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Nov 28th, 2013
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Explain where you believe the following terms are found in the article below if
applicable: claim, support, warrant, backing, rebuttal, and qualifier.

Give citations to back up your points, and create a final works cited citation
for this essay.

Prevalence and Trends of Severe Obesity Among US Children and Adolescents

Skelton, Joseph A, MD; Cook, Stephen R, MD, MPH; Auinger, Peggy, MS; Klein, Jonathan D, MD, MPH; Barlow, Sarah E, MD, MPH. Academic
Pediatrics9.5 (Sep/Oct 2009): 322-9.

Abstract

To determine the extent to which the 2007 definitions for severe obesity
(body mass index [BMT] ≥99th percentile for age and gender) and morbid
obesity (BMI 3:40 kg/m^sup 2^) affects different groups of American children
and adolescents and has increased over time. Analysis of nationally
representative data from the National Health and Nutrition Examination
Survey (NHANES) II, III, and 1999-2004; 12 384 US children and adolescents
ages 2 to 19 years were included in the analysis. Outcome measures were the
proportion of subjects with severe and morbid obesity, with age, gender,
race, and poverty-income ratio (PIR) as key variables. In 1999-2004, 3.8% of
children 2 to 19 years old had a BMI in the ≥99th percentile, with higher
prevalence among boys than girls (4.6% vs 2.9%; P < .001). Prevalence was
highest among blacks, 5.7% and Mexican Americans, 5.2%, compared with
whites, 3.1% (P < .001). The prevalence differed by the PIR category as well
(4.3% for those with PIR ≤3 vs 2.5% for those with PIR > 3; P = .002). BMI
≥40kg/m^sup 2^ was found in 1.3% of adolescents ages 12 to 19 years, with
similar associations with race and poverty. The overall prevalence of BMI ≥
99th percentile has increased by more than 300% since NHANES II (1976), and
over 70% since NHANES III (1994) in children 2 to 19 years of age. Rates of
severe childhood obesity have tripled in the last 25 years, with significant
differences by race, gender, and poverty. This places demands on health care
and community services, especially because the highest rates are among
children who are frequently underserved by the health care system.

Full text

Objective.-To determine the extent to which the 2007 definitions for severe
obesity (body mass index [BMT] ≥99th percentile for age and gender) and
morbid obesity (BMI 3:40 kg/m^sup 2^) affects different groups of American
children and adolescents and has increased over time.

Methods.-Analysis of nationally representative data from the National Health
and Nutrition Examination Survey (NHANES) II, III, and 1999-2004; 12 384 US
children and adolescents ages 2 to 19 years were included in the analysis.
Outcome measures were the proportion of subjects with severe and morbid
obesity, with age, gender, race, and poverty-income ratio (PIR) as key
variables.

Results.-In 1999-2004, 3.8% of children 2 to 19 years old had a BMI in the
≥99th percentile, with higher prevalence among boys than girls (4.6% vs
2.9%; P < .001). Prevalence was highest among blacks, 5.7% and Mexican
Americans, 5.2%, compared with whites, 3.1% (P < .001). The prevalence
differed by the PIR category as well (4.3% for those with PIR ≤3 vs 2.5%
for those with PIR > 3; P = .002). BMI ≥40kg/m^sup 2^ was found in 1.3% of
adolescents ages 12 to 19 years, with similar associations with race and
poverty. The overall prevalence of BMI ≥99th percentile has increased by
more than 300% since NHANES II (1976), and over 70% since NHANES III (1994)
in children 2 to 19 years of age.

Conclusions.-Rates of severe childhood obesity have tripled in the last 25
years, with significant differences by race, gender, and poverty. This
places demands on health care and community services, especially because the
highest rates are among children who are frequently underserved by the
health care system.

KEY WORDS: adolescents; children; morbid obesity; nutrition surveys; trends

Academic Pediatrics 2009;9:322-9

The American Academy of Pediatrics currently recommends the use of body mass
index (BMI) to screen for obesity in clinical practice.1,2 The terms
overweight or obese are used to describe a child or adolescent whose BMI is
≥95th percentile for age, on the basis of the current growth curves from
the Centers for Disease Control and Prevention (CDC), with obese being the
most currently recognized designation.3,4 A variety of studies have shown
increases in the rates of obesity among children and adolescents,5-7 with
the most recent national data showing a prevalence of 17%. 8 However, few
data exist on how common severe or extreme obesity is among US children and
adolescents.

An expert committee convened by the American Medical Association, the CDC,
and the Department of Health and Human Services proposed a new
classification of severe childhood obesity in 2007: BMI S:99th percentile
for age and gender.4 The committee based this recommendation on data from
National Health and Nutrition Examination Survey (NHANES) 1999-2004 that
found about 4% of children in the United States had a BMI in the ≥99th
percentile.9 This study applied the 99th percentile cut point to a
longitudinal cohort, the Bogalusa Heart Study participants, and found that
severely obese children had higher rates of obesity and morbid obesity as
adults. These severely obese children also had higher prevalence of
cardiovascular risk factors and higher levels of adiposity, as measured by
serum cholesterol and triglyceride levels, blood pressure, and skinfold
measurements.9 The classification of severe obesity in children has been
recently used in pediatric research, which documented the frequent
recognition of this condition in a large academic medical system (8% of 60
711 children and adolescents had a BMI in the ≥99th percentile, with 76%
being correctly identified as such).10 Childhood obesity has also been shown
to be significantly associated with increasing inpatient hospital costs,
increasing more than threefold from 1979-1981 to 1997-1999.11

Expert panels have made recommendations regarding when to consider bariatric
surgery in obese adolescents.12,13 Regional and institution-specific reports
have provided some data on the degree of severe childhood obesity,
especially in subspecialty clinics.14-17 Providers are now considering
aggressive forms of therapy because conventional approaches are often
ineffective.18,19 The recommendations have suggested several criteria to
consider an adolescent for bariatric surgery, which include BMI ≥40
kg/m^sup 2^ with serious obesity-related comorbidities or BMI ≥50 kg/m^sup
2^ with less severe comorbidities.12

Studies have shown higher rates of obesity among racial/ethnic minorities
for both adults and children.5,6,8 Another strong risk factor for obesity
appears to be poverty, with studies showing the paradox of those at risk of
hunger as having some of the highest rates of obesity, independent of ethnic
background.20,21 Data about adults from the Behavioral Risk Factor
Surveillance System Survey demonstrated a near tripling of class 3 obesity
rates in adults (BMI ≥40 kg/m^sup 2^) from 0.78% in 1990 to 2.2% in 2000,
with African American women and those who did not finish high school
disproportionately affected.22 It is unknown whether these sociodemographic
risk factors are associated with severe obesity in childhood. There is a gap
in the literature regarding extreme forms of obesity in children and
adolescents (BMI 299th percentile and 240 kg/m^sup 2^), which is
particularly important in light of the increasing use of bariatric surgery
in adolescent age groups.

The aim of this report was to examine the change in prevalence of extreme
levels of pediatric obesity (severe obesity, BMI 299th percentile; morbid
obesity, BMI ≥40 kg/m^sup 2^) between 1976-1980 and 1999-2004; to examine
how sociodemographic categories, such as poverty and race/ethnicity, are
associated with severe obesity (BMI ≥99th percentile); and to determine
whether severe obesity carries higher cardiovascular risk factors than
simple obesity (BMI 95th to 98.9th percentile).

METHODS

National Health and Nutrition Examination Survey

In NHANES, a representative sample of the noninstitutionalized US population
is selected by a complex multistage probability sampling design. This study
examined data from NHANES conducted at 5 time periods: 1976-1980, 1988-1994,
23 1999-2000,24 2001-2002,25 and 2003-2004.26 After being interviewed in
their homes, subjects were invited to be examined in a mobile examination
center. Height and weight measurements were obtained by standardized
techniques and with standardized equipment. Weight was measured on a Toledo
self-zeroing weight scale, and height was measured with a stadiometer to the
nearest millimeter. Identical procedures for conducting anthropometry were
used throughout NHANES surveys to ensure comparability of anthropometric
measures over time. Quality control procedures were observed to minimize
body measurement errors as a result of body positioning or in reading and
recording the measurements.

Other variables included in our analyses were gender, age, race/ethnicity
(ie, white, black, Mexican American, and other, representing smaller groups
including American Indian, Alaska Native, Native Hawaiian, Guamanian,
Samoan, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, other
Asian, and other race) and poverty-income ratio (PIR). Poverty-income ratio
is the ratio of the midpoint of observed family income category to the
official poverty threshold (scaled to family size). Poverty-income ratio
accounts for family size and is independent of inflation, as the poverty
threshold is based on annual US Census Bureau data. A PIR value of < 1
identifies individuals who are below the federal poverty level. Higher PIR
levels (PIR 1 to 3, PIR >3) indicate relatively higher socioeconomic status,
which have been shown to be protective factors for adult obesity.27,28

Obesity Categories

Among children and adolescents, obesity was defined at or above the 95th
percentile of the age and gender-specific BMI growth chart from the CDC.29
Obese subjects were also categorized into 3 groups of increasing severity:
BMI 95th to 96.9th percentile, BMI 97th to 98.9th percentile, and BMI ε99th
percentile. The BMI 297th percentile was included in these analyses because
there are alternate versions of the 2000 CDC growth curves with the 97th
percentile lines, and this cut point could therefore be tracked clinically.7
The cutoff of BMI >99th percentile was applied from recent expert committee
recommendations.4 A subanalysis was conducted on adolescents, 12 to 19 years
of age, to describe those with a BMI of 240 kg/m^sup 2^.

Statistical Analysis

Data were analyzed by SAS version 9. 1 (SAS Institute, Cary, NC) and SUDAAN
version 9.0 (Research Triangle Institute, Research Triangle Park, NC).
Pregnant girls were excluded from the analyses. All analyses used sample
weights to account for differential probabilities of nonresponse,
noncoverage, and selection into the sample. Standard errors were estimated
by Taylor series linearization. Bivariate (unadjusted) analyses were
conducted to determine associations with different levels of obesity, ?2
tests were used to test hypotheses at the overall significance level of P <
.05. The Bonferroni method was used to adjust for multiple comparisons
across racial/ethnic groups. The Cochran-Armitage trend test was used to
test for trends. Our a priori hypothesis was that rates of severe obesity
(BMI 299th percentile and BMI ≥40 kg/m^sup 2^) would differ by race/ethnic
groups and by PIR. We also hypothesized the trends in cross-sectional
prevalence rates would also differ by race/ethnic groups and by PIR.

RESULTS

Population Characteristics and Obesity, NHANES 1999-2004

The study population included 12 384 children, representing approximately 71
million US children ages 2 to 19 years. A total of 123 pregnant girls were
excluded from the analysis. Nearly 16% of children 2 to 19 years were obese
(BMI 295th percentile) in 1999-2004, with 10.8% having a BMI in the ≥97th
percentile and nearly 4% having a BMI in the ≥99th percentile. On the basis
of these data, die estimated number of children in the US with a BMI in the
299th percentile is 2.7 million. Detailed demographic data including gender,
age group, race/ ethnicity, and PIR are shown for children across all BMI
categories (Table 1). In both groups (BMI 97th-98.9th percentile and 299th
percentile), there were significant differences by race/ethnicity, with
minority groups (black, Mexican American) having higher prevalence of severe
obesity than whites (P < .001). There were also differences by PIR, with PIR
>3 (most affluent) having the lowest prevalence. In BMI 97th-98.9th
percentile, there were significant differences by age groups, with the
highest percentage found in older age groups (12 to 19 years). There were
significantly more boys with a BMI in the >99th percentile than girls (P
=.001).


Absolute BMI Values as Cut Point for Severe Obesity

An estimated 418 000 US adolescents, ages 12 to 19 years, had a BMI of S:40
kg/m2 on the basis of a prevalence of 1 .3% by 1999-2004 data. Detailed
demographic data are shown (Table 2). Again, minority populations had
significantly higher prevalence, with 3.4% of black teens having a BMI of ≥
40 kg/m^sup 2^ (P < .001), as well as those below the poverty level compared
with the highest PIR category (P = .002).


Severe Obesity Trends: NHANES II (1976-1980), NHANES m (1988-1994), NHANES
1999-2004

When compared with children 2 to 19 years from NHANES ?, the overall
prevalence rate of BMI ≥99th percentile increased by >300% from 0.8% in
1976-1980 to 3.8% in 1999-2004 (P < .001), and by 72% since NHANES III
(1988-1994) (P < .001) (Appendix); changes by age groups (Figure 1) and by
gender (Figure 2) are shown. Among whites, changes were minimal, yet
significant changes were seen in blacks and Mexican Americans (Figure 3).
Among those below the poverty threshold (PIR <1), prevalence rates increased
from 0.7% (NHANES H) to 3% (NHANES III) to 4.3% (NHANES 1999-2004) (P <
.001, test for trend). Prevalence rates were related to poverty level (PIR 1
to 3), with rates increasing from 1.1% to 1.9% to 4.3% (P < .001, for
trend). There were no significant race/ethnicity-poverty interactions found
on further analysis.


Cardiovascular Risk Factors

When compared with adolescents with BMI in the 95th-96.9th percentile, youth
with a BMI in the ≥99th percentile had significantly different mean levels
of systolic and diastolic blood pressure, high-density lipoprotein
cholesterol, and insulin. Additionally, liver function tests and waist
circumference were higher in those with a BMI in the ≥99th percentile
(Table 3). Fasting total and low-density lipoprotein cholesterol,
triglycerides, and glucose did not differ between these groups. When the
Adult Treatment Panel III (of the National Cholesterol Education Program)
criteria for metabolic syndrome (with glucose ≥110 mg/ dL and glucose ≥100
mg/dL) were applied, a third of the children with a BMI in the ≥99th
percentile (32% and 33%, respectively) were classified as having the
metabolic syndrome, significantly more than the 13% to 17% in the 95th to
97th percentile range.







DISCUSSION

Our analysis found that among the almost 4% (2.7 million) of US children who
have a BMI in the 299th percentile for age/gender (1999-2004), there were
significant differences by race, gender, and poverty. The higher prevalence
among black and Mexican American youth and among youth of lower income
reflects the associations between these groups and the larger group of
children with a BMI in the 295th percentile. Overall, prevalence of BMI
299th percentile has increased by over 300% since 1976, and by over 70%
since 1994. This analysis also demonstrated a high prevalence of teens with
a BMI of ≥40 kg/ m^sup 2^ (>400 000 children). This level of severe
adiposity is part of the initial criteria for considering bariatric surgery
in adolescents.12 Given the immediate and future health risk and costs
associated with this growing prevalence, these groups need more careful
attention.




Higher socioeconomic positions seem to protect against morbid and severe
obesity. Explanations for this association may include the easy availability
and low cost of energy-dense snacks in poor, inner-city neighborhoods.30 In
contrast, fresh fruits and vegetables are often not available, and adequate
amounts are expensive.31 Recent reports confirm the seemingly paradoxical
connection of poverty, food insecurity, and obesity.21 Even more surprising
is that the risk may carry through to the morbidly and severely obese. The
effect of poverty on levels of physical activity is unknown. One report
showed an increased risk of obesity in 7-year-olds when they perceived their
neighborhood as unsafe,32 whereas others have shown an inverse effect of
income on sedentary activity.33 All of these findings implicate the
environment as an important factor, but one over which the child has little
control. Most worrisome is that vulnerable populations are experiencing the
worst increase in severe obesity, as rates in whites and the affluent have
plateaued.

Many cardiovascular risk factors, such as higher waist circumference,
insulin resistance (evidenced by elevated fasting insulin), blood pressure,
and lower high-density lipoprotein cholesterol, were associated with a BMI
in the &99th percentile in this study. The application of adult criteria of
the metabolic syndrome to this population showed that more than a third met
the criteria. The higher rates of increased alanine aminotransferase levels
among severely obese youth supports the recent expert committee
recommendations for pediatric primary care providers to routinely assess
liver transaminases as a screen for nonalcoholic fatty liver disease. These
findings demonstrate the significant health risks facing this morbidly obese
group.

Anthropometric cut points for severe obesity in youth are sought in order to
guide use of aggressive interventions, such as bariatric surgery, that may
be more effective but have higher risk and costs than behavior-based
treatment.34 Recent criteria for identification of adolescents for bariatric
surgery propose absolute BMI >40 kg/m2 with a comorbidity,12 but this cut
point may not capture those younger adolescents who have dangerous levels of
obesity despite having a BMI of <40kg/m2. BMI >99th percentile is a cut
point that identifies greater risk of later obesity and cardiovascular
complications compared with obese children with lower BMI percentile.9 In
addition, this cut point identifies the same deviation from median BMI
across ages and genders. In contrast, a BMI of 40 kg/m2 defines a higher
deviation from median BMI in younger adolescents compared with older
adolescents and in boys compared with girls. Greater than 99th percentile,
because it accounts for age and gender, can be applied to préadolescents
and even preschool children. Although surgery and medication are not
appropriate for these younger children, increased resources to support
intensive behavior-based programs may lead to an effect that justifies
greater cost. Classification of severe obesity allows assessment of the
health burden and the health care system needs of these children. Treatment
of hypercholesterolemia and diabetes is reimbursable by insurers, yet these
diseases are quite rare across pediatric populations (0.8% of US teens have
hypercholesterolemia requiring pharmacotherapy,35 and only 0.18% have
diabetes36). The higher prevalence of severe childhood obesity among
generally disadvantaged sectors of society heightens the need for greater
research, prevention, and treatment efforts, as well as a coordinated
approach to public health efforts.

Limitations to our analysis include small sample sizes among some minority
groups with a BMI of ^40 kg/m2. As with other analyses that use NHANES,
results with small sample sizes may have relatively large standard errors
(>30%) and could therefore be statistically unstable and should be
interpreted with caution. The tables identify these comparisons, most common
in the NHANES ? cohort. The data are cross-sectional, and causality cannot
be inferred from any of the associations found. Povertyincome ratio is an
imperfect marker of socioeconomic status, with other factors such as parent
education levels being superior measures of socioeconomic position.37

There are 2.7 million children with a BMI that puts them at significantly
increased risk of multiple medical and psychological comorbidities, and it
is likely that their obesity will continue into adulthood. Over 400 000
adolescents might meet criteria for bariatric surgery. These highBMI groups
seem likely to increase in number. With prevalence rates high and climbing,
the expert committee recommendations have endorsed the category of severe
obesity as part of the clinical criteria to direct medical screening and to
initiate referral for care. However, specialized clinical and behavioral
services appropriate for severely obese children may be unavailable or may
not be covered by medical insurance.38 At the same time, primary-care
pediatricians face many barriers to clinical screening and management,
including lack of training, tools, referral resources, and reimbursement.
This mismatch of need and services is greatest among the poor and among
children in minority groups, who have both the highest severe obesity rates
and the greatest difficulty accessing health care. No simple answers exist,
but the best chance for success is immediate attention to this problem in
both primary- and tertiary-care systems, supported by collaboration and
mobilization of health care insurers and regional systems, and by broad
social and community support for healthier lifestyles for children.


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