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homecirculationvol 119 15american heart association childhood obesity research summit report free accessreview articlepdfepubaboutview pdfview epubsections toolsadd favoritesdownload citationstrack citationspermissions shareshare onfacebooktwitterlinked inmendeleyreddit jump tofree accessreview articlepdfepubamerican heart association childhood obesity research summit report stephen r daniels marc jacobson brian w mccrindle robert h eckel brigid mchugh sanner stephen r danielsstephen r daniels marc jacobsonmarc jacobson brian w mccrindlebrian w mccrindle robert h eckelrobert h eckel brigid mchugh sannerbrigid mchugh sanner originally published30 mar 2009httpsdoiorg101161circulationaha109192216circulation 2009119e489e517is corrected bycorrectionother versions articleyou viewing recent version article previous versions march 30 2009 previous version 1 table contentsi problem childhood obesity burgeoning epidemice490ii childhood obesity research summite490iii pathophysiology morbidity childhood obesitye490 pathophysiology obesitye490 b medical consequences childhood obesitye490 c psychosocial societal consequences childhood obesitye490iv current healthcare practices childhood obesity prevention treatmente492 lifestyle assessment diet physical activitye492 b clinical assessmente493 c psychosocialbehavioral assessmente493 implementing effective prevention treatment options diete494 e implementing effective prevention treatment options exercise sedentary behaviorse495 f implementing effective prevention treatment options family behavioral approachese496 g behavioral managemente497 h medical pharmacological managemente497 surgical managemente498v barriers optimum caree498 healthcare system factorse498 preparedness providerse498 models coverage caree499 uninsurance underinsurance among children familiese500 healthcare providers settings role modelse500 b challenge behavior changee501 motivational interviewing pediatric obesitye501 psychosocial factors influencing behavior changee502 environmental factors influencing behavioral changee503vi practicebased resources prevention managemente503 models disciplinese503 adult chronic care modele503 treatment heart failuree504 treatment type 2 diabetes mellituse504 treatment childhood asthmae505 b public health measures childhood obesitye506 tobacco control implications childhood obesitye506 c specific research issuese506 specifying priorities context complex multifactorial probleme506 taking developmental approache507 engaging stakeholderse507 targeting appropriate outcomee508vii research challengese509 research busy practicee509 b bring research practices webbased assessment pediatric obesity clinice509 c research agenda nhlbi pediatric heart networke510 research agenda childrens oncology groupe510 e research agenda cdce511 f research agenda foundationse511viii research policy knowledge translatione512 practice policy practicee512ix concluding remarkse512appendix planning committeee513appendix b presenterse513over past 3 decades prevalence obesity increased among children ages today one third american children adolescents obese overweight childhood obesity one pressing health threats facing united statesi problem childhood obesitya burgeoning epidemicover past 30 years prevalence obesity nearly tripled children 2 5 years age youth 12 19 years age quadrupled children 6 11 years old1 data 2 national health nutrition examination surveys 1976 1980 2003 2004 show children 2 5 years age prevalence overweight increased 5 139 6 11 years age prevalence increased 65 188 12 19 years age prevalence increased 50 1742overweight children adolescents risk significant health problems youth adults example youth overweight children adolescents likely children adolescents risk factors associated cardiovascular disease eg high blood pressure high cholesterol type 2 diabetes mellitus3 overweight children adolescents also likely become obese adults45 example 1 study found approximately 80 children overweight 10 15 years age obese adults 25 years age4 another study found 25 obese adults overweight children3 latter study also found overweight begins 8 years age obesity adulthood likely severe studies also documented link obesity poor school performance unhealthy risky behaviors alcohol use tobacco use premature sexual behavior inappropriate dieting practices physical inactivity67overweight children adolescents may experience health conditions associated increased weight include asthma hepatic steatosis sleep apnea type 2 diabetes mellitus obesity also puts children longterm higher risk debilitating chronic conditions stroke breast colon kidney cancers musculoskeletal disorders gall bladder diseaseobesityassociated annual hospital costs children youth tripled 2 decades rising 35 million 1979 1981 127 million 1997 1999 adjustment inflation conversion 2004 dollars national healthcare expenditures related obesity overweight adults alone range 98 billion 129 billion annually8 obesity crisis public health threat represents mandate immediate action healthcare community provide clinical intervention serve advocates development community programs help teach support healthy behaviorsii childhood obesity research summitas part strategic focus childhood obesity particularly prevention childhood obesity american heart association convened childhood obesity research summit examine research opportunities obesity epidemic intersects healthcare system outcomes conference help inform american heart association alliance healthy generation broadly terms help focus ongoing research public policy initiativesiii pathophysiology morbidity childhood obesitya pathophysiology obesitythe pathophysiology obesity childhood viewed 3 perspectives homeostatic energybalance perspective epidemiological perspective pathological perspective examining consequences excess fat risk future disease fundamental cause obesity greater imbalance energy intake expenditure expected normal growth development usually occurs period time setting susceptible genetic background environmental factors epigenetic factors defined changes gene function relate changes dna sequence begin utero cases previous generations also contribute9 infants diabetic mothers mothers smoke pregnancy increased risk subsequent obesity infant feeding practices may also play role particularly shortened period breastfeeding reduced amount sleep infancy another potential risk factor obesity medications clearly demonstrated cause excess weight gainb medical consequences childhood obesitythe increasing prevalence severity obesity children adolescents resulted higher prevalence comorbid conditions including high blood pressure early development atherosclerosis type 2 diabetes mellitus nonalcoholic fatty liver disease polycystic ovary disorder disordered breathing sleep10 complications occur shortterm longterm complications type 2 diabetes mellitus previously thought occur adulthood shown occur children adolescents raised concerns whether obesity epidemic might shorten lifespan current generation childrenolshansky et al11 evaluated potential effect childhood obesity lifespan analysis predicts shorter lifespan current generation children large part obesity related comorbidities including cardiovascular disease metabolic gastrointestinal pulmonary orthopedic neurological psychological social disorders however others speculated improved medical care ameliorate effectsthere still much learned mechanisms obesity development related comorbid conditions translational research perhaps lead information help identify children higher risk excessive weight gain development specific adverse outcomes due obesity type mechanistic research could also inform specific strategies treatment comorbidities weight management cannot accomplished less adequateselected unanswered questions related medical consequences childhood obesitywho risk development medical consequences childhood obesityhow soon surveillance children begin identify obesityrelated comorbiditieswhen weight loss inadequate fails modify medical consequences obesity aggressive healthcare providers institution pharmaceutical agents treat consequencesunder conditions children obesityrelated comorbidities evaluated managed subspecialistsc psychosocial societal consequences childhood obesityhistorically studies evaluate psychosocial consequences pediatric overweight focused primarily comparing functioning overweight children adolescents nonoverweight peers dimensions healthrelated quality life selfconcept body image depressive symptomology peer relationships crosssectional studies comparing either clinical community samples overweight children adolescents nonoverweight comparison samples demonstrate fairly consistent support decreased healthrelated quality life associated increasing weight highest weight demonstrating greatest impairment healthrelated quality life also evidence indicating lower body satisfaction physical appearancerelated selfconcept overweight children adolescents12 longitudinal studies suggest decreases selfesteem childhood early adolescence among overweight children13 evidence prospective studies indicating increased risk development obesity among depressed adolescents14 overweight children experience teasing overt relational victimization normalweight peers longitudinal research suggests weight status predictive vulnerability bullying peer relationships1516 finally studies document relationship overweight status decreased probability employment less financial support college among women well lower household incomes men women findings domains psychosocial function including depressive symptomatology externalizing behaviors selfconcept heterogeneous even samples overweight children adolescents yield lower scores often still clinically normal rangemore recent studies focused understanding variability outcomes among overweight children adolescents potential identifying risk protective factors social stigma weightbased teasing identified key dimensions may increase risk negative psychosocial outcomes among overweight pediatric populations17 crosssectional longitudinal studies demonstrated relationship weightbased teasing number negative psychosocial outcomes including unhealthy weightcontrol behaviors decreased body satisfaction decreased selfconcept depressive symptoms body dissatisfaction weightshape concerns also associated lower selfesteem well higher depression anxiety scores final set findings regard psychosocial consequences relates changes observed participation weightcontrol interventions improvements psychosocial functioning observed children adolescents participating weightcontrol treatments changes typically independent weightloss outcomesselected unanswered questions related psychosocial societal consequences childhood obesitywith regard severely overweight youth extent negative psychosocial outcomes depressive symptoms disordered eating behaviors relate degree overweight extent dimensions improve result intensive weightcontrol interventionswhat role moderators age gender ethnicity socioeconomic status play relationship overweight psychosocial outcomesto extent cultural norms regarding weight status associated stigma overweight impact psychosocial outcomes selfesteem body satisfactionwhat protective factors degree family connectedness family behaviors buffer potential negative psychosocial consequences pediatric overweightto extent protective factors enhanced interventionwhat impact psychosocial outcomes social stigma weight status risk behaviors health outcomesrecommendationseducation given heterogeneity outcomes overweight youth important professionals objectively evaluate psychological social correlates assume maladjustment patients second potential area professional education relates importance efforts decrease weightrelated teasing stigma enhance selfconcept overweight children adolescentspublic policyadvocacy policies decrease tolerance teasing stigma schools may improve emotional climate overweight children adolescents education public regarding physiological aspects overweight may enhance effortsresearch 1 focus severely obese youth attention documentation emotional social functioning well change psychosocial correlates decreases obesity 2 moderators including gender race ethnicity socioeconomic status examined relationship weight status psychosocial outcomes 3 longitudinal studies examine relationships among weight status psychosocial correlates health risk behaviors would informative elucidating temporal relationships identifying intervention targets 4 research agenda concerning weight stigma relates psychosocial academic physical health outcomes pursuediv current healthcare practices childhood obesity prevention treatmenta lifestyle assessment diet physical activitylimited data published assess specific goals pediatric primary care providers hope accomplish performing lifestyle assessment diet physical activity however routine care anecdotal reports suggest diet physical activity assessments usually first step counseling primary care setting routine care assessment questions intended bring issue give families opportunity ask questions raise concerns lifestyle assessment also opportunity identify potential targets prevention increase families selfawareness current behaviors situation may differ routine wellchild care visits visits aimed addressing specific health issue childhood obesity lifestyle assessment requiring specific indepth questions preparing diet physical activity counseling helpful assess current situation determine whether patient meets recommendations areas obesity prevention treatment also areas pediatric nutritionsome published data address frequently lifestyle assessment performed pediatric primary care setting response mailed questionnaire random sample pediatricians nurse practitioners dieticians 90 reported routine assessment diet history 95 reported assessment physical activity18 separate study 56 family practice physicians 71 pediatricians reported routinely performing diet recall 54 79 respectively reported assessing sedentary activities 88 98 respectively reported assessing exercise sports19 main limitations similar studies include usual low response rate achieved questionnaires healthcare professionals even concerning likely bias results providers perform lifestyle assessments likely respond thus overestimating frequently assessment actually occurseven important frequently assessment performed actually conducted one study reports pediatricians assess diet using questions usual typical food intake 335 diet diaries 312 1day diet recall 153 eating practices patterns 141 assess physical activity using questions organized physical activity 974 sedentary activities 936 unstructured physical activities 91614 dietary physical activity assessments typically taught medical healthprofession schools wide variability exists performed primary care assessment methods standardized remains unclear often standardized assessment methods usedseveral tools developed research setting assess dietary intake could potentially used primary care setting include weighted food records semiquantitative food records standardized diet history reliable likely unfeasible primary care setting less reliable likely feasible methods include informal diet history standardized informal foodfrequency questionnaires physical activity research methods assessment include doubly labeled water calorimetry heart rate monitors accelerometers perhaps feasible primary care setting pedometers physical sedentary activity diaries formal validated informal physical activity questionnaires feasibility issues primary care setting include time constraints cost training expertise use methods emerging technologies may provide novel methods diet physical activity assessment potentially may helpful primary care setting include internetbased diet physical activity assessment pda personal digital assistant cell phonebased dietary assessment accelerometers motion sensors cell phones clothing shoes use gps global positioning system assess physical activity another interesting concept placement riskassessment including diet physical activity kiosks waiting rooms primary care practices allow families provide important standardized information analyzed used clinician visit assessmentselected unanswered questions related lifestyle assessment diet physical activitywhich goals lifestyle assessment prioritized pediatric primary care setting question addressed assessing feasibility method terms time cost expertise well assessing expected benefits terms quality usefulness information collected utility first step counselinghow lifestyle assessment currently conducted pediatric primary care setting issues related response rate bias well issues social desirability responses methods questionnaires considered including direct observation patient interviewswhat feasibility validity tools currently used research settings office setting promising tools clinical setting include targeted foodfrequency questionnaires brief physical activity questionnaires pedometershow emerging technologies used primary care setting assess diet physical activitycan lifestyle assessment without effective counseling potentially negative impactrecommendationseducation pediatric primary care providers trained brief validated methods diet physical activity assessmentpublic policyadvocacy reimbursement diet physical assessments pediatric primary care setting promoted supportedresearch research needed areas clinical psychosocialbehavioral assessment clinical effectiveness costeffectiveness physicians versus dieticians nutritionists certified diabetes educators lifestyle assessment examinedprevention officebased settings effective prevention treatment options related diet exercise sedentary behaviors family behavioral approaches implemented well management obesity morbid obesity behavioral medical pharmacological surgical managementb clinical assessmentevaluation obesity begins calculation body mass index bmi clinical validity correlates adiposity20 adult adiposity21 cardiovascular risk factors22 longterm mortality23 unfortunately perfect cut point bmi identifies children elevated body fat bmi correlates total fat however may yet unidentified unquantified race gender differences need consideredbecause bmi norms change age differ boys girls absolute bmi appropriate screen children practitioners need plot bmi centers disease control prevention cdc percentile curves identify bmi percentile category wwwcdcgovgrowthcharts bmi z score appropriate alternative requires calculation cumbersome busy pediatricians perform skinfoldthickness measurement confirm increased body fat currently recommended accurate reproducible measures technically difficult perform waist circumference also recommended research establishes measure adds information risk already provided bmiclinicians assess obesity risk children integrating information patients bmi medical risk current eating physical activity behaviors attitudes assessment guide initiation preventive treatment strategies current definitions use 85th percentile define overweight 95th percentile define obesity23aselected unanswered questions related clinical assessmentevaluation current recommendations implementation needed evaluation determine recommendations eg national heart lung blood institute nhlbi american academy pediatrics implemented barriers implementation costs benefits implementing screening practicesshould screening management differ level obesity patient mild bmi elevation clinical information affect management additional measures would help delineate risk visceral adiposity assessment early treatment successful intervention take placefor patients bmi 99th percentile evaluation modifiedrecommendationseducation primary care providers thirdparty payers educated existing guidelines well costs benefits screeningpublic policyadvocacy systems coordinate screening efforts among various healthcare providers obstetricians pediatric physicians adult physicians developed promote bmi screening across lifetime individualsresearch 1 barriers implementation screening guidelines studied 2 screening guidelines evaluated basis severity 3 research collect epidemiological data anthropometrics early life normative data length weight funded 4 epidemiological data needed early childhood obesity including normative data high weightforlength risk persistence poor health outcomes 5 data needed success various management strategiesgeneral network obesity researchers educators clinicians policy makers developed increase communication sharing tools techniques performing researchc psychosocialbehavioral assessmentcurrent practices psychosocial screening assessments include qualityoflife assessments readiness assessments familycontext assessments studies psychosocial assessment known prevalence clinicalrange depression symptoms low although substantial prevalence subclinical range depressive symptoms low prevalence comorbid eating disorders impairments poor healthrelated quality life social isolation stigmatization adolescent low selfesteem poor body image maternal distress prevalentthe available data indicate greater depressive symptoms baseline associated higher dropout rates clinical program24 greater parent distress child social problems baseline associated poorer weightloss outcomes25 existence fewer social problems baseline predicted better longterm maintenance weight loss 2 years26 improvements weight status shown associated improvements childs social problems psychological adjustment reduction maternal distress27 addition participation intervention alone positive effect selfesteem28to help clinicians tailor treatment approaches randomized clinical trials needed appropriateness psychological treatment clinical treatment referral concurrent psychological clinical treatment treatment psychosocial issues within weightmanagement model addition understanding readiness change family useful accomplished framework stages change assessment parent child continuum readiness make lifestyle changes motivational interviewing techniques may helpful move patients families toward greater readiness parents need better educated definition health consequences obesity currently wellvalidated measures widespread use evaluate readiness change studies potential harm intervention family ready intervention also neededthe final area requires evaluation family structure family assessment recommended determine providingmonitoring care favored parenting style family functions existing literature suggests higher family conflictlower cohesion ineffective parenting style maternal distress prevalent families children present specialized obesity treatment improved understanding needed relation familyparenting factors bring lifestyle change whether familyparenting factors lead obesity development best methods assess monitor patients clinical settingselected unanswered questions related psychosocialbehavioral assessmenthow psychosocial assessment performed patients referred psychological treatment first referred concurrent psychological treatment bmi measured interpreted psychosocial issues treated within weightmanagement modelhow psychosocial impairment pose barriers adherence weightmanagement prescriptioncan obesityspecific instruments assess childadolescent lifestyle behavior psychometrics psychosocial instruments developed evaluatedrecommendationseducation primary care providers taught high prevalence psychosocial dysfunction obese patients families interactions obesity psychosocial stress shou