THE ROLE OF DIETARY FACTORS AND FOOD HABITS IN THE DEVELOPMENT OF CHILDHOOD OBESITY

DEAN RASHID JUNE 2011

ABSTRACT Childhood overweight and obesity are major health problems with immediate and longterm consequences of staggering magnitude. The objective of this report is to emphasize the aims to provide a summary of the role of nutrition-related factors on obesity prevention in childhood. This report emphasizes that dietary interventions should be incorporated into a multidisciplinary strategy for obesity prevention. No single nutrient has been unequivocally associated with the development of obesity. Methodological limitations in study design and the complex nature of obesity must be taken into account when interpreting the association with reported dietary factors. Energy intake should be individually determined, taking into account energy expenditure and growth. Preferential intake of slowly absorbed carbohydrates and limiting the ingestion of rapidly absorbed carbohydrates and simple sugars should be promoted. No specific recommendations for macronutrient intakes to prevent obesity can be made. Plant foods can be used as the main food contributors to a well-balanced diet with adequate monitoring of nutrient intake. Plain water should be promoted as the main source of fluids for children instead of sugarsweetened beverages. Nutrition and lifestyle education aimed at the prevention of obesity should be included in the routine care of children by health care professionals.

CHAPTER 1 : INTRODUCTION
Obesity is the most prevalent nutritional disorder among children and adolescents throughout the world. The World Health Organization describes obesity as one of todays most blatantly visibleyet most neglectedpublic health problems and uses the term globesity to reflect an escalating global epidemic of overweight and obesity. The International Obesity Task Force (IOTF) terms obesity the millennium disease, highlighting the major international impact of this condition. In fact, obesity is now a pandemic, affecting both adults and children in developed and developing countries. The worldwide prevalence of overweight in children and young people ages 5 to 17 years is approximately 10%, with that of obesity alone being 2 to 3%. Certain regions and countries have particularly high rates of paediatric obesity: More than 30% of children and adolescents in the Americas, and approximately 20% of those in Europe, are overweight or obese, with much lower prevalence rates being seen in sub-Saharan Africa and Asia, although in some of these regions rapid changes in prevalence values are being reported. The increased prevalence of obesity in recent decades in genetically stable populations highlights the central role of recent important environmental trends in the development of the obesity epidemic. Environmental factors that are seen to promote excess weight gain include sedentary lifestyles, a high intake of energy dense micronutrient-poor foods, a high intake of sugarsweetened drinks, the heavy marketing of energy-dense foods and fast-food outlets, adverse socioeconomic conditions, and large portion sizes. Factors that protect against obesity include regular physical activity, a high dietary fiber intake, environments that promote healthy food choices for children, and breastfeeding.
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CHAPTER 2 : CHILDHOOD OBESITY

2.1 DEFINITION The Centers for Disease Control and Prevention (CDC) recommends using the percentile BMI for age and gender as the most appropriate and easily available method to screen for childhood overweight or at risk for overweight. BMI is calculated by dividing the weight in kilograms by the height in meters squared. Age and gender norms for BMI are readily accessible. BMI correlates with adiposity and with complications of childhood overweight such as hypercholesterolemia, hypertension and later development of cardiovascular disease. Although more precise measures of lean body mass and body fat such as dual x-ray absorptiometry (DEXA) may be appropriate for clinical studies, BMI norms are particularly helpful for screening in busy office practices and for population assessment. Because BMI norms for youth vary with age and gender, BMI percentiles rather than absolute BMI must be determined. The cutoff values to define the heaviest children are the 85th and 95th percentiles. In adolescence as maturity is approached, the 85th percentile roughly approximates a BMI of 25, which is the cutoff for overweight in adults. The 95th percentile roughly approximates a BMI of 30 in the adolescent near maturity, which is the cutoff for obesity in adults. The cutoff recommended by an expert committee to define overweight (BMI at or above the 95th percentile) is a conservative choice designed to minimize the risk of misclassifying nonobese children.

2.2 PATHOPHYSIOLOGY
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During childhood and adolescence, excess fat accumulates when total energy intake exceeds total energy expenditure. This energy imbalance can result from excessive energy intake and/or reduced energy expenditure, the latter is usually a consequence of a sedentary lifestyle. This is particularly associated with excessive television viewing, excessive computer use, and insufficient physical activity. In infancy, excess fat deposition occurs when excess energy is provided, especially when protein-to-energy ratio is altered. This is often seen when feedings are supplemented with additives such as carbohydrates or fat and protein content remains the same. In addition, one study reports an increased incidence of obesity at 3 years of age in infants weaned to solid foods by 4 months. In individuals who are obese, dysfunction in the gut-brain-hypothalamic axis via the ghrelin/leptin hormonal pathway has been suggested to have a role in abnormal appetite control and excess energy intake. Studies indicate that dysfunction in this hormonal axis may be the causative factor in as many as 10% of obese subjects, with emphasis particularly on those individuals who appear to manifest familial morbid obesity. In these families, several reports have shown a dramatic, weight loss response to hormone replacement therapy in patients with leptin deficiency. Reductions in energy expenditure characterize other hormonal deficiency states, including hypothyroidism and growth hormone deficiency. Increases in energy intake are observed in genetic syndromes, such as Prader-Willi syndrome, Cushing syndrome, and drug-induced obesity. Despite observations of an etiologic role for genetic and hormonal disorders, these factors alone do not explain the excess weight gain observed in most patients who have obesity and are referred to physicians for evaluation and treatment. Although most overweight children have a
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familial form of obesity, with 1 or 2 obese parents, excess weight gain in obese children clearly depends on both genetic and environmental factors. Correlations between parent and child habitus likely reflect, at least in part, the familial patterns of food intake, exercise, and selection of leisure activity (including amount of television watching), as well as familial and cultural patterns of food selection. Nevertheless, evidence from twin, adoption, and family studies suggests that genetic factors also play a considerable role in the development of childhood obesity.

CHAPTER 3 : DIETARY FACTORS

3.1 MACRONUTRIENTS
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The role of particular macronutrients (as total or relative percentage of energy intake) in the aetiology of obesity is poorly understood. This is due in part to the complex interrelation between dietary carbohydrate (CHO), protein, and fat, given that when the intake of 1 macronutrient changes, the intake of the other 2 also changes as a consequence. 1. Carbohydrates and Fibre The intake of simple CHO has been proposed to be associated with adiposity development, whereas slowly absorbed CHO (low glycaemic index) could be protective. In adults, observational studies suggest a possible relation between consumption of sugarsweetened beverages and body weight, but there is insufficient supporting evidence from randomised controlled trials of adequate size and duration. Rapidly digested carbohydrates produced lower satiety in normal-weight and obese children, whereas low-glycaemic index foods eaten at breakfast had a significant impact on food intake at lunch, when intake was reduced after low- compared with after high-glycaemic-index breakfasts. Accordingly, the independent roles of breakfast and CHO-based foods within breakfast in satiety need to be defined to develop obesity prevention strategies. An examination was carried out to determine whether dietary glycaemic index, glycaemic load, added sugar intake, or fibre intake between ages 2 and 7 years is associated with the development of a particular body composition, and if so, to ascertain whether these associations are modified by meal frequency. They observed that neither dietary glycaemic index nor glycaemic load or added sugar intake appeared to significantly influence changes in body composition. It is possible that potential benefits associated with increasing fibre intake throughout childhood could be limited to toddlers with a lower meal frequency. 2. Fats

Enhanced percentage fat intake was significantly related to increased relative body weight, body fat mass , and body fat content in large groups of children. However, equivocal results were found when groups of children were subdivided according to sex: significant positive correlations were found between dietary fat intakes and body fat mass in boys, but not in girls. It is important to note that other observational studies failed to find a relation between fat intake and the development of obesity. The only available intervention study suggests that modification of fat intake may decrease the risk of obesity. A review concluded that the role of dietary fat types as early determinants of childhood obesity is poorly understood. The potential for mediumchain triglycerides, conjugated linoleic acid (CLA), and omega-3 long-chain polyunsaturated fatty acids to modulate food intake has been explored, and supplementation of CLA was recently reported to significantly attenuate body fat deposition in overweight or obese prepubertal children. However, safety and efficacy of such interventions require careful scrutiny in the paediatric age group. Further paediatric data are needed on the effects of total fat consumption and the potential role of dietary fat quality and composition on the development of childhood obesity. 3. Proteins Dietary proteins and specific amino acids (particularly arginine, alone or in combination with lysine) have been shown to stimulate the somatotropic axis and may thereby influence body composition. Growth hormone (GH) plays an important role in reducing fat mass, with studies showing increased lipolysis and decreased fat mass after GH administration. Agostoni et al suggested that a positive correlation between high protein intake and later obesity occurs mainly in populations with protein intake higher than 15% to 16% of total energy intake. When compared with a low-protein, high-fat intake diet, a high-protein, low-fat diet was associated with an earlier adiposity rebound (defined as the rise in body mass index [BMI] curve normally
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occurring at 57 years of age), which has been shown to be associated with the development of obesity. The analysis of data from the German DONALD study suggests that animal but not vegetable protein intakes in early childhood may play a role in later overweight and adiposity. In contrast, in a cohort of healthy Danish girls, a high protein intake was associated with a decrease in body fat and an increase in fat-free mass, depending on the available amounts and combinations of arginine and lysine. In another Danish cohort study, linear growth in prepubertal girls was influenced by habitual arginine intake, whereas body fat gain was inhibited by the intake of arginine and lysine. 3.2 MISCELLANEOUS 1. Plant Foods Plant-based diets are low in energy density and high in complex carbohydrates, fibre, and water, which may increase satiety and resting energy expenditure. Two recent reviews deal with the relation between plant food and childhood obesity. Newby concluded there was no relation between childhood obesity and fruit and vegetables. Sabate and Wien explored the concept of plant-based diets because several studies showed that vegetarians were leaner than their nonvegetarian peers. In their review, they concluded that animal foods (meats and dairy products/eggs) were associated with an increased risk of overweight, whereas plant foods were either protective (cereals, legumes, and nuts) or showed no association (fruit/vegetables and vegetable protein products).

CHAPTER 4 : FOOD HABITS

4.1 DEFINITION The term food habits (or eating habits ) refers to why and how people eat, which foods they eat, and with whom they eat, as well as the ways people obtain, store, use, and discard food.
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Individual, social, cultural, religious, economic, environmental, and political factors all influence people's eating habits. 1. Beverages The majority of studies classify the following as sugar-added beverages: any sugarsweetened or artificially sweetened fruit flavoured drinks, sports (natural or artificial) drinks, and drinks that contain 100% fruit juice; carbonated sodas that include sugar or artificial sweetener, caffeinated or decaffeinated; and sugar sweetened or artificially sweetened, caffeinated or decaffeinated tea or coffee. Two reviews systematically addressed the relation between sugaradded beverages and obesity. Malik et al concluded that sufficient evidence exists for public health strategies to discourage consumption of sugary drinks. Forshee et al concluded that both quantitative meta-analysis and qualitative review found practically no association between sweetened beverage consumption and BMI. The different conclusions can be explained by different study populations, different methodology, and confounding variables. For example, the randomised controlled trial of James et al showed that the percentage of overweight and obese children increased in the control group by 7.5%, and decreased in the intervention group (reduced sweetened beverage consumption) by 0.2%; however, those differences could not simply be attributed to a decline in the consumption of high-calorie sodas. Moreover, Ebbeling et al observed that although energy intakes from high-calorie beverages dropped by 82% in the intervention group, the difference in BMI gain was not significant. Since these 2 reviews have been made available, other longitudinal and intervention studies on this topic have been published. Some support the association between sugar-sweetened beverages consumption and BMI, whereas other studies found no association. Recently, Muckelbauer et al performed a combined environmental and educational intervention promoting water consumption among children in elementary school in a population from socially deprived areas. The intervention was
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successful in increasing water consumption and preventing overweight without an effect on juice and soft drink consumption. Overall, results are not conclusive. It is uncertain whether the critical factor is the sugar, energies, or behaviours related to beverage consumption. A relation between sugar-sweetened beverage consumption and development of obesity in children and adolescents has been reported in some studies, although conclusive evidence is not available. Sugar-sweetened beverages are a significant contributor to energy intake. The Committee therefore considers that plain water should be promoted as the main source of fluids for children. 2. Eating Frequency Observations both in adult and child populations associate a lower number of daily meals with a higher risk of obesity. Several cross-sectional and longitudinal studies have addressed this issue in children. Cross-sectional studies showed inconsistent results. In the longitudinal studies, Thompson et al observed that eating occasions between 4.0 and 5.9 times per day were negatively associated with changes in BMI z score, after controlling for baseline BMI z score. In both black and white girls ages 9 to 10 years, followed up for 10 years, Franko et al found that participants who frequently ate more than 3 meals per day had lower BMI-for-age z scores than those eating fewer meals. Black, but not white girls, who frequently ate more than 3 meals per day, were less likely to meet criteria for overweight. Adolescents or adults who eat more frequently also exercise more and make healthier food choices, a possible source of confounding. Increased thermogenesis from consuming more meals could be a potential explanation, linking fat mass and meal frequency. However, there is ongoing controversy regarding this mechanism because studies on thermic effects of food do not point to different degrees of thermogenesis when comparing nibbling (consuming frequent small meals) and gorging (consuming infrequent large meals).
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3. Skipping Breakfast Breakfast is usually defined as the meal eaten in the morning and the first meal of the day. Skipping breakfast has been suggested to be a risk factor for obesity. One systematic review found that although breakfast eaters consumed more daily calories, they were less likely to be overweight. In a recent systematic review of studies performed in Europe, observational studies have consistently shown that children and adolescents who eat breakfast have a reduced risk of being overweight or obese and have a lower BMI compared with those who skip breakfast. Three of 4 longitudinal studies performed in the United States also showed a relation between skipping breakfast and BMI gain. Children who skip breakfast regularly were found to consume a greater percentage of energy from fat and snacks that are higher in fat. Skipping breakfast may be followed by increased appetite later in the day, producing overeating, or may promote choice of foods with higher energy density, leading to greater overall intake. Alternatively, because a person consumed a nutrient-dense diet, eating breakfast may boost the persons ability to engage in regular physical activity. 4. Family Dinner Eating family dinner has been linked to healthy dietary intake patterns. Two longitudinal studies assessed the relation between family dinner and obesity development. One observed a positive relation, but only in whites, and the other only in the crosssectional analysis and not in the longitudinal one. In adolescents between 12 and 15 years of age from the 1997 survey of the National Longitudinal Survey of Youth, Sen observed that, for whites, higher frequency of eating dinner as a family was associated with reduced odds of being overweight, reduced odds of becoming overweight, and increased odds of ceasing to be overweight by 2000. No such associations were found for blacks and Hispanics. Taveras et al found that young respondents who reported eating dinner with families all or most of the time were less likely to be overweight
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than counterparts who did so only some or none of the time at the baseline, but there was no statistical relation between family dinners and becoming overweight within 1 year. Conversely, in a 5-year longitudinal study of adolescents, Fulkerson et al did not find any significant association between family dinner and obesity development. Family meals may therefore have relevance for the prevention and correction of childhood overweight. Regular family meals give parents the scope to provide their children with nutritious and healthy fare, to monitor and limit childrens intake of calorically dense and junk food, and to serve as role models for healthy eating behaviour. 5. Fast-food Consumptions Characteristic qualities of fast foods include large portion size, high energy density, high content of saturated and trans fats, high glycaemic load, low content of fibre, and palatability (appealing to primordial taste preferences for fats, sugar, and salt), which may cause excessive weight gain. Few studies have examined the effects of fast-food consumption on any nutrition or health related outcome. Three studies on the relation between fast food and obesity in children have been identified. From the reviewed studies it is concluded that increasing consumption of food from fast-food outlets is associated with excess weight gain.

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CHAPTER 5 : TREATMENT AND PREVENTION

5.1 TREATMENT Treatment for childhood obesity is based on your child's age and if he or she has other medical conditions. Treatment usually includes changes in your child's diet and level of physical activity. In certain circumstances, treatment may include medications or weight-loss surgery.

Treatment for children under age 7 For children under age 7 who have no other health concerns, the goal of treatment may be weight maintenance rather than weight loss. This strategy allows the child to add inches in height but not pounds, causing BMI-for-age to drop over time into a healthier range. However, for an obese child, maintaining weight while waiting to grow taller may be as difficult as losing weight is for older people.
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Treatment for children 7 years of age and older Weight loss is typically recommended for children over age 7 or for younger children who have related health concerns. Weight loss should be slow and steady anywhere from 1 pound (about 0.5 kilograms) a week to 1 pound a month, depending on your child's condition.

Healthy eating

When buying groceries, choose fruits and vegetables.Convenience foods, such as cookies, crackers and prepared meals, are often high in sugar and fat. Always have healthy snacks available. And never use food as a reward or punishment.

Limit sweetened beverages, including those containing fruit juice. These drinks provide little nutritional value in exchange for their high calories. They also can make your child feel too full to eat healthier foods.

Sit down together for family meals. Make it an event a time to share news and tell stories. Discourage eating in front of a screen, such as a television, computer or video game. This leads to fast eating and lowered awareness of how much you're eating.

Limit the number of times you eat out, especially at fast-food restaurants. Many of the menu options are high in fat and calories.

Physical activity A critical part of weight loss, especially for children, is physical activity. It not only burns calories but also builds strong bones and muscles and helps children sleep well at night and stay alert during the day. Such habits established in childhood help adolescents maintain healthy weight despite the hormonal changes, rapid growth and social influences that often lead to overeating. And active children are more likely to become fit adults.
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To increase your child's activity level:

Limit recreational computer and TV time to no more than 2 hours a day. Other sedentary activities playing video and computer games or talking on the phone also should be limited. Don't let your child eat while viewing an electronic screen; it keeps your child from being aware of how much he or she is eating.

Emphasize activity, not exercise. Your child's activity doesn't have to be a structured exercise program the object is just to get him or her moving. Free-play activities, such as playing hide-and-seek, tag or jump-rope, can be great for burning calories and improving fitness.

Find activities your child likes to do. For instance, if your child is artistically inclined, go on a nature hike to collect leaves and rocks that your child can use to make a collage. If your child likes to climb, head for the nearest neighborhood jungle gym or climbing wall. If your child likes to read, then walk or bike to the neighborhood library for a book.

If you want an active child, be active yourself. Find fun activities that the whole family can do together. Never make exercise seem a punishment or a chore.

Vary the activities. Let each child take a turn choosing the activity of the day or week. Batting practice, bowling and swimming all count. What matters is that you're doing something active.

Weight-loss medication One prescription weight-loss drug is available for adolescents: orlistat (Xenical). Orlistat, which is approved for adolescents older than 12, prevents the absorption of fat in the intestines. Alli is not approved for children or teenagers under age 18. Prescription weight-loss medication isn't often recommended for adolescents.
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If your child has high cholesterol, it's possible your doctor may recommend giving your child a statin medication. Statins help lower cholesterol, but their use in children remains controversial, since it's uncertain what long-term side effects they might have. Weight-loss surgery Weight-loss surgery can be a safe and effective option for some severely obese adolescents who have been unable to lose weight using conventional weight-loss methods. However, as with any type of surgery, there are potential risks and long-term complications. Also, the long-term effects of weight-loss surgery on a child's future growth and development are largely unknown. Weight-loss surgery in adolescents is uncommon. But your doctor may recommend this surgery if your child's weight poses a greater health threat than do the potential risks of surgery. 5.2 PREVENTION
1. Schedule yearly well-child visits. Take your child to the doctor for well-child checkups at

least once a year.

2. Set a good example. Make sure you eat healthy foods and exercise regularly to maintain

your weight.
3. Emphasize the positive. Encourage a healthy lifestyle by highlighting the positive and

emphasize the benefits of exercise apart from helping to manage weight. 4. Prevention in a community such as regulation of food and drinks provided in school cafeterias, improvement of public transport, and other measures to improve intake of vegetables and fruits.

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CHAPTER 6 : CONCLUSION
The current increase in childhood overweight and obesity reflects the convergence of many biologic, economic and social factors. Body mass index is a quick and easy way to screen for childhood overweight. Although genetic differences may result in subtle differences in metabolism that predispose an individual to becoming overweight or obese, no measurable differences in metabolism can be detected in the majority of obese children. With increasing frequency, serious medical sequelae of overweight have their onset during childhood rather than the adult years. The social and emotional aspects of overweight are immediate and apparent and influence many aspects of child and adolescent wellbeing independent of their physical health effects. The solution for the current epidemic of overweight and obesity is prevention. Screening of children for overweight should begin in the first year of life, and primary care practitioners can monitor the nutritional status of children in their practice by calculating and plotting BMI once standing heights are obtained after 2 years of age. Advice should be offered to parents regarding the prevention of overweight as soon as a child begins to cross BMI percentiles and should not be postponed until the child or adolescent is at or above the 95th percentile of BMI for age and gender. Although the treatment of overweight in children is not simple, fast or invariably successful, controlled studies of obese children have demonstrated good short-term
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and long-term outcomes. Treating childhood overweight relies on positive family support and lifestyle changes involving the whole family. Preconceived notions about dieting and weight loss often confound treatment. Parental and childhood education is, therefore, essential. When the right family dynamics existsa motivated child with supportive parentssuccess is possible.

REFERENCES
1. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int J Pediatr Obes 2006;1:1125. 2. Moreno LA, Pigeot I, AhrensW. Epidemiology of Obesity in Children and Adolescents: Prevalence and Etiology New York: Springer; 2011. 3. Resnicow K. The relationship between breakfast habits and plasma cholesterol levels in schoolchildren. J Sch Health 1991;61:815. 4. Wyatt HR, Grunwald GK, Mosca CL, et al. Long-term weight loss and breakfast in subjects in the NationalWeight Control Registry. Obes Res 2002;10:7882.
5. Mayo clinic. Childhood obesity. Available at :

http://www.mayoclinic.com/health/childhood-obesity/DS00698/DSECTION=treatmentsand-drugs.
6. Emedicine. Pediatric Obesity. Available at :

http://emedicine.medscape.com/article/985333-overview#a0104. 7. Niemeier HM, Raynor HA, Lloyd-Richardson EE, et al. Fast food consumption and breakfast skipping: predictors of weight gain from adolescence to adulthood in a nationally representative sample. J Adolesc Health 2006;39:8429.

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