the most prevalent nutritional disease of children and adolescents in the United States. Although obesity-associated morbidities occur more frequently in adults, significant consequences of obesity as well as the antecedents of adult disease occur in obese children and adolescents. In this review, I consider the adverse effects of obesity in children and adolescents and attempt to outline areas for future research. I refer to obesity as a body mass index greater than the 95th percentile for children of the same age and gender.

Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease

This report reviews the risks and consequences associated with childhood and adolescent obesity. Although no consensus definition of childhood obesity exists, the various measures encountered in the literature are moderately well correlated. The paper is organized in three parts. The first section reviews childhood obesity sequelae that occur during childhood. These short-term risks, for orthopedic, neurological, pulmonary, gasteroenterological, and endocrine conditions, although largely limited to severely overweight children, are becoming more common as the prevalence of severe overweight rises. The social burden of pediatric obesity, especially during middle childhood and adolescence, may have lasting effects on self-esteem, body image and economic mobility. The second section examines the intermediate consequences, such as the development of cardiovascular risk factors and persistence of obesity into adulthood. These mid-range effects of early obesity presage later adult disease and premature mortality. In the final section, the small body of research on the long-term morbidity and mortality associated with childhood obesity is reviewed. These studies suggest that risk of cardiovascular disease and all-cause mortality is elevated among those who were overweight during childhood. The high prevalence and dramatic secular trend toward increasing childhood obesity suggest that without aggressive approaches to prevention and treatment, the attendant health and social consequences will be both substantial and long-lasting.

Risks and consequences of childhood and adolescent obesity.

Objective: To examine prevalence of overweight and trends in overweight for children and adolescents in the US population. Design: Nationally representative cross-sectional surveys with an in-person interview and a medical examination, including measurement of height and weight. Participants: Between 3000 and 14000 youths aged 6 through 17 years examined in each of five separate national surveys during 1963 to 1965, 1966 to 1970, 1971 to 1974, 1976 to 1980, and 1988 to 1991 (Cycles II and III of the National Health Examination Survey, and the first, second, and third National Health and Nutrition Examination Surveys, respectively). Main Outcome Measures: Prevalence of overweight based on body mass index and 85th or 95th percentile cutoff points from Cycles II and III of the National Health Examination Survey. Results: From 1988 to 1991, the prevalence of over-weight was 10.9% based on the 95th percentile and 22% based on the 85th percentile. Overweight prevalence increased during the period examined among all sex and age groups. The increase was greatest since 1976 to 1980, similar to findings previously reported for adults in the United States. Conclusions: Increasing overweight among youths implies a need to focus on primary prevention. Attempts to increase physical activity may provide a means to address this important public health problem. (Arch Pediatr Adolesc Med. 1995;149:1085-1091)

Overweight Prevalence and Trends for Children and Adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991

Many studies document the high prevalence of dieting and abnormal eating behaviors in adolescents and young adults. The age of onset of eating disorders remains unclear because there are no published surveys of voluntary dieting and eating attitudes in young children. A total of 318 girls and boys were surveyed from two randomly chosen schools in middle-income neighborhoods. The children were equally distributed among grades 3 through 6. The survey included a children's version of the Eating Attitudes Test and a demographic and dieting questionnaire. Results showed that 45% of the children wanted to be thinner, 37% had already tried to lose weight, and 6.9% scored in the anorexia nervosa range, closely matching the published results concerning teenagers and young adult women. Several questions were isolated by univariate and multiple regression analyses that accurately (P less than .05) predicted children's Eating Attitude Test scores. The fact that young children admit having diet preoccupation and atypical eating attitudes is shown in this study. It may be possible to improve early case identification of children at risk for anorexia nervosa and perhaps improve intervention strategies by focusing on the early development of dieting behavior in young children.

Dieting Behavior and Eating Attitudes in Children

Diagnosing hysterical conversion reactions in children

The authors present a critical review of recent clinical literature on eating disorders in children and adolescents. Anorexia nervosa, bulimia, and obesity appear to be reaching such epidemic proportions that up to 25% of teenagers will demonstrate one of these eating disorders, Long-term follow-up studies of these eating disorders document a fall of mortality rates but no improvement in morbidity rates. The authors critically review techniques of weight stabilization during short-term and long-term treatment, including individual psychodynamic, behavioral, somatic, and family therapies.

An overview of anorexia nervosa, bulimia, and obesity in children and adolescents.

Clonidine is used by pediatricians and child psychiatrists for tics, Tourette9s syndrome, and attention deficit disorder with hyperactivity (ADHD) with aggressive behavior. However, recent evidence of sudden death and cardiac toxicity associated with clonidine raises concern about the widespread use of this medication. There are three unpublished cases where the combination of clonidine and methylphenidate has been associated with unexplained sudden death in children ages 7,8, and 9 years (Frenia M.L., personal communication, September 21, 1995, Drug Surveillance and Information, Boehringer Ingelheim Pharmaceuticals).

Michael J. Maloney

Papers

Dieting Behavior and Eating Attitudes in Children

Diagnosing hysterical conversion reactions in children

An overview of anorexia nervosa, bulimia, and obesity in children and adolescents.

Clonidine and Sudden Death

Caffeine toxicity as a cause of acute psychosis in anorexia nervosa