Childhood Obesity: Health Policies and Interventions

C H A P T E R

35 Childhood Obesity: Health Policies and Interventions Tandra R. Chakraborty*, Rayan Almathhur*, Catherina Suh*, and Sanjoy Chakraborty† †

*Department of Biology, Adelphi University, New York, NY, United States Department of Biological Sciences, New York City College of Technology/CUNY, Brooklyn, NY, United States

35.1 INTRODUCTION Childhood obesity is a global issue that has been growing for the past several decades [1–6]. Recent epidemiology estimates show that there is a 30% increase in childhood obesity during the last 20 years [7–9] (Fig. 35.1). Many people do not understand the implications or the seriousness of overweight and obesity, especially in children. When affected from early ages, children suffer consequences that may follow into adulthood and possibly affect them their entire life [6, 10–12]. Many of the diseases induced by higher weight status (underweight, normal, overweight, obese) in adults have also been observed in children including several of the leading causes of death such as diabetes, cancer, and cardiovascular disease [3, 8, 13–16]. Therefore it is especially crucial to address the risks of obesity from a younger age.

35.2 WHAT IS OBESITY? Obesity is defined as an excess body fat or adiposity [14, 17, 18]. Adipose tissue, also known as fat, is very metabolically active. Fat cells are constantly being burned and replaced, producing proteins, and releasing hormones and other chemical signals. When present in excessive amounts, the increased levels of activity and chemicals can begin to affect many complex metabolic and endocrine pathways that can further lead to obesity-related disorders and disease. Obesity seems to result from many interrelated factors, which can be both related to genetics and epigenetics [19]. Different studies have classified obesity in different ways. A study conducted by William et al. on 3320 children (5–18 years) considered children to be fat if their percentage of body fat was at least 25% for males and 30% for females [20]. The Center for Disease Control defined overweight as or at above 95th percentile of body maximum index. Another study classified 85th percentile as overweight and 95th percentile as obese [21]. Yet another study defined overweight and obesity with respect to growth reference [22].

35.3 PREVALENCE OF CHILDHOOD OBESITY According to many research studies and data from the World Health Organization (WHO), an international organization dedicated to increasing awareness of health issues, the rates of childhood obesity has been growing exponentially for the past 30 to 40 years all across the globe—in every continent and across all income statuses. More than 340 million children and adolescents aged 5–19 were overweight or obese in 2016. Of them, 124 million were classified as obese [1]. In the United States, for children aged 5–19, rates have risen from 18.9% overweight/5.5% obese in 1975 to 41.8% overweight/21.4% obese in 2016 [2, 23] (Fig. 35.2).

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FIG. 35.2 This graph shows the rates of overweight and obesity in male and female children aged 5–19 (1975–2016) [67].

35.4 ETIOLOGY OF CHILDHOOD OBESITY Some children are more prone to obesity than others, which may be due to their genetic makeup or other environmental factors [4, 6, 11, 14]. This was proven in a key study that implied that BMI between two individuals is more strongly correlated when the number of shared genes is greater [24]. In a study done by [24a,25], monozygotic (identical) twins who were reared apart were shown to have more similar BMI than dizygotic (fraternal) twins, followed by siblings, parent-offspring pairs, adoptive relatives, then spouses. This provided indirect evidence that genetic factors

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play a sizeable role in body weight regulation, thereby prompting scientists to understand obesity and seek treatments from the genetics aspect [11, 14, 24].

35.4.1 Genetic Makeup To retain metabolic homeostasis, different organs of the body such as stomach, liver, adipose tissue, etc. receive stimuli from the environment and release hormones and other small molecules to the brain, which then signals the satiety center to eat more or reduce energy use. When an obese child has a mutation in a single obesity-related gene (monogenic obesity) or in a set of genes (polygenic obesity), numerous and complex mechanisms and metabolic pathways that help to maintain energy and macronutrient homeostasis are affected, such as basal metabolic rate, fat oxidation rate, appetite control, satiety, and tendency to exercise [4, 6, 14, 24]. At least nine genes have been shown to have variants that cause monogenic obesity, and at least 50 genes have been associated with the more common polygenic form of obesity. A wide variety of weights, therefore, results because each child’s body is engineered differently and responds to environmental stimuli, that is, diets and activities, differently [6, 11, 14]. On the other hand, however, an obesogenic environment, with varying degrees of effect, will exacerbate the effects of genetic predisposition to obesity. Understanding the genetic basis of obesity will help better customize lifestyle changes for children who are potentially predisposed to obesity.

35.4.2 Industrialization Over the past 41 years, there has been an increase in the prevalence of overweight and obesity in children: 4.6% overweight/0.9% obese in 1975 to 18.4% overweight/6.4% obese in 2016. Change in the genetic variation of a population is unlikely to have induced such an extreme change in just several decades. The rapid growth in economy, industrialization, and urbanization has resulted in sedentary lifestyles with increased propensity toward processed and high caloric-dense food [26]. Even small caloric food when taken in excess daily, unmonitored, for prolonged periods of time, can result in significant weight gain [9, 11, 17, 27]. Therefore many scientists believe that the rise of an obesogenic environment is the cause behind the recent obesity pandemic [4, 12, 27]. An obesogenic environment is a situation in which the family and school environment, built environment (parks, grocery stores, etc.), SES, and other conditions of life, as a whole, limit opportunities for healthful diet. In an obesogenic environment, high-calorie foods are readily available and physical activity is little needed, exacerbating the effects of genetic predisposition to obesity in children [11, 27]. It is, thus, easy for total energy intake to exceed total energy expenditure, resulting in a positive energy balance. When this, even in small amounts, accumulates for prolonged periods of time, children become overweight or obese.

35.5 FACTORS INFLUENCING CHILDHOOD OBESITY 35.5.1 Family Food Environment Family food environment describes family practices and attitudes about food and eating that may impact childhood obesity risk [4, 6, 12, 13, 27]. Children are highly influenced by parents’ and peers’ eating habits. Children whose parents are obese are more likely to develop obesity themselves for conjoint environmental and genetic reasons. Food options become an important factor for healthy lifestyle. It is better to give a child several options and allow the child to choose while also providing them education and rationale for healthy food options instead of force-feeding them certain foods and restricting junk foods. Restricting foods has been shown to increase the desire for unhealthy foods high in sugar, fat, and salt, resulting in higher BMI. It is important to familiarize children to a large variety of tastes and textures of healthy foods so that they can develop a food preference from an early age while still malleable. Feeding sweet and salty, energy-dense foods leads to overeating as infants are innately attracted to those tastes [28]. High-sugar foods are less fulfilling and high in calorie than healthier, fewer calorie foods [11]. Because they are high in calories, they can cause insulin spikes and cause the individual to crave more sugar.

35.5.2 Socio-Economic Status Current literature indicates that obesity is linked to socio-economic status (SES), although various other factors such as gender, age, country, and ethnicity also play a role [5, 29–32]. Generally, children in low SES in industrialized countries and high SES in developing countries have greater access to these cheap, commercial, high-calorie, low-nutrition

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foods. Therefore they are more likely to be affected by obesity problems, because they have limited access to the more expensive healthy options and easy access to an abundance of energy-dense, low-nutritional value, commercially produced foods, and more difficult access to healthy foods (Fig. 35.3). It is important to note that there is an exponential growth in childhood obesity rates in low, low-middle, and highmiddle income countries especially in industrialized areas where cheap, high-density foods are readily available in large quantities. There has been less focus on healthy meals and at-home cooking and a growing mentality of grab-and-go. When parents are too busy to cook, children, especially teenagers, often resort to ordering food or eating quick-and-easy meals such as pizza, hot dogs, macaroni and cheese, ramen, and microwaveable chicken tenders. Many times, meals have been skipped and substituted with crackers or snacks [17]. Therefore the number and popularity of fast-food restaurants, family restaurants, chain grocery stores, snack companies, and prepackaged foods have increased. Restaurants, especially fast-food ones, often serve menus consisting of calorie-dense foods and drinks. Many commercialized grocery and convenience stores hold a countless number of snacks—chips, baked goods, candy—some of which may seem healthy but are actually filled with sugar, which can be addicting. It has been reported in a study by Rankin et al. [34] that most of the world’s overweight individuals live in developing countries; out of 42 million overweight children, about 31 million lived in developing countries. The childhood obesity rates in high-income countries seem to be plateauing [5, 9, 35, 36]. This effect may be due to increased awareness among families and intervention to stop obesity by government. Lower SES in developed countries is related to higher obesity rates, although there are different patterns within each income groups due to other factors [32, 37, 38]. At home, when parents or caretakers cook, the portion sizes are often way too big. Larger portion sizes have become the cultural norm in many households, food companies, and restaurants [11, 12]. There is often a misunderstanding of the portion size that growing children must be fed. Parents commonly believe that infants can’t be overfed. When they cry, the go-to method is to feed them, but in actuality, infants may cry for many other reasons apart from being hungry. Children and teenagers need more calories because they are growing, however, more calories do not necessarily mean more growth, and higher BMIs cannot be ignored as healthy and normal [9]. Pressuring a child to “clean the plate” and leave no leftovers especially from large portions can lead to uncontrolled overeating and overruling “hunger and fullness” cues [28].

35.5.3 Physical Activity The basal metabolic rate is the greatest factor in energy expenditure, ranging from 45% for more active individuals to 80% to more sedentary individuals [11]. It has been reported that parents play a key in healthy eating and active play

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advice for children [39]. Adverse surroundings increase the odds of a child to become overweight by 20% in part because children are less likely to engage in physical activity and parents are less likely to encourage and advocate activities in these environments. In contrast, better neighborhood features, such as improved walkability and playgrounds, are associated with a decreased prevalence of obesity [28]. A combine effect of less calorie-dense food and opportunities for physical activity enhances the quality of life in children, and they grow up as a healthy individual. This being said, it is important to remember that SES plays an important role in childhood obesity. Children in low SES usually live in neighborhoods with fewer stimuli for physical exercise such as safe and well-built sidewalks and greenery. It can also mean less access to physical fitness resources, such as the gym, and less access to healthier foods [28]. Walking to school can serve as a form of exercise, however oftentimes children ride the bus or are driven to school because it is too far away or the walking routes are not safe or well-lit. However, trends are different in different countries and ethnicities [38].

35.5.4 Food Promotions and Advertisements Evidence shows that, when children watch television, they tend to consume more of the foods that are advertisedprepackaged meals, sweetened foods-enforcing mindless eating [4, 27]. The food is also advertised in a way that can cause children to associate food with the reward system, excitement, and stress relief, leading to an unhealthy relationship with food that leads to excess eating and obesity [40]. These various marketing tools are directed to children who are too young to understand the difference between truth and an advertisement. As such, they are induced to eat high-calorie, low-nutrient foods with or without their parent’s authorization. As a result, the reports by the Institute of Medicine show that at least 30% of the calories children consume come from soft drinks, sweets, snacks, and fast foods [11]. High intake of sugar-sweetened beverages in childhood is linked to increased risk of obesity and type 2 diabetes later in life [41]. A study done by Ludwig et al. [42] found that each additional 12-oz soda consumed by a child each day increases the odds of becoming obese by 60% within few years. There is a direct link between children’s preferences and their surrounding food marketing [11, 42]. As a consequence, it has been estimated that American children spend close to $30 billion on junk food coming from their own pockets; more than 300 new unhealthy snacks and products had been introduced in the market between the years 1994 and 2006 alone [43], and food marketing has not stopped working since. To add to that, television advertising expenditures have increased from less than $50 million to more than $250 million (US dollars) since 2006 [9] as seen in Fig. 35.4.

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35.5.5 Technology Use With the advent of the technology age, there has been a significant increase in the use of electronics whether it is watching television, surfing the internet, or playing video games. These sedentary activities are also accompanied by mindless snacking, which leads to lower energy expenditure coupled with higher energy intake [4, 17, 27].

35.5.6 Sleep Short sleep time during infancy and early childhood also leads to increased risk of obesity [37]. Children (3–6 years) sleeping less than 9 h have been reported to increase childhood obesity [44]. Sleep restriction causes increase in hunger, appetite, and food intake, causing increase in caloric intake, which helps in extended wakefulness. Therefore exogenous factors such as SES, access to certain types of food, culture, diet, and physical activity will also affect the phenotypic outcome. Although obese children with genetic predisposition have hindered control over their eating, it is important to know that their choices can make a difference.

35.5.7 Prenatal and Infant Care There is well-established evidence that maternal diabetes, smoking, no or limited breastfeeding, higher maternal prepregnancy weight status, excess maternal weight gain during pregnancy, higher infant birth weight, rapid infant weight gain, and use of antibiotics in infancy has an effect on obesity [37].

35.6 CONSEQUENCES OF OVERWEIGHT AND OBESITY Overweight and obesity are known to have a significant impact on physical and mental conditions of a child. With an increase in obesity, there is an increase in diabetes, cardiovascular disease, and cancer [8, 12, 15, 27]. Overweight or obesity is also associated with increased mortality as well as myriad comorbidities [8, 11–15].

35.6.1 Mortality Many studies report that overweight and obesity are associated with increased risk of death due to associated comorbidities, especially from cardiovascular disease and cancer [3, 14, 15, 18, 45]. Obesity and its comorbidities are particularly dangerous for children and adolescents because they can suffer the same major comorbidities as adults at an early age, along with stunted growth or affected sexual development [6, 11, 13, 46, 47]. They also can suffer psychological effects such as attention deficit hyperactivity disorder (ADHD) and stigmatization, which lead to problems such as poor self-esteem and sleeping that can affect their academic success and future mental health [8, 14]. Hyperlipidemia, a condition in which there is an increase in lipid concentration in the blood, is quite prevalent among obese children [48]. Hepatic steatosis, found in children and adolescents, is a condition characterized by presence of high quantities of enzymes in liver [14, 49]. Apart from these supreme problems, anxiety disorders, depression, hypertension, pseudotumor cerebri, sleep apnea, polycystic ovary diseases, and orthopedic illnesses are also reported to occur among obese children [8, 10, 49].

35.6.2 Psychological Effects on Children Negative weight-based stereotypes toward children with overweight emerge as young as 3 years old. For children and adolescents with overweight or obesity, weight stigmas are primarily expressed as weight-based victimization, teasing, and bullying [9, 32, 49]. Sources of weight stigma include peers, parents, family members, teachers, health care professionals, society at large, and popular media at school, home, and clinical settings. Those who are bullied or teased are more susceptible to depression, self-harm, suicidal thoughts, anxiety, substance use, and poor body image [34]. One important study by Schwimmer et al. [50] showed that children and adolescents suffering from severe obesity had lower quality-of-life scores than children with cancer.

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35.6.3 Productivity/School Performance Some societies tolerate and even propagate the shaming and stigmatization of overweight and obesity because of belief that it will push people to change their dietary habits, exercise more, and, in effect, lose weight [32]. However, overweight and obesity is often not as simple as lack of self-discipline or laziness, therefore such stigma can contribute to less comfort in being physically active, feelings of loneliness, and social isolation that lead to depression, less confidence in self-made goals, avoidance of health care services, and binge eating. This worsens obesity even after accounting for baseline BMI, sex, race, and socioeconomic factors [32]. Obesity can also affect school performance [3, 31, 46]. There is some evidence that overweight or obese weight status increases the likelihood of poorer school performance and avoidance of school. This may be due to higher rates of sadness and nervousness, and higher risk of unhealthy behaviors such as smoking and alcohol consumption that become obstacles to learning. This can negatively affect career development as well as indirectly affect their wage-earning potential [9].

35.6.4 Economic Consequences It is well known that health costs of obesity create pressure on the health care sector and challenges the sustainability of health care systems [30]. Indirect costs through productivity losses associated with overweight and obesity, which include sick leave, disability pension, death before retirement, or other types of exclusion from the labor market such as stigmatization, are estimated to exceed direct costs. Lower educational attainment among children with overweight and obesity may reduce their chances in the labor market [46]. A study by the McKinsey Global Institute estimated that the annual global medical cost of obesity is $2.0 trillion, which at 2.8% of the worldwide gross domestic product, is almost equal to the cost of smoking and war, violence, and terrorism. However, the total number of published economic evaluations of interventions is small possibly due to lack of significant effect sizes [46].

35.7 PREVENTION OF CHILDHOOD OBESITY Treatment of obesity, especially childhood obesity, is still in its early stages. Despite intervention efforts, it is still challenging for children as well as adults to lose weight if the weight gain is too much, leading to obesity or morbid obesity. Prevention in childhood has a better chance of combating the problem [51].

35.7.1 Addressing Poor Diet Intake of sugar and high caloric snacks should be substituted with a vegetable and fruit-based diet. It should be calcium-rich, high fiber, and balanced in micronutrients. This can be controlled with daily, home-cooked family meals, smaller portion size, and less occurrences of eating out. Following nutritional goals such as the traffic-light diet is also helpful [51].

35.7.2 Addressing Physical Activity Physical activity is a key component for prevention and management of obesity. To increase daily physical activity, children and adolescents should be educated on obesity-related health risks, nutrition, and physical activity accompanied by a behavioral change model [51]. It is important that the behavioral change model is implemented to achieve success at decreasing sedentary activity [13, 37, 51]. It should include self-monitoring, environmental control, SMART goal-setting, and positive reinforcement of target behaviors. School-wide campaigns and messages have also been shown to be helpful. It is also important to reduce the amount of media use. Techniques will be different between younger children and adolescents who are likely to be more independent. Refraining from placing a television set in children’s bedrooms, watching television during meal times, and limiting media exposure to 2 h in children and no screen time for children under the age of 2 years is important. For older children, a combination of self-monitoring, negotiations on family media limits, and proposal of substitute activities will be more achievable; media activities such as reading, board games, hula-hooping, and obstacle courses can both create more family time as well as instigate more physical activity. Implementing these activities during commercial breaks will also decrease exposure to food commercials that may stimulate food cravings [51].

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Behavioral and lifestyle modifications are important in reducing obesity, however, it is also important to have an environment that promotes healthy eating practices and increased physical activity [17, 45]. Different approaches should be taken for different aged children [13]. During the prenatal period, it is important for the mother to be nutritionally healthy and gain weight at a healthy rate [27, 37]. If the mother has diabetes, good blood sugar level should be maintained [51, 52]. For 6 months, infants should only be breast-fed followed by a nutritionally balanced diet of solid foods. Weight gain should be closely monitored. Nutritional education is required for both parents and children to develop healthy eating patterns [51]. A variety of healthy food options should be introduced, and weight gain should continue to be closely monitored [6, 9, 12, 13]. Nutritional counseling should be continued, and physical activity needs to be emphasized. Height and weight should be monitored to prevent excessive prepubertal adiposity. Healthy eating behavior should be maintained, and the need for daily exercise and workouts should be reinforced. Increase in weight after a growth spurt should be prevented [51].

35.7.3 Breastfeeding Breastfeeding has been shown to modestly reduce the obesity risk in children. Breast-fed infants are known to present a slower growth curve compared to formula-fed infants. Breast milk is lower in energy, protein, and fat. Formula milk is higher in energy density, fed in higher volumes and less frequently. Most artificial milk formulations contain as much as 50%–80% more protein, which significantly affects growth patterns and increases the risk of obesity [27, 52, 53]. Fat content is higher in human milk than in commercially available formulas. Breast milk contains a different concentration of long-chain polyunsaturated fatty acids. A significant association between fat intake from breast milk and weight gain or BMI has been found. However, breast milk fatty acids have been shown to correlate with lower glucose levels in the skeletal muscles and reduced plasma levels of proinflammatory cytokines in breast-fed infants [52, 53]. Moreover, unlike formula milk, breast milk consumption varies between mothers over time; a close mother-tooffspring nutritional interrelation exists, and there is a significant association between higher infancy weight gain and later childhood overweight status. There is convincing evidence of the benefit of avoiding early timing of the introduction of solid foods [52].

35.8 BOYS VERSUS GIRLS On a global level, there is no significant difference between boys and girls: 19.3%–17.5% overweight and 7.8%–5.7% obese, respectively, in 2016 [2, 23]. However, ethnicity, SES, culture, region, and subpopulations can affect the inclination to obesity in genders in different ways (Sweeting). For example, in Thailand and Greece, a much larger percentage of males are obese than females, but in Equatorial Guinea and Somalia, there is a larger percentage of obese females than males [54]. However, even while percentages may be similar, there is a general difference in body composition, due to hormones, especially visible after puberty. The main difference between boys and girls are mostly visible after puberty but can also partially be seen prepuberty. Boys have android fat patterns where fat is greater in the upper body, and females have gynoid fat patterns where fat is greater in the hip and thigh areas [55].

35.9 THE ROLE OF GOVERNMENT ON HEALTH ISSUES The role of government on health issues is especially important in the case of childhood obesity, a health problem that poses a serious threat to the population of the United States due to its association with an increased disability, comorbidities, and their respective increases in social costs [56]. If obesity increase can be managed, we will have a healthier community along with decreasing costs in health services. Therefore it is not about turning the government into a “nanny state”, a paternalistic authority that regulates personal choices, instead government action can inspire and facilitate individual choices with more personal responsibility and promote healthy environments that allow people to access a healthier lifestyle. Governments need to address health issues associated with obesity through policies and regulations like Obesity Policy Action or Children’s Food and Beverage Advertising Initiative [57]. Governments, especially at the national or federal level, can regulate nutrients in the food supply, limiting deleterious trans-fats, sodium, or added sugar. Governments play a leading role

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in creating infrastructure for active transportation to offer alternatives to autocentric travel. Public funding for bike and pedestrian trails and walkways, and “Complete Streets” policies can facilitate more active communities [58]. Following are the various policy options that can be considered: • To ensure that antiobesity policies have no unintended consequences, the policies should be suitable for population experiencing deficiency both in linear growth and adiposity. • The rapid penetration of food multinationals in middle-income and low-income countries needs to be regulated because it has a lot to do in formulation of development strategies and nutrition policies. With rapid advancements in technology, it is not difficult for commercial brands to engage with younger populace without parental supervision. Therefore digital marketing should be specifically targeted, and such commercial or advertisements needs to be run live, which promotes healthy behaviors among children. • The setting of specific nutrient standards for products is very important because government regulation keeps the systems checked and informed. • The food market interventions need to have a strong political determination for challenging the interests of industries. • An integrated nutrition policy can be adopted that not only addresses the issue of stunting but also highlights the side effects of obesity. Therefore a comprehensive policy can be adopted that focuses on linear growth. • Monitoring children’s nutritional status along with food promotion advertisements and type of food environment they experience. • Regularly encourage physical activity. The healthy lifestyle has much to do with physical exercise. E-branding can target children by starting competitions and games. Physical activity reduces stunting and encourages linear growth, therefore it holds significant importance among young children. • Communication is the key for successful implementation of policies. The health professionals therefore need to communicate more often with parents and teachers regarding healthy eating habits so that they can monitor their children. The most influential preventive government policies can be drafted by federal law as it exhibits wide range of control on television and the Internet. However, federal-level policy changes are subject to more compromise because they need to suit many political players in many instances [59]. This is why local policy makers are usually the ones who promote public health with cutting-edge concepts and vanguard strategies. For example, various industries have lobbied successfully for state laws preempting local regulations that would curb the use of tobacco, alcohol, firearms, and pesticides. They are also more aware of local conditions that would ultimately affect the results of a determined measure. This is the reason why the most successful strategies must come from a local policy after a complete assessment of the local reality along with the aid and recommendation of health professionals [59].

35.10 ROLE OF LOCAL GOVERNMENT IN THE PREVENTION OF CHILDHOOD OBESITY The role of local government is paramount in planning childhood obesity preventive efforts. The places where families stay, play, study, and work are the prime locations where they consume healthy food or do physical exercise. There are few steps that should be considered to properly plan preventive efforts [60]: 1. Frequent community assessment would help in determining the target population for providing a conducive environment for healthy growth of children. Involvement of all stakeholders are required as well. A policy becomes effective if it is consensual. Without the consent of all stakeholders, a policy cannot be properly implemented. 2. Identification of top policy priorities. Experimentation and surveys could help in making better decisions. 3. Identification of sources for funding for better management of childhood obesity. 4. Choosing options that are sustainable. By providing evidence-based studies of what works and what does not would help in selecting the right program for the target population. 5. Evaluation of programs periodically. To ensure the intended positive outcomes and for initiation of future programs, it is important to evaluate programs. The need for a multidimensional strategy preventive strategy is proven by all research. Single-component interventions have proven useful to identify single-risk factors and compare them to one another; but when it comes to results in communities and practical interventions, we should understand that obesity is a multifactorial health issue and should be tackled as such [61, 62]. Environmental changes that promote a healthy behavior in homes, schools, and communities are the best places to implement preventive strategies, and more so if both parents and children are involved [9].

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35.11 CHILDHOOD OBESITY POLICIES Childhood government policy can be broken down into three categories, which are represented in Fig. 35.5, namely policy interventions, educational/social marketing campaigns, and clinical interventions.

35.11.1 Policy Interventions Obesity is a multifactorial health condition that may include environmental, behavioral, and physiologic causes. Although clinical interventions are set to fixed physiologic causes, they leave out behavioral patterns and their untreated environments. Most policy interventions act on systemic drivers (such as food prices and economic access) and environmental drivers (such as marketing, physical proximity to food, and others). Meanwhile, educational campaigns target behavioral patterns and can be used by health personnel or as a part of policies and strategies to tackle childhood obesity [57]. Federal and state policies are usually implemented at the local level, according to the needs and priorities of each community, its demographics, geography, and assets. The same way that local governments have promoted children’s health and safety by ensuring immunizations and mandating bicycle helmets, they can also promote a healthy weight in their pediatric population by taking different actions and steps to prevent childhood obesity. To do so, they should assess their population and ensure equal access to services, resources, and places through local policies to reduce additional disparities in obesity risk factors that may lead a certain group to increase their prevalence of childhood obesity. Because rates of childhood obesity are higher in low income populations and some ethnic groups, these should be given priority when it comes to planning policy strategies to minimize health inequities [56]. Governments may also need to build strong partnerships and collaborations with community members within and outside local governments. Health department staff should work alongside city planners, traffic engineers, land use advocates, school boards, local businesses, and many other community organizations that may influence the prevalence of childhood obesity or collaborate in their efforts to achieve certain goals or steps to prevent it [61]. This collaboration may be even easier to achieve in some cases in which certain policies and environmental strategies to tackle childhood obesity potentially impact on other community changes not related to childhood obesity. 35.11.1.1 Government Interventions to Promote Healthy Eating According to the National Research Council (2010), many different actions can be initiated to promote healthy eating. One of the most important factors is the food environment and taking steps to improve the access to healthy and affordable foods, and reduce access to nutrient-poor and calorie-dense foods. This can be achieved through the following actions [56, 57]:

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FIG. 35.5 Framework to categorize causes of obesity and corresponding policy responses [57].

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• Incentive programs, tax credits, loan programs, and many other economic incentives can be created to attract supermarkets to underserved neighborhoods. • Transportation routes can be realigned to provide better access to supermarkets and grocery stores. Increase outdoor lighting and police patrolling. • Restaurants can be requested to provide a labeling in their menu with calorie information, and recognition or endorsement can be offered as incentive for them to promote healthy food options. • Limit access to high-calorie, nutrient-poor foods in recreation centers, child care facilities, and afterschool programs by implementing stronger nutrition standards. • Implementing taxes to discourage the consumption of calorie-dense, nutrient-poor beverages and foods. • Using consistent and well-designed messages to promote healthy eating through the radio, Internet, social networks, and digital media. • Encourage healthy food providers to locate in underserved neighborhoods. Promote farmer’s market, mobile markets, and community gardens. • Encourage farmer markets to accept Special Supplemental Nutritional Program for Women, Infants, and Child (WIC) food package vouchers and coupons. Partner with government nutrition programs like School Breakfast and Lunch Programs, The Child and Adult Care Programs, Afterschool Snack Program, and Summer Food Service Program. • Ensure that afterschool programs, recreation centers, and local governments promote healthy and affordable nutrient-rich food. • Encourage and promote practices for breastfeeding-friendly communities. • Ensure free safe drinking water is accessible to all public places. Besides the previously mentioned incentives to encourage healthy eating, governments can also regulate the nutrients found in food supplies to limit the trans-fat and added sugars and improve food labeling. Moreover, they can also implement guidelines and nutritional standards for foods and beverages sold in schools and institutions, yet at the same time address diet quality in various feeding programs led by the state [58]. Systematic reviews performed over the years have shown that young children need diversity in their diet to reach an optimum growth, consisting of healthy sources of animal protein and micronutrients. Children reach the same demand for energy as adults when they reach age 12 years, so they also need energy in the form of carbohydrates, but researchers have shown repeatedly that nutrient density is a key factor in their nutrition. To prevent obesity among children, there is a need for more nutrient-rich foods and less high-energy foods for their healthy growth [9, 63]. When addressing healthy eating, policy makers, teachers, and health practitioners should be careful with the message they send to parents. The objective of policies and programs is to promote healthy eating habits that are sustainable and accessible to the general population. 35.11.1.2 Government Intervention to Promote Physical Activity According to the National Research Council (2010), increasing physical activity is a mandatory step in any successful strategy to decrease the incidence of childhood obesity. Physical activity can be encouraged by building an environment to facilitate and encourage exercise and recreational physical activity that would decrease sedentary behavior. Examples of promising steps to achieve these goals are as follows [56]: • Create and maintain sidewalks and street crossings that promote a comfortable walking environment and connect parks, schools, and other places. • Guarantee security in streets to encourage walking, biking, and outdoor activities in high crime neighborhoods. • Ensure that kids are safe when walking and bicycling to their schools and back home through the implementation of “Safe Route to School” programs. • Building safe and attractive parks and playgrounds close to residential areas and adopting policing strategies to guarantee their safety and security in high crime neighborhoods. • Using multiple digital media campaigns to promote physical activity with consistent and well-designed messages. • Use counteradvertising messages against sedentary activity, similar to those implemented to counter tobacco and alcohol use. • Implement policies that encourage physical activity into daily routines. As we can see, the main role of government when it comes to physical activity is to create, maintain, and facilitate the ease of access to an appealing infrastructure in which physical activity is performed. Pedestrian trails, public funding for bikes, and an active and efficient police force also facilitates active communities and children. Schools are the best

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place to implement minimum requirement of physical activity for children, and safe routes to school should be guaranteed to make kids more active [58] and create a healthy and happy community.

35.11.2 Educational/Social Marketing Policies 35.11.2.1 Home The role of parents in preventing childhood obesity is fundamental. Nutritional education usually starts at home, and it is encouraged by the children’s family and caregivers, who usually work as their decision-making agents when they are younger and their role models as they grow up [6, 11, 13, 27, 28, 45]. However, it doesn’t matter how positive their home education is, parental efforts can be undermined if the environment in which their children spend most of their time does not support healthy behaviors and sends opposing messages to those found back at home. The opposite is also true, as children growing up in households with obesogenic practices may improve their food choices and start a consistent physical activity program after being exposed to an environment that promotes a healthy living [64]. This is when childhood obesity policies are significant, as they build up many different environmental conditions that would shape children’s choices and encourage them to have a carefully chosen nutrition and a consistent physical activity [56]. Government-geared educational programs to educate parents and children regarding healthy eating and physical activity may be the first step toward combating obesity. 35.11.2.2 Schools Because the majority of young people are enrolled in public schools, they are an important venue to promote healthy behaviors or encourage unhealthy eating. Many schools make vending machines available with sweets, fizzy drinks, and other unhealthy food choices, and some school cafeterias serve high fat meals such as French fries and pizza. A lot of advertising on schoolgrounds promote junk food and drinks to sponsor sports and other educational material. As such, many schools have misused their strong influence on children’s food environment, and this happens because there are no health policies concerning these important factors. If there are no school policies, the state can take action setting nutritional standards for foods and drinks sold and promoted on campus [59]. Schools are also a key place to promote physical activity, usually ruled by state policies that local districts interpret and apply at their discretion. For instance, an afterschool recreation program might be set to prevent childhood obesity, but in the process, it may also help prevent crime by keeping youth engaged and safe during afterschool hours. Such positive effects might engage local police departments to bring an enthusiastic support for recreational afterschool programs to prevent crime [56]. In 2007, the state legislature in Florida discovered that some schools were counting the walking time to cross the campus to meet the state’s minimum requirement of 150 minutes of physical activity. As a response of this interpretation, the state of Florida changed the wording of the law to require “at least 30 consecutive minutes” of physical activity. This example clearly shows that state legislatures should monitor schools and how they are meeting the requirements set in state policy [59]. Michelle Obama’s initiative “Let’s Move” is another highly effective movement to combat childhood obesity. Through this initiative, children are provided healthier food in their schools. This initiative also embarks on educating parents regarding healthier choices so that, together as a society through adoption of comprehensive strategies, we help our children achieve their dreams. 35.11.2.3 Shops and Restaurants Shops and restaurants have significant impact on the promotion of healthy foods. Although it is not allowed to restrict sales and ban certain products, local policies can impact the retail environment by making healthy foods more accessible and discouraging the use and access to unhealthy choices [59]. There are economic incentives, taxes, local ordinances, and other tools that policy makers can use to change the way healthy and unhealthy foods are sold and offered, and how accessible they are to children. For instance, research has shown that families consume more fruits and vegetables if more supermarkets are in the neighborhood [65]. Policy makers need to have a better understanding of the target population to make policies and implement them to the community as a whole. 35.11.2.4 Recreational Areas Local governments not only have the role of planning and building public recreational areas, but they may also ensure an easy access to such facilities for all residents by including an easy transport route, sideways designed for walking and bicycling, and guaranteeing security in high crime areas. Increasing the ease of access to recreational

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facilities is one of the most promising strategies for success. Even poorly designed neighborhoods have schools with existing facilities that may be used more efficiently during school hours and after school [59]. The ease of access is just the starting point to improve the use of recreational areas for a healthier population. In many cases, the visitors to recreation centers and parks are faced with snacks, sweetened drinks, and high-calorie foods through vending machines located throughout the property. In this case, local agencies can change the nutritional standard for the foods offered in these vending machines, limiting the unhealthy food choices while increasing the ease of access to these recreational areas [59].

35.11.3 Food Marketing and Childhood Obesity Not enough has been said and even less has been done about the threat of marketing of unhealthy foods, which are often brilliantly presented in children’s TV programs and targeted commercials. These various marketing tools are directed at children, who are too young to understand the difference between truth and an advertisement [43]. As such, they are induced to eat high-calorie, low-nutrient foods, with or without their parent’s authorization. As a result, the reports by the Institute of Medicine [43] show that at least 30% of the calories children consume come from soft drinks, sweets, snacks, and fast food. Studies show a persistent link between children’s preferences and their surrounding food marketing. Out of the previously mentioned studies [9], one of the most cost-effective is to implement population-wide policies that focus on restricting unhealthy food marketing for children. However, food multinationals have a rapid penetration in low and middle-income markets that competes with public health campaigning and exhortation, as well as several other policies that have been implemented to encourage healthy nutrition. Unhealthy food marketing is not a problem in low and middle-income countries only; different surveys performed in the United States, Australia, and Europe show a high level of promotion of sweetened foods and snacks, soft drinks, confectionery, and other highenergy foods. These makes up the noncore group of foods (Fig. 35.6). Finally, it should be noted that policies involving food marketing should also take into consideration food environments as a lead factor to childhood obesity. Health policies and interventions on the food market should consider changing the availability and prices of healthy food products along with the marketing practices associated with sales. Not changing the environment of food marketing could lead to undermining parental efforts to provide healthy options to their children, despite their best efforts [9]. There have been some changes made by few companies like General Mills that added whole grains to all of its cereal, creating Whole Wheat Cocoa Puffs, which have high

100 90

Major food group, %

80 70 60 50 40 30 20 10

FIG. 35.6

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Proportion of major food groups advertised, by country.

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fiber content. Such small changes could have enormous effects on the weight gain for children. If all food marketing companies could address the problem by making small improvements, most market products would be better and healthier [66]. In spite of the former claims, which are widely known and accepted, corporate advertising shields on the First Amendment of the US Constitution, which limits the government to interfere with the “freedom of speech”, or in this case, the “commercial speech”. In many cases, it is not possible to ban advertisements in key places such as schoolgrounds, but public schools have a leeway to limit the advertising of junk food on their campus backed up by their unique educational mission. So it is not a battle lost if all key participants contribute, and there is still much to be done [59].

35.12 CLINICAL INTERVENTIONS Childhood obesity can be recognized through clinical evaluation and even with easy at-home measurements [5, 51]. Periodic clinical evaluations can help in accessing the weight change in children before they become obese. The WHO, an agency that focuses on numerous international public health problems, classifies overweight and obesity according to BMI. There are two different definitions, one for preschool-aged children (2–5 years) and another for children aged 5 to 19 years. For children aged 2 to 5, greater than 2 standard deviations above the WHO Child Growth Standards median is overweight and greater than 3 standard deviations is obesity. For children aged 5 to 19, greater than 1 standard deviation above the WHO Growth Reference median is overweight, and greater than 2 standard deviations is obese [1, 2, 15, 23, 33, 54, 67]. There are several methods, as well as fat percentage cutoffs, available to assess body weight status. The methods are the same between children and adults, however, age and gender factors are much more crucial in assessing obesity in children and adolescents. Individuals across the ages 1 to 19 have drastically different bodily compositions, maturity, and sizes. The body fat percentage of children change rapidly as they grow, and girls tend to develop more fat, yet boys lose fat, as they develop into puberty [27, 55]. Some children are more prone to disease at lower levels or higher levels of body fat due to factors such as ethnicity, region, SES, and family history. Therefore it is important to consider all of these factors to accurately assess the body weight status of children in clinical settings. Anthropometrics, which measures the size and proportion of human body, are quick and easy general assessment methods of measurement, and technology-based methods can give more accurate and robust results, both of which can be coupled with professional assessment. The most common method of anthropometrics-based diagnosis is body mass index (BMI). It is measured as (weight in kg) divided by (height in meters)2. Growth standards by the World Obesity Federation (IOTF) and the WHO exist to use on an international basis.

35.12.1 WHO Growth Reference for Overweight and Obesity Weight Status/Age

Ages 2–5

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Overweight Obesity

BMI > + 2SD BMI > + 3SD

BMI > + 1SD or BMI 25 kg/m2 BMI > + 2SD or BMI 30 kg/m2

The World Obesity Federation is another organization dedicated to solving the problems of obesity globally. It has classified BMI into overweight, obesity, and morbid obesity. They have age-standardized the BMI cutoffs of 25 and 30 kg/m2 in 18-year-olds for overweight and obesity, respectively, to create month-by-month cutoffs for both girls and boys from ages 2 to 18. Weight Status/Age

Ages 2–18

Overweight Obesity Morbid obesity

Age-standardized BMI of25 kg/m2 Age-standardized BMI of30 kg/m2 Age-standardized BMI of35 kg/m2

Waist circumference, waist-to-hip circumference ratio, and caliper (“skin-fold”) testing are other useful measurements that target central or abdominal fat levels. Determining abdominal or central obesity can be more helpful in assessing metabolic disorders such as type II diabetes, dyslipidemia, and nonalcoholic fatty liver disease and is also age-dependent.

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There are other more robust and accurate measurements, however they are more expensive. These other methods measure body composition in amounts of fat and fat-free mass. These include dual energy X-ray absorptiometry (DXA), a simple and safe X-ray-based method for children; bioelectrical impedance assay (BIA), which can vary in accuracy; and computed tomography (CT) scan and magnetic resonance imaging (MRI), which show virtual images of specific areas of the body [4, 11]. Whether the measurement method is BMI, waist circumference, or an expensive MRI, none of the methods are perfect. With the mentioned anthropometric methods, factors such as muscle mass and physique are not taken into account. The ratios of subcutaneous to visceral fat cannot be determined which results in a wide variety of bodily conditions fitting into the same category. This can lead to lean children being diagnosed as overweight even when they do not have excess adipose tissue. The more expensive technology-based methods can vary in accuracy, and with imaging such as CT scans and MRI, many expensive images must be taken to fully and accurately assess the body fat composition. Therefore a sensitive but clinically practical and robust method should be developed to better combat the growing levels of childhood overweight and obesity.

35.13 HEALTH POLICIES IN DIFFERENT LOCATIONS 35.13.1 New York and London New York City and London have both large and diverse population with the highest rate of economic inequality in their corresponding nations. They also have common patterns of childhood obesity, which increases with age and is more common among certain immigrant and low-income ethnic groups [68]. Both cities have responded to childhood obesity with policy changes in six different sectors: transportation, food, schools, green space, health care, and planning and housing. They have used policy changes, programs to increase the ease of access to services, and initiatives to inform and assist the community. In New York City, promoting walking by imposing traffic congestion fees, taxing sweetened beverages, using zoning laws to reduce fast food, and avoiding the cut of budget in health and educational services for the poor have not succeeded to reduce childhood obesity. Conversely, in both cities, the most substantial changes in the food environment is achieved by more modest efforts such as increasing the availability of opportunities of physical activity and consumption of healthier foods [68].

35.13.2 Canada and Alaska Both Canadian aboriginal populations and Alaska Native and American Indians have a very high prevalence of obesity. Canada promotes a healthy lifestyle by providing fresh vegetables and fruits to remote locations and subsidizing the shipping fees since the 1980s, which reduced food prices by 25% and has likely reduced the consumption of soda and similar drinks to one per day. As a result, and almost the same as Alaska Native preschool children, more than 60% of aboriginal children in Canada consume vegetables once a day or more [69].

35.14 BARRIERS OF GOVERNMENT INTERVENTIONS There are many factors that may act as barriers to the effectiveness of a policy approach to reduce childhood obesity. One of them is the use of information technology, social networking, and today’s need to be connected to the Internet for information and entertainment [70]. This factor reduces physical activity exponentially and may be one of the factors involved in the rise of obesity as a public health problem. The habit of snacking and the excessive eating that results from anxiety and stress along with the unhealthy lifestyles associated with poverty are all challenging obstacles that undermine any attempt to reduce childhood obesity through local policy, and in such cases a consistent prevention must be accompanied with lifestyle modification and behavioral changes at the individual level [70].

35.15 COST-EFFECTIVENESS OF CHILDHOOD OBESITY INTERVENTIONS Costs are a relevant matter when it comes to planning and creating strategies to prevent obesity. Policy makers wish to improve the health condition in their target population, but they do so while waving options to best use their resources [71, 72]. The study of the costs against the benefits of a certain action is called cost-effectiveness, and there

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are few studies estimating this variable in childhood obesity interventions. This is because effectiveness of childhood obesity policies cannot be always easy to study. Because much is left for children and families to choose and motivate themselves, studying their behavior changes and consequently their BMI improvements after a certain policy is implemented may be challenging, especially in the long-term [9]. Several studies to evaluate cost-effectiveness have been performed on school settings, and very few have been performed to evaluate population-wide policies, such as reducing advertisements of unhealthy food choices for children. It was found that this intervention resulted in health improvements in the studied population, as well as cost savings in health services. Furthermore, we may consider many additional benefits many of these studies do not contemplate [73]. For example, the health benefits of healthy eating and increased physical activity even if they do not have an effect on obesity has positive effects on obesity comorbidities; physical, social, and psychological. These factors translate into a better quality of life in children and may strengthen the arguments for implementing health policies, irresponsive of the setting (home, school, or wide-population policies).

35.16 CONCLUDING REMARKS Global increases in childhood obesity along with its serious consequences have now been acknowledged by governments of all developed and developing countries. However, child health and behavior can be positively influenced by parents or caregivers who are able to encourage nutrient-rich, low-calorie foods; regular exercise; and frequent visits to pediatricians to avoid sugar-laden alternatives and keep increases in weight under control. The role of government at the local, state, and federal level is especially important in the case of childhood obesity, as obesity remains a ubiquitous health problem that poses a serious threat to the populous as a result of its association with increased disability, comorbidities, and life-threatening diseases. In addition, these maladies accompany significant social costs and related health burdens, challenging the sustainability of our medical system. Still, undoubtedly, we have tools at our disposal to begin working toward a solution. As former first lady Michelle Obama eloquently remarked, “In the end… this isn’t just a policy issue for me. This is a passion. This is my mission. I am determined to work with folks across this country to change the way a generation of kids thinks about food and nutrition.” We need be accountable, as a unified community, and make it our priority to combat this cross-generational health nightmare.

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VII. HEALTH POLICIES AND INTERVENTIONS