Childhood overweight and obesity are a global pandemic. Worldwide, in 2016, 340 million children ages 5–19 were overweight or obese, and in 2020, 39 million kids under the age of 5 were overweight or obese. Over the past six decades in the United States alone, childhood obesity has risen from 5% in 1965 to 19% in 2018. If this trend continues, by 2050, the US is slated to have 57% of its kids ages 2–19 with obesity by the time they hit their mid-thirties.
These numbers are alarming not only because kids with obesity face reduced quality of life, bullying, and significant health challenges. However, being obese at a young age increases the risk of obesity in adulthood five-fold when compared to kids who are at a healthy weight.
While these statistics may seem insurmountable, integrative approaches that address the root causes of obesity and metabolic concerns offer hope for turning the tide. In this article, we’ll discuss what causes childhood obesity along with its metabolic concerns. We’ll also share how providers can combine conventional and integrative approaches to promote the very best outcome.
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Causes of Childhood Obesity
Before getting into the causes of pediatric obesity, it’s important to know what it is. Technically, the definition of childhood obesity is a body mass index (BMI) greater than or equal to the 95th percentile for age and sex. Other weight classifications include:
- Overweight: BMI between 85–94th percentile for age and sex
- Severe obesity: BMI greater than or equal to the 120th percentile for sex and age
Kids with severe obesity are at higher risk of cardiometabolic diseases, adult obesity, and premature death. However living with any amount of overweight and obesity significantly increases the likelihood that a child will develop chronic diseases like cancer, heart disease, type 2 diabetes, autoimmunity, mental health illness, osteoarthritis, and sleep apnea at some point in their lifetime.
Childhood obesity is a complex disease with many causes. While poor diet and physical inactivity are major players, they don’t tell the whole story. Rather a complex interplay between genetics, trauma and stress, screen time, and disrupted sleep in conjunction with poor diet and lack of physical activity culminate to create an environment that supports unwanted weight gain. Additionally, kids from disadvantaged racial and socioeconomic groups are at higher risk of developing overweight and obesity. Greater than 12% of African American and Hispanic kids have severe obesity when compared to 5% of non-Hispanic white kids.
Metabolic Concerns Associated with Childhood Obesity
Children with overweight and obesity have an increased risk of a variety of health issues related to metabolic dysregulation. Adipose tissue is now well-recognized as an endocrine organ. The adipokines it secretes regulate everything from energy expenditure and insulin sensitivity to lipid metabolism and inflammation. Adipokine signaling is altered in kids with overweight and obese. As a result, the hormones and proteins that are secreted from excess fat tissue alter how much insulin is produced and how sensitive the cells are to it, leading to insulin resistance and the upregulation of inflammatory biomarkers.
Early insulin resistance in kids with overweight and obesity contributes to poor glucose control and fatty liver disease, which may go unnoticed without specific lab testing. In one cross-sectional study of kids with obesity in India, almost 77% had acanthosis nigricans (a skin pigmentation disorder associated with insulin resistance). Additionally, 10% had impaired fasting glucose, 30% had HgA1c levels indicative of prediabetes, 40% had elevated triglycerides, 35-45% had elevated liver enzymes, and almost 42% had fatty liver as determined by ultrasound.
Chronic, systemic inflammation, insulin resistance, impaired fasting glucose, and poor glucose tolerance significantly increase the risk of high blood lipids, high blood pressure, metabolic syndrome, and their long-term health implications like type 2 diabetes, cardiovascular disease, and cancer. In the long run, kids with obesity tend to have a higher risk of disability and a shorter lifespan when compared to kids of healthy weight.
Conventional Approaches to Management
The American Academy of Pediatrics published clinical guidelines for the management of pediatric overweight and obesity in 2023. At the top of the list of interventions is Intensive Health Behavior and Lifestyle Treatment (IHBLT). IHBLT is delivered in a formal setting to help parents and kids learn how to make sustainable healthy nutrition and physical activity habits. The most effective programs provide 26 hours of intervention over 3–12 months. IHBLT programs lead to clinically significant improvements in BMI in children, as well as blood pressure, insulin, and glucose levels. IHBLT also improves asthma, sleep apnea, and fatty liver.
If IHBLT programs are unavailable, referrals to appropriate disciplines like registered dietitians who can assist with dietary modifications for children, exercise professionals who can educate families on how to incorporate fun physical activities, and mental health counselors to provide cognitive behavioral therapy can be successful.
Specific dietary and lifestyle recommendations for childhood overweight and obesity from the AAP include:
- Reduce sugar-sweetened beverage intake (sports drinks, fruit juice, energy drinks, and soda)
- Follow the USDA MyPlate dietary guidelines
- Aim for a minimum of 60 minutes of moderate to vigorous physical activity each day
- Reduce sedentary behavior, specifically screen time
- Prioritize an appropriate amount of sleep for age (in a 24-hour period, children ages 1–2 need 11–14 hours of sleep, ages 3–5 need 10–13 hours, ages 6–12 need 9–12 hours, and 13–18 need 8–10 hours)
In addition to IHBLT, professional referrals, and specific dietary and lifestyle behaviors, the AAP supports various classes of medication and bariatric surgery for children in certain cases.
Integrative and Alternative Approaches
Conventional approaches to childhood obesity have historically been moderate-to-low in efficacy. And unfortunately, when reducing calories and helping kids become more active doesn’t lead to significant improvement, medications, and even weight loss surgery may be considered. While these interventions may be needed in severe cases, an integrative approach that addresses the root causes of overweight and obesity may lead to enhanced outcomes without the side effects of medication and the risks associated with surgery.
In addition to tailored nutrition therapy and physical activity interventions, integrative providers prioritize family involvement and environmental changes. Studies suggest that families who eat meals together tend to have healthier diets and more nutritional variety, and are less likely to have kids with overweight and obesity. Getting parents involved in creating and modeling healthy diet and lifestyle behaviors may help kids be more successful in their endeavor to reach a healthy weight.
Integrative providers may also incorporate alternative approaches like mindfulness, yoga, and acupuncture. Mindfulness and yoga may enhance weight loss when paired with dietary modification. In one randomized controlled trial, kids ages 8–15 with overweight and obese who practiced yoga in conjunction with dietary modification for 18 weeks experienced similar improvements in BMI compared to kids undergoing standard weight management treatment.
Yoga and mindfulness in children may also improve quality of life, decrease insulin resistance, normalize lipids, and reduce depression, anxiety, and suicidality.
Acupuncture may lead to greater reductions in BMI and improve metabolic outcomes compared to standard weight reduction treatment. In one systematic review, kids and teens with overweight or obesity who incorporated acupuncture, either by itself or combined with diet, exercise, and therapy experienced greater improvements in BMI, lipids, and blood sugar regulation when compared to kids using standard therapies.
Nutritional Interventions and Supplementation
Nutritional interventions and education even before conception are important for childhood obesity prevention. Maternal BMI, diet, and lifestyle at the time of conception, as well as weight gain during pregnancy, are all important modulators of obesity in newborns. Breastfeeding appears to be protective and is associated with a 13% reduced risk of overweight and obesity. If breastfeeding isn’t feasible, a lower protein, wholesome infant formula may be best.
Once solid food is introduced, there’s no perfect diet for preventing or reversing childhood overweight and obesity. Kids and adolescents should aim for 3 well-balanced meals and 1–2 healthy snacks per day with appropriate portion sizes based on age. Nutritional interventions should be tailored to the child based on adverse food reactions, gut health, and specific nutritional needs. A whole foods diet such as Mediterranean or Nordic may be protective against obesity and may help to reduce weight in kids with overweight and obesity.
Specific dietary recommendations similar to conventional guidelines include discouraging the consumption of sugar-sweetened beverages, avoiding processed and fast foods, prioritizing a wholesome breakfast, and increasing fruit and vegetable intake.
Integrative providers may also consider various dietary supplements to address nutritional deficiencies and metabolic concerns. Supplementation for childhood obesity may include probiotics, vitamin D, and omega-3 fatty acids.
Probiotics
Probiotics are safe for kids and help to modulate the intestinal flora to promote a healthier balance of microbes, which in turn improves metabolic health and weight concerns. Kids with overweight and obese who take probiotics and synbiotics experience clinically significant reductions in weight, lower levels of inflammation, less insulin resistance, and better lipid levels. And kids with fatty liver disease also have improved liver function when taking probiotics.
Vitamin D
Vitamin D and obesity have an inverse relationship. Kids with overweight and obesity tend to have low vitamin D levels. Correcting deficient and insufficient levels may help to improve insulin resistance, impaired glucose tolerance, and type 2 diabetes in children.
Omega-3 Fatty Acids
Omega-3 fatty acids may help to decrease the cardiometabolic risks associated with childhood overweight and obesity. Specifically, omega-3s may reduce triglyceride levels and glucose, as well as improve insulin sensitivity.
Physical Activity and Exercise Programs
Physical activity is associated with better blood sugar regulation, lower body fat, and reduced cardiometabolic risk factors. Not surprisingly, kids who are more sedentary tend to have higher BMI when compared to kids who participate in moderate-to-vigorous activity. Additionally, as kids get older, they tend to become less active unless they’re involved in sports, but kids with obesity are less likely to play sports.
Kids ages 3–17 need a minimum of 60 minutes of moderate to vigorous physical activity each day, whereas adolescents with obesity should aim for 60–90 minutes. Organized or recreational sports participation is an easy way to increase a child’s daily activity. But parents can help kids become more active overall by taking family walks after meals, going on hiking adventures, dancing, riding bikes, and playing active games like tag and basketball. It’s important to keep physical activity positive and fun for kids and teens and avoid all-or-nothing language around exercise.
Exercise programs for children are only one part of the equation though. Reducing screen time is imperative for weight loss success. The AAP recommends the following when it comes to screen time:
- Children under 18 months of age should have no screen time outside of video chatting
- Children ages 2–5 should have less than 1 hour of screen time each day
- Children ages 6 and up should have less than 2 hours per day of parent-monitored screen time
Behavioral and Psychological Support
Kids with overweight and obesity face not only physical health challenges but mental health struggles as well. Depression and low self-esteem are significantly higher in this population when compared to kids of healthy weight. Kids with overweight and obese may also have a lower perceived self-worth, body dissatisfaction, conduct issues, inattention, lower school performance, and eating disorders. Bullying and teasing tend to increase these psychological complications further increasing the risk of depression.
Psychological support for obesity can promote healthy behavior change and help kids sustain their healthy behaviors in the long run. Cognitive behavioral therapy (CBT) is one option that helps kids with overweight and obesity modify their unhealthy thoughts, emotions, or behaviors to bring about positive changes that will assist them in meeting nutrition and lifestyle goals.
In addition to CBT, family counseling that engages the entire family in creating healthier behaviors can help kids with obesity be more successful. This type of counseling teaches parents how to set appropriate goals, problem-solve, model healthy lifestyle behaviors, and monitor their child’s progress. Intensive family-based therapy has been shown to lead to better weight loss outcomes when compared to standard therapy treatments.
Policy and Community Initiatives
Building healthy diets and lifestyle habits starts at home for children, but school-based programs, public health policies, and community initiatives are vital for reversing the childhood obesity crisis.
Kids may spend up to 20% of their time in school or child care. These programs should offer kids and teens education about healthy eating and physical activity habits. This means incorporating activity into the daily curriculum, as well as offering a wholesome menu that does not include sugar-sweetened beverages and ultra-processed foods. France adopted a ban on vending machines in schools in 2005 and saw a reduction in morning snacking which led to less sugar intake.
Food policy initiatives are another important piece of the puzzle. A Westernized diet is highly processed, deficient in many important nutrients, and promotes gut dysbiosis, all of which increase the risk of chronic diseases. This dietary pattern also includes many additives with questionable safety in children. Additives like colorings, sweeteners, emulsifiers, and preservatives have been linked to poor health outcomes in many studies and they may have an impact on child development and health. The standard American diet has normalized the use of highly processed, additive-laden foods for children. The childhood obesity crisis should be a call to action for the creation of food policies that demand an improved food environment for all kids.
Community programs to educate parents about breastfeeding, nutrition, and lifestyle, as well as food taxes on ultra-processed foods may help to encourage healthier choices.
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Key Takeaways
Childhood obesity is a complex issue that requires a multifaceted, personalized approach. Conventional treatments including diet, physical activity, reduced screen time, and restful sleep are foundational but historically haven’t been enough to reverse this crisis. Weight loss medications and surgery are additional conventional options but they don’t address the root causes of obesity and can come with unnecessary side effects and possibly long-term complications, especially for children.
An integrative approach to childhood obesity promotes collaboration between a variety of healthcare providers, policymakers, families, and communities. It also combines safe conventional treatments with personalized integrative approaches like mindfulness, acupuncture, dietary supplements, and therapy to improve outcomes and increase the likelihood of long-term success.
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