- February 15, 1999 - American Academy of Family Physicians

Editorials

Childhood Obesity: Time for Action, Not Complacency

DENNIS MICHAEL STYNE, M.D.
University of California, Davis, Medical Center
Sacramento, California

As Moran¹ describes in this issue of American Family Physician, an epidemic of childhood obesity is occurring in the United States; the prevalence of the most severe cases--defined as a body mass index (BMI) for age over the 95th percentile--has virtually doubled over the past 20 years, while the prevalence of standard cases (BMI for age over the 85th percentile) has increased about 50 percent.² Possibly because of a feeling of hopelessness about the effectiveness of treatment for obesity or an expectation that most children will "outgrow it," textbooks of pediatrics have barely touched on the subject of childhood obesity in the past, and present-day authorities worry about the lack of efficacy of available treatment.³

See Article in this issue.

Currently, a majority of resident physicians do not address the issue of obesity with their patients,⁴ and it is questionable how many practicing physicians do. However, increased interest in this subject is now apparent from publication of articles on the subject in medical journals,^5-7 from increases in funding available for research and treatment in this important area, and from frequent reports in the lay press about this subject.

Obesity in childhood persists into adulthood predominantly when there is a strong genetic component.⁸ The complications of obesity in adulthood are well known (heart disease, hypertension, type 2 diabetes mellitus [formerly known as noninsulin-dependent diabetes], etc.). Estimation of annual costs related to obesity and its complications approach $100 billion.⁹ Childhood obesity carries its own morbidity (type 2 diabetes mellitus is now the most common type of diabetes diagnosed in several pediatric diabetes centers)¹⁰ and mortality (we and others have seen children between the ages of six through 10 years with a BMI over the 99th percentile who die of sudden cardiopulmonary arrest apparently caused by arrhythmias associated with their obesity).

Treatment of obesity in children, like the treatment of obesity in adults, is expensive, lengthy and generally only effective if the whole family is involved,^11,12 and even then it is not "curative." It is essential that our goal should be directed toward prevention, as Moran states,¹ in the entire population, with particular attention to more susceptible ethnic groups.

Obesity, determined partially by genetics and partially by the environment,¹³ is best considered a chronic disease. The increase in obesity in the United States (and a similar increase in other countries as their economies "develop") is not caused by a change in the gene pool, but rather by changes in the environment that have caused genetically susceptible populations to express the obesity phenotype in increasing numbers. For many reasons, including fewer mandated physical education programs in schools, lack of safe areas to exercise in many inner-city neighborhoods, and the ever-present television set, physical activity levels are lower now than they were 20 years ago. Energy input (read food) has increased remarkably because of the availability of fast-foods that are high in calories and because of an increasing lack of adult supervision in the lives of many children.

Thus, a nationwide population-based approach to the prevention of childhood obesity is essential. Increasing physical activity and practical nutritional knowledge through education in schools or through extracurricular programs should be an obvious first step that may require legislative action. However, even spending one hour sweating on an exercycle will not work off the calories found in a fast-food meal; energy intake must be controlled in this land of super-sized portions.

A public service campaign is needed to combat the overwhelming messages of caloric and fat intake bombarding children at every turn; during one hour of watching cartoons, a young child might see advertisements for more than enough calories, fat and sodium than is appropriate for an average adult male to consume in 24 hours.¹⁴ Advertisements for children to resist inappropriate food choices and for their parents to avoid pressure from their children to buy this undesirable food could be modeled after the successful antismoking campaigns targeted at young persons.

With no safe, effective pharmacologic agent on the horizon, there is no easy answer to the treatment of childhood obesity. The prevention of this condition is a daunting task, but we cannot remain complacent and expect all overweight children to "outgrow it," or we might find ourselves facing even more alarming statistics in 20 years as we look back to the "good old days" at the end of the 20th century when the incidence of childhood obesity was only 22 percent.¹⁵

Dr. Styne is professor in the Department of Pediatrics and director of Pediatric Endocrinology, University of California, Davis, Medical Center. He runs the Shapedown program at the center for moderately obese children and adolescents.

Address correspondence to Dennis M. Styne, M.D., University of California, Davis, Medical Center, Department of Pediatrics, 2516 Stockton Blvd., Sacramento, CA 95817.

REFERENCES

Moran R. The evaluation and treatment of childhood obesity. Am Fam Physician 1999;59:859-73.

Gortmaker SL, Dietz WH Jr, Sobol AM, Webler CA. Increasing pediatric obesity in the United States. Am J Dis Child 1987;141:535-40.

Charney E. Childhood obesity: the measurable and the meaningful [editorial]. J Pediatr 1998;132:193-5.

Denen ME, Hennessey JV, Markert RJ. Outpatient evaluation of obesity in adults and children: a review of the performance of internal medicine/ pediatrics residents. J Gen Intern Med 1993;8:268-70.

Pietrobelli A, Faith MS, Allison DB, Gallagher D, Chiumello G, Heymsfield SB. Body mass index as a measure of adiposity among children and adolescents: a validation study. J Pediatr 1998;132:204-10.

Rosner B, Prineas R, Loggie J, Daniels SR. Percentiles for body mass index in U.S. children 5 to 17 years of age. J Pediatr 1998;132:211-22.

Hill JO, Trowbridge FL. The causes and health consequences of obesity in children and adolescents. Pediatrics 1998;101:(3 part 2)497-574.

Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-73.

Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obes Res 1998;6:97-106.

Glaser N, Jones KL. Noninsulin-dependent diabetes mellitus in children and adolescents. Adv Pediatr 1996;43:359-96.

Epstein LH. Methodological issues and ten-year outcomes for obese children. Ann N Y Acad Sci 1993;699:237-49.

Mellin L. Shapedown: weight management program for adolescents. 3rd ed. San Francisco: Balboa, 1983: 181.

Schonfeld-Warden N, Warden CH. 1997. Pediatric obesity. An overview of etiology and treatment. Pediatr Clin North Am 1997;44:339-61.

Parsons I, Green-Burgeson D, Styne DM. Calories per hour: Television commercials target children for unhealthy dietary habits. American Federation for Medical Research Midwestern Regional Meeting. Abstracts. J Investig Med 1998;46:88A.

Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents. The National Health and Nutrition and Examination Surveys, 1963-1991. Arch Pediatr Adolesc Med 1995;149:1085-91.

Problem Sleepiness: An Often Unrecognized Condition

BILL ZEPF, M.D.
Sutter Family Practice Residency Program
Davis, California

Just as "problem drinking" is a useful term that defines excessive drinking by its repercussions rather than by a specific amount, so is the term "problem sleepiness" meant to refer to sleepiness that causes adverse effects for the person involved. The specific quantity or quality of sleep that is needed by a given person to avoid problem sleepiness will vary somewhat. When sleepiness reaches a certain point, however, it leads to predictable and recognizable problems for all individuals. The article on recognizing problem sleepiness in this issue of American Family Physician presents a brief overview of sleep disorders and their presentations in primary care populations.¹

See Article in this issue.

It is not surprising that sleep disorders have recently garnered more attention in the lay press and the medical literature. The benefits and demands of modern society have loosened the tight grip that cycles of light and dark used to have on our daily routines. We awaken to alarm clocks rather than by our natural circadian rhythm and remain awake long after our fellow diurnal mammals have turned in for the night. While few of us would wish to give up the modern conveniences of our 24-hour society, the sleep deficits that many of us consistently carry do exact a toll.

The ill effects of problem sleepiness are seldom dramatic and, therefore, often go unrecognized. The insidious damage that is done to a person's emotional and physical health from problem sleepiness is frequently attributed to other causes when both physicians and their patients fail to detect the underlying sleep deprivation.

Physicians themselves are some of the worst culprits for constructing lifestyles that incorporate habitual sleep deprivation. We even seem to take a peculiar pride on occasion in our disregard for the adverse effects of chronic sleepiness. It is not surprising then, that we may miss these same effects when they present in our patients. While the related article¹ in this issue is primarily intended to help us to diagnose our patients, no doubt a few readers will start by diagnosing their own occult sleep disorder.

The article¹ is the product of a working group convened by the National Heart, Lung, and Blood Institute and the National Center for Sleep Disorders Research that included both sleep specialists and primary care physicians. Whenever possible, the document supports its assertions with references to pertinent research. The reader should be cautioned, however, that the document is not an explicitly developed evidence-based guideline but rather a consensus of expert opinion.

Much of sleep medicine research is still somewhat preliminary, and there is a paucity of large, randomized studies to draw from when looking for evidentiary support of specific expert opinions. Indeed, some authors have remarked recently that the public health risks of certain sleep disorders may have been overstated and have decried the large numbers of uncontrolled trials in the supporting research.²

Sleep disorders are often seen in a fairly unhealthy and elderly cohort with many comorbid conditions. While problem sleepiness may be just as endemic (even epidemic) as obesity in our modern society, it is not as easily recognized or quantified. The present limitations of sleep research and expert opinion will of course lead one to view the article with a critical eye; that notwithstanding, the working group has constructed a concise document relevant to a family physician reader with considerable good information on problem sleepiness that is not likely to be encountered elsewhere in the primary care literature.

Dr. Zepf is in private practice in the Sutter West Medical Group, Davis, Calif., and is a part-time faculty member of the Sutter Family Practice Residency Program. He is an assistant editor of American Family Physician.

Address correspondence to Bill Zepf, M.D., 2020 Sutter Place, #101, Davis, CA 95616.

REFERENCES

National Heart, Lung, and Blood Institute and National Center on Sleep Disorder Research Working Group. Recognizing problem sleepiness in your patients. Am Fam Physician 1999;59:937-44.

Wright J, et al. Health effects of obstructive sleep apnea and the effectiveness of continuous positive airway pressure: a systematic review of the research evidence. BMJ 1997;314:851-60.

Copyright © 1999 by the American Academy of Family Physicians.
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