MLA annotated bibliography

timer Asked: Nov 20th, 2016

Question description

  1. Your annotated bibliography can either be a summary or assessment  (3 to 5 complete sentences) for each of the 3 articles you’veselected.  I attatced the 3 article i just need the summary doesnt have to do the anotation 

CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications Kathryn Faguy, MA, ELS Overweight and obesity are pandemic health problems, not just among the adult population, but in children and adolescents as well. This article presents information on the prevalence, causes, prevention, and treatment of overweight and obesity in young people, with particular focus on the medical and psychological complications associated with the diseases. In addition, the challenges of imaging the obese pediatric population are discussed, and public policy changes that could help reverse obesity trends in children and adolescents are introduced. This article is a Directed Reading. Your access to Directed Reading quizzes for continuing education credit is determined by your membership status and CE preference. After completing this article, the reader should be able to:  Explain how overweight and obesity are measured and categorized.  Specify the prevalence of obesity in children and adolescents in the United States, internationally, and among certain racial and ethnic groups.  State the causes of obesity.  List and describe health problems associated with obesity in children and adolescents.  Discuss the effects of obesity on children’s and adolescents’ quality of life and psychological well-being.  Describe special considerations and techniques for imaging overweight and obese patients.  Summarize key points regarding the prevention and treatment of overweight and obesity in children and adolescents.  Identify public policy changes that could reduce the obesity pandemic. C hildhood obesity has become so pervasive that some now describe it as the most common chronic condition of childhood.1 Since the 1980s, the number of obese children and adolescents in the United States has tripled,2 and nearly one-third of American children and adolescents now are classified as either overweight or obese. 3 Obesity is a serious health concern, associated with shorter life spans, higher health care costs, and complications affecting nearly all of the body’s organ systems.2 Without intervention, obese children are likely to become obese adults; therefore, it is important for health care providers to recognize, treat, and prevent obesity in children and adolescents before obesity-related complications become severe and RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 debilitating. Pediatric obesity is not consistently diagnosed by primary care providers or regularly noted by radiologists on imaging reports.2 Reversing the tide of overweight and obesity in children and adolescents requires the united efforts of health care professionals, parents, schools, community organizations, public policy makers, and children. Defining and Measuring Obesity In adults, overweight and obesity are determined using body mass index (BMI) categories. BMI is a measurement of body weight relative to height. The formula for calculating BMI is weight (kg)/height (m)2 . Converting to more familiar pounds and inches, the formula is weight (lb)/height (in)2  703. 279 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications The Table presents BMI weight categories for adults 20 years and older. To illustrate these categories, a woman of average height (5 ft, 4 in) who weighs between 108 lb and 144 lb is within the normal BMI range. Weights between 145 lb and 173 lb fall into the overweight BMI category, and weights of 174 lb or more are classified as obese.7 Almost 70% of adults 20 years and older in the United States are either overweight or obese.8 BMI charts are objective and explicitly identify which patients are overweight or obese, so patients and parents can be informed about a problem they might otherwise ignore or deny. For children and adolescents, weight categories are determined by comparing BMI with children of the same age and sex. The American Academy of Pediatrics 2007 guidelines state that a patient should be categorized as overweight if his or her BMI is between the 85th and 94th percentiles for patients the same sex and age and obese if his or her BMI is in the 95th percentile or higher for sex and age (see Figure 1).9 Although BMI comparison charts for children and adolescents are a powerful and easy-to-use tool, they are reportedly underused by clinicians.9 Other nations and organizations, such as the World Health Organization and the International Obesity Task Force, have set different cutoff points for overweight and obesity in children and adolescents.9 In the United Kingdom, for example, the cutoff point for pediatric overweight under national guidelines is a BMI of 91% or greater for age and sex, and the cutoff for obesity is a BMI of 98% or greater for age and sex.10 Pediatric overweight and obesity is more prevalent under the World Health Organization cutoff points than under some other classification systems.9 Table Body Mass Index (BMI) Ranges and Associated 4-6 Weight Status for Adults 20 Years and Older BMI (kg/m2) Weight Status  18.5 Underweight 18.5-24.9 Normal 25.0-29.9 Overweight 30.0-39.9 Obese  40.0 Morbidly obese 280 Body mass index-for-age percentiles: Boys, 2 to 20 years 95th Percentile A10-year-old boy with a BMI of 23 would be in the obese category (95th percentile or greater). 90th 85th Percentile 75th A 10-year-old boy with a BMI of 21 would be in the overweight category (85th to less than 95th percentile). 50th 25th 10th 5th Percentile A 10-year-old boy with a BMI of 18 would be in the healthy weight category (5th percentile to less than 85th percentile). kg/m2 2 3 4 5 6 7 8 A 10-year-old boy with a BMI of 13 would be in the underweight category (less than 5th percentile). kg/m2 9 10 11 12 13 14 15 16 17 18 19 20 Figure 1. This graph illustrates how different body mass index numbers would be classified for a boy aged 10 years. Reprinted from About BMI for children and adolescents. Centers for Disease Control and Prevention Web site. weight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. Updated July 11, 2014. Accessed October 12, 2014. In addition to computing BMI and comparing the results to a population of children or adolescents the same age and sex, other simple and inexpensive means of assessing pediatric obesity are measuring waist circumference, hip circumference, or skinfold thickness and calculating waist/height ratio or waist/hip ratio. Other useful but more costly techniques for assessing the amount of body fat include bioelectrical impedance analysis and dual-energy x-ray absorptiometry (DXA).9 Bioelectrical impedance analysis is based on the rate at which a harmless electric current passes through components of the body, such as muscle, bone, fat, and water. It can be used to quickly and noninvasively determine lean and fat body mass.11 However, readings can RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy be affected by how recently a person has eaten, drunk, or exercised.11 Whole-body DXA scanning is quick, taking less than 5 minutes, and delivers a low radiation dose of approximately 0.3 Sv.12 DXA images can be used to calculate percent body fat, fat mass, lean body mass, total tissue mass, and bone mineral content. A limitation of DXA scanning is its inability to distinguish visceral fat (ie, fat surrounding the internal organs) from subcutaneous fat. Another potential drawback is that some obese adolescents might be too heavy or too wide for the scanning equipment.12 However, Breihaupt and colleagues found no statistically significant differences between half-body DXA scan results vs full-body results in a study of 58 obese children and adolescents. They concluded that half-body scanning is a valid alternative for adolescents whose body width exceeded the 60-cm scan area of the DXA equipment used in their study.12 Other imaging techniques can be used to assess body fat, but each is associated with drawbacks. Ultrasonography is a widely available tool but cannot assess the total volume of visceral fat.13 Computed tomography (CT) accurately depicts visceral fat but entails high levels of radiation exposure and therefore is not justifiable for obesity assessment in children and adolescents, particularly considering that multiple assessments might be required over time.13 Magnetic resonance (MR) imaging has proven effective for measuring total body fat as well as subcutaneous and visceral fat in the abdomen, but is costly.13 Prevalence United States In the 1980s and 1990s, the prevalence of obesity among children and adolescents in the United States skyrocketed, doubling or even tripling in some age groups3,14 and prompting one researcher to call obesity “the most common chronic disorder in childhood” as well as “one of the most serious public health challenges” of our time.1 Recent data suggest that obesity rates might have begun to level, although overweight and obesity in young people remain common, with adolescents more likely to be affected than young children, boys more affected than girls, and some minority groups affected more than whites, particularly blacks, RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 Hispanics, and Native Americans.14,15 Obesity also is more prevalent in children and adolescents with lower socioeconomic status.15 Skinner and Skelton analyzed data from the National Health and Nutrition Examination Survey from the years 1999 to 2012. A total of 26 690 children and adolescents aged 2 to 19 years participated in the survey and were included in the analysis. The researchers determined that prevalence of all categories of obesity increased in most groups of study participants between 2009 and 2012, although the increases were not statistically significant.3 However, Skinner and Skelton found the prevalence of obesity and overweight increased significantly for certain subgroups in the study, particularly Hispanic girls and black boys.3 Similarly, Ogden and colleagues found no significant changes in the overall prevalence of obesity in youths between 2003 to 2004 and 2011 to 2012, also based on National Health and Nutrition Examination Survey data.16 Nevertheless, they cautioned, “Obesity prevalence remains high and thus it is important to continue surveillance.”16 According to National Health and Nutrition Examination Survey data from 2011 to 2012, 32.2% of children and adolescents in the United States aged 2 to 19 years were either overweight or obese, and 17.3% were obese.3 In addition, 5.9% of children and adolescents qualified as type 2 obese, a category defined as 120% of the 95th percentile BMI for age and sex or a BMI of 35, whichever is lower. Finally, 2.1% were classified as type 3 obese, indicating a BMI greater than 140% of the 95th percentile BMI for sex and age or a BMI of 40, whichever is lower.3 Overweight and obesity now affect even very young children, whereas formerly the condition was seen mostly in children 4 years and older.17 Ten percent of infants and one-quarter of toddlers and preschool-aged children in the United States qualify as overweight or obese.17 Regional Variations The prevalence of childhood overweight and obesity varies significantly among the states.18 Generally, obesity and overweight are more prevalent in the southeastern United States, particularly in Mississippi, Georgia, and Tennessee. Conversely, states in the Northwest 281 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications and upper Midwest have the lowest prevalence of overweight and obesity. Geographical patterns of overweight and obesity in children and adolescents tend to mirror the patterns for adults.18 Worldwide Although the United States might be the most severely affected nation, obesity and overweight are not limited to this country.1,9,10,19 Data from 2010 suggest that the problem is truly worldwide, with 38% of children and adolescents in Europe and 27% of children in the western Pacific Caucasian Male Age: 15 Percent Fat: 34.9 Subcutaneous Fat: 597.9 cm2 Visceral Fat: 112.2 cm2 region either overweight or obese.20 (Recall, however, that obesity and overweight are defined somewhat differently under different national and organizational criteria.) Maggio and colleagues reported a 20% prevalence of childhood obesity in Switzerland in 2014, adding, however, that the rate appeared to be stabilizing.21 A 2009 survey in Ireland showed that 25% of children aged 3 years and 9 years were either overweight or obese.1 In 2013, the estimated total number of overweight children worldwide was 155 million, with between 30 million and 45 million of these qualifying as obese.22 African-American Male Age: 17 Percent Fat: 38.3 Subcutaneous Fat: 777.4 cm2 Visceral Fat: 46.2 cm2 HFF: 0% HFF: 4.8% EMCL 1.18% 2.5 2.0 1.5 1.0 HFF: 19.2% IMCL 1.88% EMCL 1.99% IMCL 0.93% 3.0 Hispanic Male Age: 13 Percent Fat: 39.8 Subcutaneous Fat: 437.8 cm2 Visceral Fat: 94.7 cm2 EMCL 2.62% IMCL 0.60% 0.5 ppm 3.0 2.5 2.0 1.5 1.0 0.5 ppm 3.0 2.5 2.0 1.5 1.0 0.5 ppm Figure 2. Abdominal magnetic resonance (MR) images (top row) and liver MR scans (middle row) of 3 obese adolescent boys. The Hispanic boy (right) had marked elevation in intramyocellular lipids (IMCL), hepatic fat fraction (HFF), and visceral fat. The African American boy (center) had low IMCL, undetectable liver fat, and low visceral fat and marked expansion of the total subcutaneous fat. The white boy (left) had a low IMCL and liver fat but significant visceral fat content. Extramyocellular lipids (EMCL) also differed significantly among the boys (bottom row). Reprinted from Liska D, Dufour S, Zern TL, et al. Interethnic differences in muscle, liver and abdominal fat partitioning in obese adolescents. PLoS ONE. 2007;2(6):e569. doi:10.1371/journal.pone.0000569. 282 RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy Racial and Ethnic Disparities Obesity appears to be more prevalent among black and Hispanic children and adolescents than among white, non-Hispanics. According to the 2009-2010 National Health and Nutrition Examination Survey, the prevalence of obesity was 24.3% among black non-Hispanic children and adolescents, compared with 21.2% among Hispanic youths and 14% for non-Hispanic white youths.9 Other studies have confirmed these disparities along ethnic and racial lines, although these findings are confounded by the effects of socioeconomic factors on overweight and obesity. Furthermore, an analysis of 1999 to 2012 National Health and Nutrition Examination Survey data indicated that all levels of overweight and obesity increased significantly among Hispanic girls and non-Hispanic black boys, prompting researchers to urge that future studies focus on whether specific risk factors for these groups could be addressed. 3 In addition to differences in the prevalence of overweight and obesity, the distribution of fat within the body also differs among racial and ethnic groups (see Figure 2). For example, African Americans typically have less visceral fat and more superficial subcutaneous fat than do whites or Hispanics with similar total body fat who are the same age and sex.23 African Americans also tend to have undetectable amounts of intrahepatic fat, even when overweight or obese. These observations are true for people of African descent generally, whether they live in the United States, the Caribbean, South America, or Europe. However, the reasons for these racial differences in fat distribution are unknown.23 Causes of Obesity in Children and Adolescents In most cases (95%-99%), childhood obesity is caused by caloric imbalance, meaning more calories are consumed than are expended.24 Caloric imbalance is affected by factors including diet, activity level, and genetic predisposition.1,24 Researchers are still investigating the genetic predisposition to obesity, and in many cases it appears likely that genetics, environmental factors, and personal behavior all play a role.1 Although the exact genetic mechanism is not clearly RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 understood, it has been shown that having obese parents increases both the risk and severity of obesity in a child.1 Lifestyle factors linked to caloric imbalance in children and adolescents include increased television viewing and computer gaming, decreased physical activity levels, increased consumption of high-calorie beverages such as soft drinks, larger serving sizes, and increased consumption of high-fat foods.2 In 1% to 5% of cases, the causes of obesity are organic, including a variety of endocrine and central nervous system disorders as well as certain genetic syndromes (see Box 1).1,20 For example, obesity in children combined with short stature might indicate an endocrine disorder such as hypothyroidism or growth hormone deficiency and should be investigated further.10 Rare genetic syndromes can cause rapid onset of severe obesity, especially in young children.10 These disorders also tend to be associated with short stature, as well as developmental and intellectual delays, other abnormal clinical features, and a positive family history of the syndrome.1 Certain drugs can contribute to weight gain and should be considered when evaluating overweight and obesity in children and adolescents.20 Besides some antihypertensives, antihistamines, tricyclic antidepressants, and anticonvulsants, these medications include20: ■ Insulin. ■ Glucocorticoids. Box 1 Causes of Obesity Other Than 1,20 Caloric Imbalance Endocrine Disorders Cushing syndrome Growth hormone deficiency Hypothyroidism Genetic Syndromes Albright hereditary osteodystrophy Laurence Moon-Biedl Prader Willi Single gene mutations Central Nervous System Disorders Hypothalamic tumors/lesions 283 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications ■ Hormonal contraceptives. ■ Clozapine. ■ Lithium. Studies have implicated lack of adequate sleep as a possible contributor to obesity.20,25 About 20% of adolescents get the optimum amount of sleep for their age group.25 Factors that prevent adolescents from getting enough sleep include homework, sports and other extracurricular activities, part-time jobs, and use of the Internet, television, and mobile phones. In addition, parents are less likely to enforce bed times with adolescents than they are with younger children.25 Lack of sufficient sleep causes fatigue, bad moods, and psychological distress, which can affect eating patterns and contribute to weight problems.25 In addition, adolescents as a group tend to be less physically active than younger children, which can contribute to weight gain during adolescence. Whereas more than 40% of children aged 6 to 11 years reportedly participated in one hour or more of physical activity daily, the figure drops to just 8% among those aged 12 to 15 years, and is slightly lower among older adolescents.8 Arnold Slyper, MD, suggested that another cause of obesity in children and adolescents in recent decades is that their diets are now less “satiety inducing” than in the past, which is to say, less likely to produce a sense of being full.26 Many children eat only limited amounts of high-fiber foods that are associated with fullness such as whole grains, fruits, and vegetables. In addition, children and adolescents eat fewer eggs and drink less milk today, both of which are associated with satiety because of their high protein content. Instead, children and adolescents are consuming more soft drinks, fruit juices, and low-quality carbohydrates, which are not particularly filling but are high in calories.26 Slyper traced this trend to the 1960s, when adults were urged to reduce the amount of saturated fat and cholesterol in their diets.26 However, the advice might have backfired by unintentionally encouraging consumption of less-filling, high-calorie foods. To combat childhood obesity, he suggested a new focus on choosing foods that induce satiety, such as whole-grain cereals, eggs, and whole milk, and limiting portion sizes and total caloric intake. “For children on Western-style diets, the calories from a moderate amount of dairy fat 284 are preferable to those from the soda, juice, and highly refined starches that have often replaced them,” he explained.26 In addition, increased television viewing and media exposure generally are directly correlated with overweight and obesity.25 Television and other forms of media expose children to advertising for less-healthy foods and prevent physical activity during viewing. Eating while watching television also is associated with overweight. The Children’s Nutrition Research Center and Baylor University studied eating habits of 287 4th through 6th grade children.27 They found that half the time, overweight children ate their dinners while watching television. By comparison, the children with a healthy weight ate their dinners while watching television only 35% of the time.27 The researchers pointed out that watching television while eating tends to tune out the body’s natural hunger and satiety cues, which encourages overeating.27 The decline of family meals is another possible contributor to overweight and obesity in children and adolescents. “The once-traditional pattern of the family having dinner together at the table has changed,” noted the Academy of Nutrition and Dietetics in 2014.14 “However, children who eat meals with their families at home have better diet quality than those who do not, and they are also more likely to have healthy body weights.”14 Specifically, children who eat at least 3 meals per week with their families tended to have higher intakes of fruits and vegetables and were more likely to eat breakfast regularly.14 Researchers suggested that parents might be modeling healthy eating habits when families eat together, and that children might be more likely to abide by family rules regarding eating at family meals.14 At the same time the number of family meals eaten together has declined, food eaten away from home has increased significantly. In 1977, less than a quarter of all food consumed was eaten away from home; as of 2006, the figure was more than one-third.14 Moreover, the single largest category of food eaten away from home is fast food.14 Foods eaten at home but prepared elsewhere (ie, take-out meals) also are increasing. Foods not prepared at home tend to be higher in calories and fat than home-prepared foods.14 Fast-food restaurants usually RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy do not provide many fruits, vegetables, whole grains, or dairy foods on children’s menus.14 Another factor that might contribute to overweight and obesity in children and adolescents is beverage consumption trends. Fewer children drink milk now than in the 1970s, while more are drinking fruit juices. The American Academy of Pediatrics recommends only a small amount of fruit juice per day (4 to 6 ounces), for example, but infants aged 1 year are reportedly consuming an average of 10 to 12 ounces per day.14 Children are consuming more soft drinks as well.14 The number of snacks eaten per day by children and adolescents also has increased.28 Snacking per se is not necessarily associated with overweight or obesity,28 but research has shown that desserts and sugary drinks are major sources of snack-associated calories.14 Some of the most commonly chosen snacks among adolescents include chips, ice cream, candy, and cookies.28 Emotional difficulties are another suspected contributor to obesity.1 Children and adolescents who are depressed, anxious, or frustrated might overeat as a coping mechanism.1 This sets up a negative cycle because overweight and obesity can contribute to children’s depression and thus exacerbate overeating.1 Finally, prenatal factors and diet during infancy are known to influence overweight and obesity in childhood. For example, women who were undernourished during pregnancy tend to give birth to infants with low-for-gestational-age birth weights who are at higher risk for becoming obese later in life.22 Conversely, high birth weight also is associated with risk for obesity.22 Breastfeeding during the first year of life is associated with a lower risk of obesity later, possibly because of slower growth rates in the first weeks of life among breastfed infants compared with formula-fed infants.22,29 Positive Trends in Adolescent Behavior Although there are many possible factors contributing to overweight and obesity in children and adolescents, there also has been some progress among American adolescents in terms of activity levels and healthier diets, according to a study of 11- to 16-yearolds across the United States.30 Iannotti and Wang studied nationally representative samples of students in 6th to 10th grades during RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 3 time periods: 2001 to 2002, 2005 to 2006, and 2009 to 2010. 30 Participants were surveyed about their physical activity levels, sedentary behaviors, and diet. The researchers found improvements among all racial and ethnic groups. Specifically, the number of students who ate fruits and vegetables daily improved, as did the number of days on which participants were physically active for at least 60 minutes. In addition, television viewing and consumption of sweets decreased, and more students reported eating breakfast regularly.30 Another positive finding was no significant change in participants’ average BMI from the 2005-2006 survey to the 2009-2010 survey.30 Based on these findings, Iannotti and Wang suggested that public health efforts aimed at reducing obesity might be beginning to pay off. However, they cautioned that there still is room for improvement in adolescents’ obesogenic (obesity-promoting) behaviors.30 Most of the adolescents surveyed were not physically active for the recommended 60 minutes per day and did not consume the recommended 5 or more servings of fruits and vegetables daily. In addition, most of the participants indicated that they watched television or engaged in another sedentary behavior, such as video gaming, for 2 or more hours daily.30 Health Problems Associated With Obesity Obesity in childhood or adolescence is strongly associated with adult obesity: One-third of obese preschoolaged children, one-half of obese school-aged children, and 80% of obese adolescents become obese adults.1 Of further concern is that obese adults who were obese as children experience more rapid and serious obesityrelated complications than do people who were normal weight during childhood but become obese as adults.1 Numerous studies have confirmed that being obese or overweight as a child or adolescent is associated with risk of chronic disease in adulthood, especially cardiometabolic dysfunction. This includes type 2 diabetes, hypertension, and coronary heart disease.19 However, weight loss in adulthood has many positive effects and appears to mitigate these risks.19 In addition to suffering from obesity-related health problems when they reach adulthood, obese children and 285 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications Box 2 Possible Complications of Obesity in Children 1,2,10,15,20,22,31-34 and Adolescents Accelerated puberty Asthma Blount disease Cardiovascular disease, including atherosclerosis Continuing obesity into adulthood Depression and anxiety Dyslipidemia Eating disorders such as binging and purging Gastroesophageal reflux disease Hypertension Insulin resistance/type 2 diabetes mellitus Low self-esteem Metabolic syndrome Nonalcoholic fatty liver disease Obstructive sleep apnea syndrome and other breathing problems Osteoarthritis Polycystic ovary syndrome Slipped capital femoral epiphysis Some types of cancer Reduced quality of life adolescents also are at risk for obesity-related conditions before they become adults (see Box 2 and Figure 3). Maggio and colleagues attempted to quantify certain obesity complications in a cohort of 774 patients aged 1.7 to 17.9 years who attended a pediatric obesity care center in Switzerland.21 The patients were classified as overweight, obese, or extremely obese based on their BMIs and World Health Organization categories.21 Maggio et al found that 23% of the study participants had systolic or diastolic hypertension, with the heaviest patients at highest risk. Also, 40% of participants had dyslipidemia (abnormal concentrations of lipids in the blood), and 27% had increased liver enzymes suggestive of fatty liver disease.21 More than half (54%) had orthopedic abnormalities associated with obesity, and 79.4% complained of qualityof-life issues related to their weight such as bullying and shortness of breath.21 Cardiovascular Disease Obesity is a major modifiable risk factor for cardiovascular disease, along with hyperlipidemia, 286 hypertension, hyperglycemia, and smoking.9 The link between obesity and cardiovascular disease, especially accelerated atherosclerosis, is particularly strong.9,35 A primary goal of identifying and treating obese children and adolescents is to prevent future cardiovascular disease or to stop it early in its course.9 Signs of cardiovascular disease are evident even in young people, and particularly in obese young people. For example, the Pathologic Determinants of Atherosclerosis in Youth study examined a large cohort of adolescents and young adults aged 15 to 34 years who died of trauma. 36 Postmortem examinations of the study subjects focused on their coronary arteries and aortas. The subjects’ cardiovascular risk factors were recorded as well. In this study, obesity in male subjects was associated with raised lesions and fatty streaks in the right coronary artery as well as microscopic atherosclerosis and stenosis in the left anterior descending artery.9,36 One author concluded that the evidence “suggests that the process of accelerated atherosclerosis begins in adolescence, and that risk factors present in youth predict adult cardiovascular disease.”9 In particular, the effect of BMI on lesions in the right coronary artery was more pronounced in young men and adolescent boys with a central or visceral pattern of adiposity, as opposed to peripheral adiposity.36 Interestingly, no association between BMI in the female study subjects and atherosclerosis was reported,9 although a weak association was seen between BMI and fatty streaks in the arteries of women with centralpattern adiposity. 36 Another study, the Muscatine study, used electron beam CT to evaluate coronary artery calcification in children and young adults with risk factors for coronary artery disease. This study demonstrated a strong association between high BMI and calcification of the coronary arteries, particularly in young men.9 In addition, the Bogalusa Heart Study, a long-term study that has tracked a group of Louisiana children into adulthood, showed a strong relationship between BMI in youths and increased carotid intima-media thickness in adulthood.9 Carotid intima-media thickness is assessed using ultrasonography, which measures the thickness of the inner 2 layers of the carotid RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy Complications of Childhood Obesity CNS/psychosocial Pseudotumor cerebri Decreased quality of life Cardiovascular Elevated blood pressure Dyslipidemia Atherosclerosis Chronic inflammation Coagulopathy Pulmonary Obstructive sleep apnea Asthma Exercise intolerance Renal Hyperfiltration Glomerulopathy Endocrine Insulin resistance PCOS Pubertal advancement GI/nutrition Fatty liver disease Gastroesophageal reflux Cholelithiasis Iron deficiency Vitamin D deficiency Orthopedic Lower limb malalignment SCFE Osteoarthritis Figure 3. Complications associated with childhood obesity. Image obtained by dual-energy x-ray absorptiometry of an adolescent girl with a BMI of 38 kg/m2 . Reprinted with permission from Han JC, Lawlor DA, Kimm SYS. Childhood obesity. Lancet. 2010;375(9727):1737-1748. doi:10.1016/S0140-6736(10) 60171-7. Abbreviations: CNS, central nervous system, GI, gastrointestinal; PCOS, polycystic ovary syndrome; SCFE, slipped capital femoral epiphysis. artery. This technique can diagnose atherosclerotic vascular disease before symptoms develop.22 Data from the Bogalusa Heart Study revealed that obesity is “an important, independent cause” of increased left ventricular mass, which can be a precursor for high blood pressure9 as well as a risk factor for cardiovascular-related morbidity and mortality.2 RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 Furthermore, obese children and adolescents have a subclinical, proinflammatory state that can be quantified by measuring levels of C-reactive protein in their blood. 35 Severely obese children (ie, those with a BMI  40) have markedly increased inflammation markers.35 This condition further contributes to atherosclerosis. Metabolic Syndrome Metabolic syndrome in childhood or adolescence is a proven predictor of metabolic syndrome in adults, as well as a predictor of type 2 diabetes mellitus and cardiovascular disease.9 In adults, metabolic syndrome includes a combination of at least 3 of the following conditions9: ■ High waist circumference. ■ High systolic or diastolic blood pressure. ■ Increased blood glucose or triglyceride levels, or both. ■ Low high-density lipoprotein cholesterol. However, there is no consensus about what constitutes metabolic syndrome in children or adolescents, and different definitions have been proposed.9 For example, Choudhary et al defined pediatric metabolic syndrome as “a group of risk factors in one person that includes obesity, insulin resistance, and other metabolic abnormalities.”2 Under this definition, almost 50% of morbidly obese children have metabolic syndrome.2 Morandi and Maffeis, alternatively, suggested a definition of adolescent metabolic syndrome that more closely mirrors the adult definition.37 Type 2 Diabetes Mellitus The association between type 2 diabetes and obesity is well established.22 Previously, the disease was mostly limited to adults and was sometimes known as adult-onset diabetes. However, it is now increasingly diagnosed in children and adolescents, and is especially 287 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications prevalent in obese children and adolescents who are African American, Native American, Hispanic, or Asian/Pacific Islanders.22 A common sign in obese children and adolescents with type 2 diabetes is acanthosis nigricans, an abnormally darkened, thick, and velvety area on the skin, often on the neck, armpit or groin, that might itch or smell bad. Up to 90% of pediatric patients with type 2 diabetes have acanthosis nigricans.22 Other symptoms and signs include abnormal thirst and frequent urination.22 The American Diabetes Association recommends regular screening for type 2 diabetes in overweight and obese children and adolescents if they have 2 of the following risk factors33: ■ A family history of type 2 diabetes. ■ Native American, African American, Hispanic, or Asian/Pacific Islander heritage. ■ Signs of insulin resistance (eg, excessive thirst and frequent urination). Diabetes screening in at-risk overweight and obese children should begin at age 10 years or at puberty, whichever is earlier, and should be repeated every 2 years.33 Onset of type 2 diabetes during childhood or adolescence is particularly concerning because diabetic complications are related to the duration of the disease.38 In addition to cardiovascular disease, complications of type 2 diabetes can include damage to the kidneys, nerves, and eyes, among other conditions.39 Shah and colleagues studied obese adolescents with prediabetes (n  102) and obese adolescents with normal glucose tolerance (n  139) to assess the effects of prediabetes on cardiovascular health. 40 Specifically, they measured carotid intima-media thickness and arterial stiffness. Shah et al found that the obese youths with prediabetes had greater arterial thickness and stiffness than did the nondiabetic obese youths in the control group. The researchers encouraged interventions to prevent diabetes and prediabetes in obese adolescents as a way to reduce arterial disease early in life.40 Liver Disease Nonalcoholic fatty liver disease is the most common type of liver disease in children, as well as one of the more common complications of childhood obesity. 41 The disease is characterized by unusual amounts of fat 288 in the liver and generally is asymptomatic, although some patients have mild upper abdominal discomfort.2,42 Technically, fatty liver disease is defined as fat infiltration in more than 5% of hepatocytes. 41 Autopsy data indicate that the overall prevalence of fatty liver disease is 13% among children in the United States. However, in overweight and obese children and adolescents, the prevalence is as high as 46%.41 Nonalcoholic fatty liver disease sometimes is detected incidentally on abdominal imaging examinations ordered for other indications.2 On sonograms, the disease is characterized by a bright-appearing liver with increased echo texture and blurring of the liver’s vasculature. 42 It is definitively diagnosed with liver biopsy. In some patients, fatty liver disease progresses to cirrhosis and end-stage liver disease, which requires liver transplantation. 41 Besides obesity, insulin resistance is a primary risk factor for fatty liver disease in children and adolescents. Boys are more likely to develop the disease than are girls, by a ratio of 2:1. This difference might be due to estrogen’s protective effects on the liver. 41 In addition, prevalence is highest among Hispanics and lowest among African Americans, with a middle prevalence for whites. Multiple genes are thought to contribute to individual genetic susceptibility to developing fatty liver disease. Dietary risk factors include high consumption of carbohydrates, fructose, sucrose, and omega 6 polyunsaturated fatty acids.41 The current treatment strategy for pediatric nonalcoholic fatty liver disease is increased physical activity and improved diet, leading to gradual weight loss or slower weight gain. For example, decreasing fructose and sucrose consumption by eliminating foods such as soft drinks from the diet is beneficial. 41 However, patient compliance with diet and lifestyle changes often is poor, and other potential treatments are under investigation, including Vitamin E (an antioxidant), metformin (an insulin-sensitizing drug), and probiotics (live microorganisms added to the digestive system).41 Asthma Asthma is one of the most common chronic diseases in children and the leading cause of school absences in the United States.43 Obese children are known to be at RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy higher risk for developing asthma than nonobese children, although the nature of the link between asthma and obesity is not clearly understood. 43,44 One hypothesis is that obesity is a proinflammatory state associated with low-grade inflammation throughout the body, including airway inflammation. However, this might not be the only mechanism involved, and more research is needed to understand the connection between obesity and asthma in children and adolescents, as well as to determine the optimum asthma treatment in this patient population.43,44 Sleep Apnea Obstructive sleep apnea syndrome is marked by repeated partial or complete blockages of the upper airway during sleep.2,45 People with the syndrome might wake up suddenly with a gasping or choking sensation, or they might not experience any symptoms. 45 More than 12 million people in the United States are affected, and half of these are overweight. 45 Excess body fat is thought to cause sleep apnea by decreasing the tone of the airway, which then tends to collapse during sleep, or by reducing the diameter of the airway.2 Because sleep apnea impairs the quality of sleep and interferes with the body’s oxygen supply, it can be associated with neurocognitive deficits.2,45 Treatment for obstructive sleep apnea syndrome varies. Many patients use continuous positive airway pressure equipment, which blows air into the nose or mouth through a mask to keep the airway open during sleep. In overweight and obese individuals, a moderate weight loss (ie, 10% of total body weight) often can improve sleep apnea symptoms. 45 Orthopedic Problems Overweight and obese children and adolescents are more prone to skeletal disorders than are their normalweight peers.2 One of these disorders is slipped capital femoral epiphysis, a painful hip condition in which the head of the femur is displaced posteriorly and inferiorly. Symptoms include hip or knee pain, intermittent limping, and inability to bear weight on the affected leg. 46 When the condition is a result of obesity, it is more likely to be bilateral.2 Slipped capital femoral epiphysis occurs more commonly in boys than in girls RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 and requires surgical fixation with pins or screws. 46 Serious complications such as avascular necrosis can occur. 46 Childhood obesity also is associated with Blount disease, a growth disorder of the tibia caused by excessive force on the growth plate.2,47 Blount disease causes the lower leg to turn inward; treatment might require bracing or surgery. 47 In addition, obese children and adolescents are more likely to suffer fractures despite having greater bone density than normal-weight peers as demonstrated on DXA scans.2 Also, obesity causes osteoarthritis from excess loads on joints, and osteoarthritis has been demonstrated in obese adolescents.2 Idiopathic Intracranial Hypertension Obese people are more likely than those of normal weight to develop idiopathic intracranial hypertension, or high pressure of the cerebrospinal fluid in the brain.2,48 Obese women of childbearing age are particularly at risk, for unknown reasons. 49 This condition also is known as pseudotumor cerebri because increased spinal fluid pressure often accompanies brain tumors. 48 The etiology of idiopathic intracranial hypertension is not well understood.49 Headaches are a common symptom, and the condition can lead to vision problems including blindness. Medication, repeated lumbar punctures, and shunting of excess spinal fluid can reduce pressure; weight loss is an effective treatment in some patients. 48 Polycystic Ovary Syndrome Polycystic ovary syndrome is an endocrine disorder that primarily affects women of childbearing age.50 Signs and symptoms include menstrual irregularities, difficulty getting pregnant, excessive body hair, acne, and cysts in the ovaries.51 Although the syndrome is most commonly diagnosed in women aged 20 to 40 years, adolescent girls also are affected. Polycystic ovary syndrome is associated with excess weight. Half of all patients with the syndrome are either obese or overweight, and girls and women with excess abdominal fat are at higher risk.52 Weight loss is a recommended treatment for these patients, and some are prescribed an insulin-sensitizing agent such as metformin.52 289 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications Cancer In adults, the link between obesity and many types of cancer is well established. These include cancers of the breast, ovary, colon, esophagus, kidney, pancreas, gall bladder, thyroid, and prostate, as well as multiple myeloma and Hodgkin lymphoma.24 The relationship between childhood obesity and cancer is not as well understood.38 However, in obese girls, puberty is believed to occur earlier than in nonobese girls, and early puberty is associated with a higher risk of cancers that are influenced by hormones, such as breast cancer.38 Patients with high BMIs tend to have poorer outcomes when they develop cancer.38 Therefore, the relationship among childhood obesity, cancer prevalence, and cancer survival merits further research.38 Mental Health and Health-related Quality of Life Studies have demonstrated a reduced quality of life among obese adults compared with normal-weight adults, particularly in terms of physical functioning.53 To assess the effects of obesity on children’s and adolescents’ quality of life, Schwimmer and colleagues studied a group of 106 obese children and adolescents, mean BMI 34.7, who had been referred for treatment to an academic children’s hospital.53 For control purposes, they administered the same quality-of-life questionnaire to a group of healthy, normal-weight children and adolescents, as well as to a group of pediatric patients with cancer who were undergoing chemotherapy. The questionnaire assessed 5 quality-of-life domains: psychosocial, physical, emotional, social, and school functioning.53 The severely obese children and adolescents showed significant impairment in total quality-of-life scores and in each of the 5 domains.53 The study subjects were 5.5 times more likely than the healthy subjects to report impaired quality of life, and had a similar likelihood of impairment as the children and adolescents undergoing cancer treatment. In addition, they experienced impaired quality of life even when they did not have comorbidities associated with obesity.53 These results are concerning because previous studies have shown that pediatric cancer patients have lower quality-of-life scores than do children and adolescents with serious medical conditions such as congenital heart disease, type 1 diabetes, and juvenile rheumatoid 290 arthritis. 53 Therefore, Schwimmer et al concluded, parents, teachers, and physicians should be alert to the likelihood and possible severity of impaired quality of life in severely obese children and adolescents.53 Similar to Schwimmer et al, Walders-Abramson and her colleagues concluded that the degree of obesity is more relevant to adolescents’ level of psychological distress than the presence or absence of obesity-related comorbidities. 54 Walders-Abramson et al assessed comorbidities and psychological distress in a group of 166 obese adolescents aged 11 to 18 years. Based on their findings, the researchers suggested that clinicians might have more success motivating obese adolescent patients to change their dietary and physical activity habits by focusing more on the emotional difficulties associated with obesity, rather than on the potential for medical complications. 54 Depression and anxiety also are known to affect obese children and adolescents disproportionately compared with their normal-weight peers.34 To assess the prevalence of depression and anxiety among obese adolescents, Herget and colleagues conducted a systematic review of the literature on adolescent patients’ psychological health before and after bariatric surgery. 34 They found that about one-third of obese adolescents were moderately to severely depressed presurgery and onequarter had symptoms of an anxiety disorder.34 After surgery, patients’ depression improved.34 Imaging Obese Children and Adolescents Imaging obese children and adolescents poses special challenges. Obese patients might have difficulty with standard positioning for some examinations because of their size,2 they might need extra assistance transferring to the examination table, or they might be too large or heavy for some imaging equipment.2,6 Transporting obese adolescents to the imaging department might require special stretchers or wheelchairs designed specifically for obese patients. 6 Also of concern is the higher doses of radiation necessary to penetrate larger amounts of soft tissue and produce diagnostic-quality images.2 Radiologic technologists should know the apertures and weight limits for the equipment in their department RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy and should ensure that a patient’s body weight and diameter do not exceed equipment limitations before beginning an examination. 6 Attempting to image a patient whose weight exceeds the limit can damage the table, its motor, or both. 6 Fluoroscopy equipment typically has the lowest weight limit (350 lb) and the smallest equipment aperture (45 cm); CT and MR scanners might have larger apertures and accommodate heavier patients. 6 For example, vertical-field open MR equipment typically can image patients weighing up to 550 lb. 6 When performing radiographic examinations, technologists should use multiple, overlapping image receptors if a single one does not cover the patient’s body surface. 6 Also, because the x-ray beam might not adequately penetrate an obese body, increasing the kilovotage peak (kVp) and milliampere seconds (mAs) might be necessary. For example, Uppot suggested increasing kVp to 100 and mAs to 4 for a chest radiograph of an obese adult, compared with typical settings of 90 kVp to 95 kVp and 2 mAs to 2.5 mAs for normal-weight adult patients. 6 Use of a grid also is recommended. 6 Ultrasonographic imaging also is affected by obesity. The ultrasound beam has poor penetration beyond its focal depth, and beam attenuation increases as the beam passes through body fat. 6 Using a low-frequency transducer, such as 2 MHz, can improve image quality in obese patients. When possible, a sonographer should review an obese patient’s previous imaging examinations to determine the thickness of subcutaneous fat. This can help ensure that the area of interest is within the transducer’s focal length range. 6 With CT imaging, inadequate beam penetration can increase image noise. Increasing the kVp to 140 as well as increasing the effective mAs can reduce noise. This can be accomplished, for example, by slowing the gantry rotation speed to one rotation per second instead of one rotation per half-second. 6 However, because this tactic increases patient radiation dose, the decision to use the higher dose must be weighed against the improved image quality. Another possible limitation of CT imaging of obese adolescent patients is that beamhardening artifacts can occur when the patient’s body is larger than the field of view. 6 To minimize this problem, the patient should be positioned so that the area of RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 interest lies within the field of view. 6 Although it is possible to crop subcutaneous fat from CT images to focus on internal organs, this is not recommended; cropping subcutaneous tissue can interfere with diagnoses such as certain malignancies. 6 When performing MR examinations, radiologic technologists should use the smallest field of view appropriate for the area of interest because larger fields of view are associated with lower image resolution. 6 Technologists also can improve MR image quality for obese patients by using a body coil instead of a phasedarray multicoil. 6 Another helpful technique is using saturation bands to reduce noise from subcutaneous fat. 6 Some imaging facilities provide padding where an obese patient’s body contacts the bore to prevent possible skin burns. 6 Preventing Obesity in Children and Adolescents Parents, schools, health care providers, and communities can help prevent overweight and obesity in children and adolescents, although there are inherent challenges. For example, in 2003, Arkansas mandated annual BMI assessment for public school students, with reporting of results to parents. However, it is not yet clear whether this type of public health program is effective for preventing or reducing obesity.20 Well-child checkups are another opportunity for intervention and prevention. The American Academy of Pediatrics recommends annual evaluation of children’s weight using BMI, as well as discussion about diet and exercise habits for early intervention if a weight problem begins to develop.33 The 3 periods during childhood that are particularly associated with changes in the rate of adipose tissue gain are the first year of life, ages 3 to 7 years, and menarche in girls.20 These periods might represent the best windows of opportunity for intervention.20 In addition, an expert committee of clinicians and scientists convened by the American Academy of Pediatrics made the following recommendations to help parents and families prevent overweight and obesity in children and adolescents55: ■ Limit screen time to 2 hours per day. ■ Engage in one hour of moderate to vigorous physical activity every day. 291 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications ■ Limit the number of sugar-sweetened beverages and energy-dense foods in the diet. ■ Eat breakfast every day. ■ Limit restaurant meals, particularly fast-food meals. ■ Eat meals together as a family. ■ Eat appropriate portion sizes. ■ Include the recommended amounts of calcium and fiber in the diet. ■ Balance the amounts of protein, carbohydrates, and fats in the diet. ■ Encourage fruit and vegetable consumption in line with U.S. Department of Agriculture recommendations. Visit to see the Eat Smart To Play Hard poster designed for children. Furthermore, a meta-analysis by the Cochrane Collaboration suggested that schools have an important role to play in preventing obesity.56 The analysis included 37 studies of obesity prevention programs involving 27 946 children, mostly aged 6 to 12 years. The researchers concluded that some of the more helpful preventive strategies were56: ■ Including healthy eating, physical activity, and body image education in the school curriculum. ■ Increasing the amount of physical activity during the school day. ■ Serving healthier food in schools. For more on the federal government’s recent efforts to improve the nutritional quality of meals served in schools, see Box 3. One of the main challenges for children in learning to eat healthfully is the marketing of low-nutritional-value foods to children and adolescents, which includes not only television advertisements, billboards, and product placements in games, toys, movies, and music, but also Internet ads and mobile phone text messages.25 Half of the foods marketed to children are candy, gum, or similar items; one-quarter are other sugary or salty snack foods; and one-quarter are healthier foods such as bottled water.25 In addition, fast-food restaurant ads are ubiquitous in children’s television programming and on Web sites aimed at children.25 A meta-analysis of 123 studies suggested a 292 Box 3 School Lunch and the Healthy Hunger 57-60 Free Kids Act The Healthy Hunger Free Kids Act of 2010 was designed to ensure access to healthy foods for children in low-income families. One of its objectives is to improve the nutritional quality of meals served in schools, including preschools.57 As a result of the act, nutrition standards for school meals were updated to require more whole grains, fruits, vegetables, lean protein, and low-fat dairy foods. The new standards also call for less sugar, fat, and sodium.58 The U.S. Department of Agriculture reported that more than 90% of schools are now in compliance with the new standards, and that the healthier meals have been well received in many schools.58 However, the changes also have generated controversy.59,60 Some school officials reported that students don’t like some of the new foods introduced to meet the updated standards, and that food waste and costs have both gone up.59 Unwanted fruits and vegetables, in particular, tend to end up in trash cans.59 In addition, some students have complained that the new lunches have left them feeling hungry. 60 likely link among food marketing to children, children’s food choices, and overweight and obesity among children.25 Moreover, the harmful effects of advertising food to children are more pronounced among children who are already overweight or obese and in younger children.25 Another difficulty is that programs intended to teach children and families about healthy eating might not have long-term effects.25 For example, a randomized controlled trial examined the effectiveness of a 5-session pilot program for parents and their children. The program, intended to prevent overweight and obesity in the children, included sessions on nutrition, cooking skills, taste testing, meal preparation, and parent discussion groups. Although the program’s participants showed improvements in terms of choosing healthier foods compared with the control group, the improvements were not maintained 6 months later.25 Treatment Treating overweight and obesity in children and adolescents is problematic for several reasons. Many pediatricians do not suggest treatment unless an obese RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy child or adolescent has already developed comorbidities. 53 Also, some pediatricians do not have sufficient time or training to provide effective, comprehensive treatment to their obese patients.28 Most treatment interventions have not shown long-term effectiveness.2,25 In particular, studies have demonstrated that interventions that do not include the patient’s parents or guardians and other family members are less likely to be effective.17,25 Involving parents in treatment can be challenging. Many parents do not realize that their child is overweight or obese and are not aware of the health effects of obesity in children and adolescents.10 One study suggested that up to 30% of parents believe their children are not eating enough even though the children are of normal weight and eating appropriate amounts of food.25 In addition to being slow to recognize a weight problem in their children, many parents fail to take action. Thirty percent to 50% of parents of overweight or obese children do not try to reduce their children’s weight or slow weight gain.25 A possible reason for this is the common but mistaken belief that overweight and obese children eventually “grow into” their weight. 38 However, BMI has been shown to track over time, with a majority of overweight children in one longitudinal study becoming obese 25 years later.38 One expert recommended that health care professionals discuss pediatric obesity with parents in an empathetic and nonjudgmental manner.10 For example, health care providers might take a step-by-step approach to the conversation, asking parents first whether they consider their child’s weight a problem, then whether they want to do something about their child’s weight, and finally what steps they would be willing to take.10 Treatment should begin only when the patient’s parents and caregivers are ready to commit to lifestyle changes, which should involve the whole family.10 All children and adolescents classified as obese should receive treatment, and overweight children and adolescents who have weight-related comorbidities should be considered for treatment.20 Weight loss is not necessarily the goal for all obese or overweight children and adolescents; rather, the goal might be maintaining weight while the patient continues to grow in height so BMI decreases over time.10 Modest, gradual weight RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 loss, such as 1 lb to 2 lb per month, might be advised for some older adolescents.10 An expert committee convened by the American Academy of Pediatrics endorsed a staged approach to obesity treatment.28,55 The committee outlined 4 stages, with increasing intensity. For many patients, starting with the least-intensive stage is appropriate, then switching to a more-intensive stage if needed and if patient and family motivation allow. Other patients might begin at a higher treatment stage. The stages are as follows55: ■ Prevention Plus – Focuses on healthy eating and activity habits, with increased physician monitoring. ■ Structured Weight Management – Provides more support and structure than Prevention Plus, including a diet or daily eating plan developed by a dietician, as well as planned, supervised physical activity. This stage might include monthly office visits with a pediatrician and family counseling sessions, if needed. ■ Comprehensive Multidisciplinary Intervention – Involves a team of specialists, more frequent office visits, and more intense behavioral changes. For example, a behavioral counselor, dietician, exercise specialist, and pediatrician might collaborate to support the patient and his or her family. Weekly office visits might be planned for 2 to 3 months, followed by monthly visits. ■ Tertiary Intervention – Reserved for severely obese pediatric patients who already have attempted weight control with a comprehensive multidisciplinary intervention. Medication, meal replacements or a very-low-calorie diet, and surgery might be included at this stage. The American Academy of Pediatrics recommends weight-reducing diets that provide fewer calories than are needed to maintain weight, but in no case less than 1200 calories per day.20,28 Another approach is to consume 300 to 400 fewer calories than needed for weight maintenance.20 Long-term studies show no differences in the effectiveness of various diets based on their macronutrient content.20 Low-carbohydrate, high-protein diets, for example, have not been well studied in children. However, one study demonstrated that this approach can be as effective as a conventional 293 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications portion-controlled diet, although adherence rates were lower with the low-carbohydrate diet. 33 One popular program for improving children’s diets and controlling weight is the “traffic light” approach developed by Leonard Epstein, PhD.20 In this system, foods are classified as red, yellow, or green. Red foods are high in calories and sugar or fat and should be considered occasional treats. Children are taught to stop and think before consuming these foods and might be instructed to consume them only a few times a week.28 Yellow foods include lean meats and whole-grain foods that are moderately high in calories. Although these foods make up an important part of a healthy diet, children should slow down with yellow foods and think about appropriate portion sizes. Green foods include fruits, vegetables, water, and nonfat milk. Children should be encouraged to eat as much of these as they like, ideally at least one serving of fruit, one serving of vegetables, and water or nonfat milk at each meal. 61 The goal of the traffic light system is to provide maximum nutrition with minimal energy intake.28 In studies involving children on the traffic light diet, caloric intake ranged from 900 to 1500 calories per day, and participants demonstrated modest, sustained decreases in BMI even 5 and 10 years after the intervention.28,33 One possible limitation of the traffic light approach is that it has been studied primarily with white, middleclass children aged 6 to 12 years28 and might not be as effective in adolescents or children of other races, ethnic groups, or socioeconomic statuses. One strategy shown to be ineffective is parental control or restriction of children’s and adolescents’ food intake.25 This approach increases the risk of overweight and obesity later in life, possibly because it interferes with children’s sense of satiety and their ability to regulate their own eating. Children who are subjected to dietary control by their parents might be more likely to snack, to choose less healthy foods, and to eat when they are not hungry.25 Rather than controlling or restricting what their children eat, parents should instead focus on the following25: ■ Eat family meals together. ■ Stock plenty of fruits and vegetables at home. ■ Encourage children to drink more water. ■ Help children and adolescents form a self-identity 294 that includes their accomplishments and personal characteristics other than physical appearance. ■ Provide a safe haven at home from weight-related teasing at school or in other settings. Interventions that increase physical activity have had mixed results in terms of decreasing BMI.25 Studies have shown that increasing activity decreases BMI in both children and adolescents.28 For example, one randomized controlled trial examined results of a 2-month program in which children and their parents participated in a weekly physical activity that lasted 2 hours and was designed to be fun.25 Children who participated in the program showed improvement in their BMI, waist circumference measurement, body composition, cardiovascular fitness, and other measurements compared with the control group.25 Conversely, another randomized controlled trial of a physical activity program for preschool-aged children failed to show improvement in BMI at 6-month and one-year follow-up.25 Generally, a nonpharmaceutical approach is preferred for treating obesity in children and adolescents, but in some cases medication can be helpful. Antiobesity medications suppress the appetite, impair absorption, or raise energy expenditure. 5,33 Orlistat, for example, is a lipase inhibitor that prevents absorption of fat.20,33 Currently, orlistat is the only drug approved by the U.S. Food and Drug Administration for weight loss in children 12 years and older.33 Although it has been shown to be slightly effective when used in combination with lifestyle changes, orlistat also is associated with adverse effects that include abdominal pain, fecal incontinence, and cholelithiasis (gallstones).20 In a randomized controlled trial comparing orlistat with a placebo in a group of adolescent patients, the patients taking orlistat decreased their BMIs by an average of 0.55 compared with a BMI reduction of 0.31 in patients assigned to take a placebo.33 However, the patients taking orlistat were more likely to report gastrointestinal symptoms (up to 50% of patients) than were the patients taking a placebo (up to 13%).33 Consequently, drug treatment typically is recommended for adolescent patients only when obesity is severe and comorbidities have been diagnosed.10 Weight-loss surgery is the only treatment for obesity that has proven, long-term effectiveness, 62 and it is being RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy performed more commonly on obese adolescents.2 Specifically, bariatric surgery might be considered for patients with severe obesity and comorbidities who have completed puberty. For instance, Han suggested that only patients with a BMI of 50 or greater, or 40 or greater with significant comorbidities, should be considered for bariatric surgery and then only with caution.20 Because the long-term adverse effects in adolescents have not been well studied, these patients should have long-term follow-up care.10 There are 2 types of bariatric surgery: procedures that restrict the stomach’s capacity, such as gastric banding, and procedures that interfere with absorption, such as gastric bypass.20,34 Both are associated with potentially serious complications including nutritional deficiencies.20,28 However, bariatric surgery can improve quality of life for some obese adolescents and resolve obesity-related comorbidities in many patients.2,34 For example, Nadler and colleagues evaluated a group of 50 obese adolescents, aged 14 to 18 years, who underwent gastric banding surgery with the Lap-Band device (Inamed Corporation). 62 All of the patients had BMIs greater than 40 (mean weight 299 lb) and unsuccessful attempts to lose weight with medical supervision. The patients were evaluated before surgery and at follow-up for a number of comorbid conditions associated with obesity, including dyslipidemia, back pain, hypertension, and depression. Patients also were evaluated presurgery and postsurgery for impaired glucose tolerance, dyspnea, osteoarthritis, obstructive sleep apnea, asthma, and gastroesophageal reflux. 62 Among patients who completed follow-up at one year, the mean weight was 227 lb and the average percentage of excess weight lost was 46%. 62 More fat mass than lean mass was lost, although the patients also lost a significant amount of lean mass. In addition, 55% of the patients’ comorbid conditions resolved completely after surgery, and 29% of the comorbidities improved compared with presurgical assessments. Among patients with dyslipidemia, however, some showed improvement but others worsened or had no change. 62 No complications occurred during the surgeries, although 2 patients subsequently dropped out of the study because of adverse events including gastric perforation. Nonetheless, the authors concluded that the surgery is RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 “an excellent option” for weight loss in certain extremely obese adolescents. 62 Public Policy Recommendations Battling the obesity epidemic might require more than individual, family, school, and community efforts. Changes in public policy also might be necessary.20 An HBO documentary series on obesity in America, for example, discussed the need for changes in the way government supports the farming industry, such as reducing subsidies that keep the cost of fast food artificially low and increasing support for small and medium-sized farms that produce fruits and vegetables. 63 Another policy recommendation is restricting advertising for less-healthy foods and beverages while increasing public funding for efforts aimed at improving eating habits and physical activity levels. 63 In addition, some public health experts have called for mandatory physical education for students of all ages and health insurance premium structures that include incentives for maintaining a healthy weight.2 Changing the patterns that contribute to overweight and obesity is an enormous, long-term societal challenge. But as one obesity expert suggested, it seems less daunting when considered in light of similar public health challenges already being confronted successfully.2 For example, seat belt laws have reduced traffic fatalities and injuries, antismoking campaigns are helping to prevent lung cancer, and education about safer sex and sexually transmitted disease screening has slowed the spread of AIDS.2 The same resources and commitment can help reverse the pandemic of childhood obesity. Conclusion Obesity among children and adolescents is an international problem, and is particularly severe in the United States. Obese and overweight children and adolescents suffer from an array of weight-related problems, including psychological and quality-of-life concerns as well as cardiovascular, metabolic, orthopedic, and other complications. Recent evidence suggests that the prevalence of childhood obesity in the United States might be leveling, although it remains high in some ethnic and racial groups and in some areas of the country. Obesity can create special imaging challenges and might require 295 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications a customized approach, so radiologic technologists and radiologist assistants need to be knowledgeable about caring for this patient population. Experts recommend that obesity treatment for children and adolescents follow a staged approach, beginning with lifestyle changes and progressing to medication or surgery only under certain circumstances. Preventing and reducing obesity among young people requires the united efforts of parents, schools, health care professionals, communities, and public policy makers. Kathryn Faguy, MA, ELS, is a freelance medical writer and editor. She has been certified by the Board of Editors in the Life Sciences since 1999 and is a past winner of the American Medical Writers Association Eric W Martin Award for outstanding article written for a professional audience. Reprint requests may be mailed to the American Society of Radiologic Technologists, Communications Department, at 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mailed to © 2016 American Society of Radiologic Technologists References 1. Hoey H. Management of obesity in children differs from that of adults. Proc Nutr Soc. 2014;73(4):519-525. doi:10.1017 /S0029665114000652. 2. Choudhary AK, Donnelly LF, Racadio JM, Strife JL. Diseases associated with childhood obesity. AJR Am J Roentgenol. 2007;188(4):1118-1130. doi:10.2214/AJR.06.0651. 3. Skinner AC, Skelton JA. Prevalence and trends in obesity and severe obesity among children in the United States, 19992012. JAMA Pediatrics. 2014;168(6):561-566. doi:10.1001 /jamapediatrics.2014.21. 4. About adult BMI. Centers for Disease Control and Prevention Web site. /assessing/bmi/adult_bmi/index.html?s_cid=tw_ob064. Reviewed and updated July 11, 2014. Accessed September 9, 2014. 5. Hamdy O. Obesity. MedScape Web site. http://emedicine Updated June 9, 2014. Accessed September 10, 2014. 6. Uppot RN, Sahani DV, Hahn PF, Gervais D, Mueller PR. Impact of obesity on medical imaging and image-guided intervention. AJR Am J Roentgenol. 2007;188(2):433-440. doi:10.2214/AJR06.0409. 296 7. Centers for Disease Control and Prevention. Healthy weight, overweight, and obesity among U.S. adults. http://www.cdc .gov/nchs/data/nhanes/databriefs/adultweight.pdf. Accessed September 17, 2014. 8. U.S. Department of Health and Human Services, National Institute of Diabetes and Digestive and Kidney Diseases. Overweight and obesity statistics. /publications/PDFs/stat904z.pdf. Updated October 2012. Accessed October 11, 2014. 9. Balakrishnan PL. Identification of obesity and cardiovascular risk factors in childhood and adolescence. Pediatr Clin N Am. 2014;61(1):153-171. doi:10.1016/j.pcl.2013.09.013. 10. Stewart L. Childhood obesity. Medicine. 2010;39(1):42-44. 11. Dehghan M, Merchant AT. Is bioelectrical impedance accurate for use in large epidemiological studies? Nutrition J. 2008;7:26. doi:10.1186/1475-2891-7-26. 12. Breithaupt P, Colley RC, Adamo KB. Body composition measured by dual-energy X-ray absorptiometry: half-body scans in obese children. Acta Paediatra. 2011;100(12):e260-e266. doi:10.1111/j.1651-2227.2011.02378.x. 13. Siegel MJ, Hildebolt CF, Bae KT, Hong C, White NH. Total and intraabdominal fat distribution in preadolescents and adolescents: measurement with MR imaging. Radiology. 2007;242(3):846-856. 14. Ogata BN, Hayes D. Position of the Academy of Nutrition and Dietetics: nutrition guidance for healthy children ages 2 to 11 years. J Acad Nutr Diet. 2014;114(8):1257-1276. doi:10.1016/j.jand.2014.06.001. 15. Pratt CA, Boyington J, Esposito L, et al. Childhood obesity prevention and treatment research (COPTR): interventions addressing multiple influences in childhood and adolescent obesity. Contemp Clin Trials. 2013;36(2):406-413. doi:10.1016/j.cct.2013.08.010. 16. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732. 17. Davison KK, Jurkowski JM, Li K, Kranz S, Lawson HA. A childhood obesity intervention developed by families for families: results from a pilot study. Int J Behav Nutr Phys Act. 2013;10:3. doi:10.1186/1479-5868-10-3. 18. Singh GK, Kogan MD, van Dyck PC. Changes in statespecific childhood obesity and overweight prevalence in the United States from 2003 to 2007. Arch Pediatr Adolesc Med. 2010;164(7):598-607. doi:10.1001/archpediatrics.2010.84. 19. McMullen S. Childhood obesity: the impact on long-term risk of metabolic and CVD is not necessarily inevitable. Proc Nutr Soc. 2014;73(3):389-396. doi:10.1017/S0029665 114000111. RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 CE Directed Reading Faguy 20. Han JC, Lawlor DA, Kimm SYS. Childhood obesity. Lancet. 2010;375(9727):1737-1748. doi:10.1016/S0140-6736 (10)60171-7. 21. Maggio ABR, Martin XE, Gasser CS, et al. Medical and nonmedical complications among children and adolescents with excessive body weight. BMC Pediatrics. 2014;14:232. 22. Herouvi D, Karanasios E, Karayianni C, Karavanaki K. Cardiovascular disease in childhood: the role of obesity. Eur J Pediatr. 2013;172(6):721-732. doi:10.1007/s00431-013 -1932-8. 23. Liska D, Dufour S, Zern TL, et al. Interethnic differences in muscle, liver and abdominal fat partitioning in obese adolescents. PLoS ONE. 2007;2(6):e569. doi:10.1371/journal .pone.0000569. 24. Childhood obesity facts. Centers for Disease Control and Prevention Web site. /obesity/facts.htm. Reviewed and updated August 13, 2014. Accessed September 19, 2014. 25. Stein D, Weinberger-Litman SL, Latzer Y. Psychosocial perspectives and the issue of prevention in childhood obesity. Front Public Health. 2014;2:104. doi:10.3389/fpubh.2014 .00104. 26. Slyper AH. New directions in the prevention of pediatric atherogenesis and obesity. J Am Coll Nutr. 2013;32(5):355-358. doi:10.1080/07315724.2013.826107. 27. Weinstein M. Who, what, where. In: The Surprising Power of Family Meals: How Eating Together Makes Us Smarter, Stronger, Healthier, and Happier. Hanover, New Hampshire: Steerforth Press; 2005:60-117. 28. Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120 Suppl 4:S254-S288. doi:10.1542 /pdes.2007-2329F. 29. Guardamagna O, Abello F, Cagliero P, Lughetti L. Impact of nutrition since early life on cardiovascular prevention. Ital J Pediatr. 2012;38:73. doi:10.1186/1824-7288-38-73. 30. Iannotti RJ, Wang J. Trends in physical activity, sedentary behavior, diet, and BMI among U.S. adolescents, 2001-2009. Pediatrics. 2013;132(4):606-614. doi:10.1542/peds.2013 -1488. 31. Schwarz SM. Obesity in children. Medscape Web site. http:// Updated December 4, 2013. Accessed September 10, 2014. 32. Diseases and conditions: childhood obesity. Mayo Clinic Web site. /childhood-obesity/basics/complications/con-20027428. Published February 15, 2014. Accessed September 11, 2014. 33. Feldstein AE, Patton-Ku D, Boutelle KN. Obesity, nutrition, and liver disease in children. Clin Liver Dis. 2014;18(1):219231. doi:10.1016/j.cld.2013.09.003. RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 34. Herget S, Rudolph A, Hilbert A, Blüher S. Psychosocial status and mental health in adolescents before and after bariatric surgery: a systematic literature review. Obes Facts. 2014;7(4):233-245. doi:10.1159/0000365793. 35. Kapiotis S, Holzer G, Schaller G, et al. A proinflammatory state is detectable in obese children and is accompanied by functional and morphological vascular changes. Arterioscler Thromb Vasc Biol. 2006;26(11):2541-2546. doi:10.1161/01 .ATV.0000245795.08139.70. 36. McGill HC, McMahan CA, Herderick EE, et al. Obesity accelerates the progression of coronary atherosclerosis in young men. Circulation. 2002;105(23):2712-2718. doi:10.1161/01.CIR.0000018121.67607.CE. 37. Morandi A, Maffeis C. Predictors of metabolic risk in childhood obesity. Horm Res Paediatr. 2014;82(1):3-11. doi:10.1159/000362237. 38. Kelsey MM, Zaepfel A, Bjornstad P, Nadeau KJ. Agerelated consequences of childhood obesity. Gerontology. 2014;60(3):222-228. doi:10.1159/000356023. 39. Type 2 diabetes: complications. Mayo Clinic Web site. http:// /basics/complications/con-20031902. Updated July 24, 2014. Accessed September 24, 2014. 40. Shah AS, Gao Z, Urbina EM, Kimball TR, Dolan LM. Prediabetes: the effects on arterial thickness and stiffness in youth. J Clin Endocrinol Metab. 2014;99(3):1037-1043. doi:10.1210/jc.2013-3519. 41. Marzuillo P, del Guidice EM, Santoro N. Pediatric nonalcoholic fatty liver disease: new insights and future directions. World J Hepatol. 2014;6(4):217-225. doi:10.4254/wjh .v6.i4.217. 42. Tolman KG, Dalpiaz AS. Treatment of non-alcoholic liver disease. Ther Clin Risk Manag. 2007;3(6):1153-1163. 43. Permaul P, Kanchongkittiphon W, Phipatanakul W. Childhood asthma and obesity–what is the true link? Ann Allergy Asthma Immunol. 2014;113(3):244-246. doi:10.1016/j .anai.2014.07.001. 44. Ding G, Ji R, Bao Y. Risk and protective factors for the development of childhood asthma [published online ahead of print August 1, 2014]. Paediatr Respir Rev. 2015;16(2):133-139. doi:10.1016/j.prrv.2014.07.004. 45. Understanding obstructive sleep apnea. WebMD Web site. ing-obstructive-sleep-apnea-syndrome. Reviewed October 6, 2012. Accessed September 24, 2014. 46. Slipped capital femoral epiphysis. American Academy of Orthopaedic Surgeons. OrthoInfo Web site. http://orthoinfo Reviewed August 2007. Accessed September 24, 2014. 297 CE Directed Reading Obesity in Children and Adolescents: Health Effects and Imaging Implications 47. Blount’s disease. Medline Plus Web site. http://www.nlm Updated September 8, 2014. Accessed September 24, 2014. 48. Idiopathic intracranial hypertension (IIH). Johns Hopkins Medicine Web site. /neurology_neurosurgery/centers_clinics/headache/condi tions/idiopathic_intracranial_hypertension.html. Accessed September 24, 2014. 49. Degnan AJ, Levy LM. Pseudotumor cerebri: brief review of clinical syndrome and imaging findings. AJNR Am J Neuroradiol. 2011;32(11):1986-1993. doi:10.3174/ajnr .A2404. 50. Motta AB. The role of obesity in the development of polycystic ovary syndrome. Curr Pharm Des. 2012;18(17):2482-2491. 51. Polycystic ovary syndrome. Medline Plus Web site. http:// Updated February 24, 2014. Accessed October 8, 2014. 52. Gambineri A, Pelusi C, Vicennati V, Pagotto U, Pasquali R. Obesity and the polycystic ovary syndrome. Int J Obes Relat Metab Disord. 2002;26(7):883-896. 53. Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA. 2003;289(14):1813-1819. 54. Walders-Abramson N, Nadeau KJ, Kelsey MM, et al. Psychological functioning in adolescents with obesity comorbidities. Child Obes. 2013;9(4):319-325. doi:10.1089 /chi.2012.0120. 55. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary. Pediatrics. 2007;120 Suppl 4:S164-S192. doi:10.1542 /peds.2007-2329C. 56. Waters E, de Silva-Sanigorski A, Burford BJ, et al. Interventions for preventing obesity in children (review). Cochrane Database Syst Rev. 2011;7(12):CD001871. doi:10.1002/14651858.CD001871.pub3. 57. Highlights: Healthy, Hunger Free Kids Act of 2010. Food Research and Action Center Web site. /highlights-healthy-hunger-free-kids-act-of-2010/. Accessed October 8, 2014. 58. Fact sheet: Healthy, Hunger-Free Kids Act school meals implementation. U.S. Department of Agriculture Food and Nutrition Service Web site. release/2014/009814. Modified June 13, 2014. Accessed October 9, 2014. 59. Hamburger T. Michelle Obama’s school lunch agenda faces backlash from some school nutrition officials. Washington Post. -obamas-school-lunch-agenda-faces-backlash-from-some -school-nutrition-officials/2014/05/29/6a8e4af6-e744-1 298 1e3-afc6-a1dd9407abcf_story.html. Published May 30, 2014. Accessed October 10, 2014. 60. Confessore N. How school lunch became the latest political battleground. The New York Times Magazine. http://www -lunch-became-the-latest-political-battleground.html?utm _source=nextdraft&utm_medium=email&_r=0. Published October 7, 2014. Accessed October 8, 2014. 61. Runyan T. Why the traffic light food classification system works for kids’ weight management. Web site. -light-food-classification-system-works-for-kids-weight-loss/. Accessed September 12, 2014. 62. Nadler EP, Reddy S, Isenalumhe A, et al. Laparoscopic adjustable gastric banding for morbidly obese adolescents affects android fat, resolution of comorbidities, and improved metabolic status. J Am Coll Surg. 2009;209(5):638-644. doi:10.1016/jamcollsurg.2009.07.022. 63. HBO. The weight of the nation: confronting America’s obesity epidemic. Part 4: challenges [video recording]. http://the Accessed September 27, 2014. RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 Directed Reading Quiz 16801-01 1.5 Category A credits 2.5 MDCB credits Expires Feb. 28, 2018* Obesity in Children and Adolescents: Health Effects and Imaging Implications To earn continuing education credit:  Take this Directed Reading quiz online at  Or, transfer your responses to the answer sheet on Page 304 410M and and mail mail toto ASRT, ASRT, POPO Box Box 51870, 51870, Albuquerque, NM 87181-1870. New and rejoining members are ineligible to take DRs from journal issues published prior to their most recent join date unless they have purchased access to the quiz from the ASRT. To purchase access to other quizzes, go to *Your answer sheet for this Directed Reading must be received in the ASRT office on or before this date. Read the preceding Directed Reading and choose the answer that is most correct based on the article. 1. According to guidelines from the American Academy of Pediatrics, a pediatric patient should be categorized as _______ if his or her body mass index (BMI) is between the 85th and 94th percentiles for children or adolescents of the same sex and age. a. high-normal weight b. at risk for obesity c. overweight d. morbidly obese 2. Which of the following are advantages of wholebody dual-energy x-ray absorptiometry scanning for assessing obesity? 1. low radiation dose 2. can be used to calculate fat, lean, and total tissue mass 3. distinguishes between visceral and subcutaneous fat a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3 3. Recent data suggest that overall obesity rates might have begun leveling among children and adolescents in the United States. a. true b. false 4. According to the 2009-2010 National Health and Nutrition Examination Survey, prevalence of obesity was highest among children and adolescents of which racial or ethnic group? a. non-Hispanic whites b. non-Hispanic blacks c. Hispanics d. Asian/Pacific Islanders 5. African Americans typically have less _______ fat than whites and Hispanics with similar total body fat, although the reasons for this difference are unknown. a. subcutaneous b. peripheral c. visceral d. abdominal continued on next page RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 299 Directed Reading Quiz 6. In most cases, childhood obesity is caused by: a. genetic syndromes. b. endocrine disorders. c. prescription medications. d. caloric imbalance. 7. Which of the following have been identified as possible contributors to overweight and obesity in adolescents? 1. inadequate sleep 2. less-satiating diets 3. eating meals while watching television a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3 8. Which of the following was not one of several positive trends identified by Iannotti and Wang in their surveys of 6th to 10th grade students between 2001 and 2010? a. More students ate fruits and vegetables daily. b. Consumption of sweets decreased. c. More students ate meals with their families. d. Television viewing decreased. 9. According to the study by Maggio and colleagues of overweight, obese, and extremely obese children and adolescents, which of the following was the most common complication, affecting nearly 80% of study participants? a. hypertension b. dyslipidemia c. orthopedic abnormalities d. quality-of-life issues such as bullying 10. All of the following were findings of the Pathological Determinants of Atherosclerosis in Youth study that examined young trauma victims’ coronary arteries and aortas postmortem except: a. Obesity was associated with right coronary artery lesions and fatty streaks in young men. b. Obesity was associated with stenosis in the left anterior descending artery in young men. c. Obesity was not associated with atherosclerosis in young women. d. Arterial lesions were more pronounced in study subjects with peripheral adiposity vs central adiposity. 11. Acanthosis nigricans is: 1. an abnormally darkened, thick area of skin. 2. often located on the neck, armpit, or groin. 3. very common in obese children and adolescents with type 2 diabetes. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3 12. Dietary risk factors for nonalcoholic fatty liver disease include high consumption of all of the following except: a. sucrose. b. carbohydrates. c. saturated fats. d. fructose. 13. A growth disorder of the tibia caused by excessive force on the growth plate is called: a. slipped capital femoral epiphysis. b. Blount disease. c. Osgood-Schlatter disease. d. Paget disease. continued on next page 300 RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 Directed Reading Quiz 14. One study of obese children and adolescents found that they have a similar likelihood of impaired quality of life as children and adolescents with: a. asthma. b. type 1 diabetes mellitus. c. congenital heart disease. d. cancer. 15. Because the x-ray beam might not adequately penetrate an obese body, increasing the kilovoltage peak and milliampere seconds might be necessary to obtain diagnostic-quality images. a. true b. false 16. According to the article, which techniques improve computed tomography (CT) imaging of obese adolescent patients? 1. Slow the gantry rotation speed. 2. Position the patient so that the area of interest lies within the field of view. 3. Crop subcutaneous body fat from the images to focus on internal organs. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3 17. According to the article, which techniques improve magnetic resonance imaging of obese adolescent patients? 1. Use the smallest field of view appropriate for the area of interest. 2. Use a phased-array multicoil instead of a body coil. 3. Use saturation bands to reduce noise from subcutaneous fat. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3 18. Half of the foods marketed to children are: a. fast-food restaurant menu items. b. candy, gum, or similar items. c. soda and other sugary beverages. d. salty snacks such as chips. 19. A randomized, controlled study revealed that one problem with programs intended to prevent obesity by teaching children and families about healthy eating is that: a. parents say they do not have time to participate. b. children have difficulty understanding and remembering the information. c. effects might not be long term. d. the programs are prohibitively expensive to develop and administer. 20. In the staged approach to obesity treatment proposed by an expert committee, which is the initial, least-intensive treatment stage for obesity and overweight in the pediatric population? a. Tertiary Intervention b. Comprehensive Multidisciplinary Intervention c. Structured Weight Management d. Prevention Plus 21. According to the traffic light approach to weight control, which of the following would most likely be considered yellow-light foods? a. candy and soda b. French fries and hamburgers c. whole-wheat bread and tuna fish d. nonfat milk and apples 22. Which parenting practice is not recommended to help children manage their weight? a. parental control of children’s food intake b. regularly eating meals together as a family c. stocking fruits and vegetables in the home d. encouraging children to drink more water continued on next page RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 301 Directed Reading Quiz 23. Orlistat, a weight-loss drug approved for use in adolescents aged 12 years and older, has been shown to be slightly effective when combined with lifestyle changes. However, orlistat also is associated with adverse effects such as: 1. fecal incontinence. 2. abdominal pain. 3. hypoglycemia. a. b. c. d. 1 and 2 1 and 3 2 and 3 1, 2, and 3 24. In Nadler et al’s study of 50 obese adolescents who underwent gastric banding surgery, which comorbidity did not consistently improve postsurgery and worsened in some patients? a. back pain b. depression c. dyslipidemia d. hypertension 25. According to the article, which public policy changes might help reverse trends in childhood obesity? 1. restricting advertising for less-healthy foods 2. increasing government support for farms that produce fruits and vegetables 3. mandating physical education for students at all levels a. b. c. d. 302 1 and 2 1 and 3 2 and 3 1, 2, and 3 RADIOLOGIC TECHNOLOGY, January/February 2016, Volume 87, Number 3 Copyright of Radiologic Technology is the property of American Society of Radiologic Technologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
AMERICAN JOURNAL OF PUBLIC HEALTH EDITOR-IN-CHIEF DEPUTY EDITOR FEATURE EDITOR IMAGE EDITOR ASSOCIATE EDITORS EDITOR’S CHOICE On the Front Lines of Childhood Obesity More than one third of adults in this country are obese, up from about one in ten 50 years ago. The rate for adolescents is even more dramatic, going from one in twenty 30 years ago to a shocking one in six today. Equally alarming, obesity has become a byproduct of social and economic injustice: obesity is more prevalent in poor communities and strikes minorities most. Obesity-related illnesses strain our health care system and harm whole communities. They are, tragically, increasingly a problem of the young, and they are of such concern that First Lady Michelle Obama has adopted childhood obesity as her cause. The evidence is compelling that the obesity epidemic is largely caused by people’s eating unhealthy food, consuming bigger portion sizes, and engaging in less physical activity. These unhealthy behaviors are not just, or even mainly, a matter of poor decisions individuals make; rather, the environment in which people live determines behavioral choice. If fresh vegetables are not available and affordable, people cannot buy them. If playgrounds are unsafe, parents will not let their kids play there. If children are bombarded by ads for fast food, they will fill up on junk. People cannot be expected to exercise choices they do not have. Given this, government- and foundationfunded obesity-prevention programs have focused on improving the environment to encourage healthier eating and more physical activity by, among other means,       encouraging farmers’ markets and inner-city supermarkets, increasing healthy food in corner stores, and making healthy produce easily available in public food programs; requiring wellness policies and banning the sale of unhealthy food and drinks in schools; providing more time for physical education and more active recess periods; making it easier and safer for kids to walk or bicycle to school; banning unhealthy foods such as trans fats; and requiring menu labeling. communities have generated considerable interest. They include the Robert Wood Johnson Foundation’s Healthy Kids, Healthy Communities; the W. K. Kellogg Foundation’s Healthy Eating Active Living; the Centers for Disease Control and Prevention’s Steps to a HealthierUS; and the California Department of Public Health’s CX3 program. The CATCH (Coordinated Approach to Child Health) program in Texas and Shape Up Somerville in Massachusetts have attracted national attention. Three important programs aimed at creating a healthier environment in disadvantaged communities—the California Endowment’s Healthy Eating Active Communities program and Central California Regional Obesity Prevention Program, and Kaiser Permanente’s Community Health Initiative—are highlighted in this issue. The papers do not shy away from the challenges. Though difficult, changing the social environment is not unprecedented: Americans now feel comfortable buckling up, drinking fluoridated water, and practicing safe sex. The social environment now discourages smoking, and behavior has followed suit. These public health success stories have four elements in common: a body of persuasive research, strong advocacy, widespread media exposure, and policies discouraging unhealthy behavior (Isaacs S, Schroeder S. Where the public good prevailed: lessons from success stories in health. The American Prospect, June 4, 2001). As funders emphasize obesity prevention and these four elements take hold, the environment should start to change. Recent reports that obesity rates are plateauing are encouraging. But with obesity levels at record highs, greater efforts at both community and policy levels are needed. j Stephen Isaacs, JD Isaacs/Jellinek Ava Swartz, MPH, MSUP Writer on Health and Housing doi:10.2105/AJPH.2010.193037 Mary E. Northridge, PhD, MPH Farzana Kapadia, PhD Gabriel N. Stover, MPA Aleisha Kropf Mary T. Bassett, MD, MPH Felipe González Castro, PhD, MSW Michael R. Greenberg, PhD Sofia Gruskin, JD, MIA Said Ibrahim, MD, MPH Robert J. Kim-Farley, MD, MPH Stewart J. Landers, JD, MCP Stella M. Yu, ScD, MPH ASSOCIATE EDITOR FOR STATISTICS AND EVALUATION Roger Vaughan, DrPH, MS INTERNATIONAL ASSOCIATE EDITORS Kenneth Rochel de Camargo Jr, MD, PhD (Rio de Janeiro, Brazil) Daniel Tarantola, MD (Sydney, Australia) DEPARTMENT EDITORS Leslie Beitsch, MD, JD Government, Politics, and Law Elizabeth Fee, PhD, and Theodore M. Brown, PhD Images of Health Public Health Then and Now Voices From the Past Bernard M. Dickens, PhD, LLD, FRSC Health Policy and Ethics Forum Kenneth R. McLeroy, PhD, and Deborah Holtzman, PhD, MSW Framing Health Matters EDITORIAL BOARD Hector Balcazar, PhD (2011), Chair Bobbie Berkowitz, PhD, RN (2011) Russell Brewer, DrPH (2010) Bonnie Duran, DrPH (2011) Neil Hann, MPH, CHES (2010) Alice M. Horowitz, PhD, MA (2012) Cassandra L. Joubert, ScD (2012) Jared Lane K. Maeda, MPH (2010), Student Louise-Anne McNutt, PhD (2010) Dana B. Mukamel, PhD (2010) Brian Saylor, PhD, MPH (2010) Allan Steckler, DrPH (2009) David H. Wegman, MD, MSc (2011) Lynne S. Wilcox, MD, MPH (2012) Jeffrey R. Wilson, PhD, MS (2012) STAFF Georges C. Benjamin, MD, FACP Executive Director/Publisher Nina Tristani, Publications Director Brian Selzer, Manager of Production Teena Lucas, Production Coordinator Ashell Alston, Director of Advertising Maya Ribault, Associate Production Editor (Jr) Ellie D’Sa, Graphic Designer Vivian Tinsley, Subscriptions Coordinator FREELANCE STAFF Greg Edmondson, Michele Quirk, Gretchen Becker, Trish Weisman, Gary Norton, Jennifer Holmes, Brent Winter, Eileen Wolfberg, Kelly Burch, Alisa Guerzon, Copyeditors Chris Filiatreau, Sarah Smith, Sarah Gaskin, Proofreaders Vanessa Sifford, Michele Pryor, Graphic Designers Comprehensive obesity-prevention initiatives focused on children in low-income 2018 | Editor’s Choice American Journal of Public Health | November 2010, Vol 100, No. 11 Copyright of American Journal of Public Health is the property of American Public Health Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
AJPH RESEARCH Impact of Food Assistance Programs on Obesity in Mothers and Children: A Prospective Cohort Study in Peru Rodrigo M. Carrillo-Larco, J. Jaime Miranda, PhD, and Antonio Bernabé-Ortiz, MPH Objectives. To assess obesity risk among mothers participating in Community Kitchens and children participating in Glass of Milk (Peru food assistance programs). Methods. We analyzed prospective data from the Young Lives study. The exposure consisted in varying degrees of benefit from any of the programs (no participation in any of the programs, program participation for some months, or program participation nearly every month) at baseline (2006–2007). The outcome was overweight and obesity in mothers and children at follow-up (2009–2010). Results. Prevalence of childhood overweight and obesity was 15.5% and 5.1%, respectively; the corresponding figures for mothers were 40.5% and 14.6%. Children exposed nearly every month to the Glass of Milk program had a 65% lower risk of becoming obese compared with children not participating in the program (relative risk [RR] = 0.35; 95% confidence interval [CI] = 0.18, 0.66). Mothers participating frequently in the Community Kitchens program had almost twice the risk of becoming obese compared with those who did not participate (RR = 1.93; 95% CI = 1.18, 3.15). Conclusions. Participating in food assistance programs in Peru was associated with a lower risk of obesity in children and greater risk of obesity in mothers. (Am J Public Health. 2016;106:1301–1307. doi:10.2105/AJPH.2016.303191) O besity is a global health issue from which Latin America is not exempt.1 For women aged 20 years and older in Andean Latin America, obesity prevalence is 23.4%,2 which is higher than in some countries in Asia, Africa, and Europe. Childhood obesity is also a concern in Latin America, where between 22 million and 25 million school-aged children are overweight or obese.3 In Peru, obesity rates for adults and children (aged 5–9 years) are 28.5% and 8.9%, respectively.4 These estimates vary according to rural, urban, coastal, or highland setting.4,5 Peru shows a greater prevalence rate of childhood and adolescent obesity than other countries in the region, and in Asia, Africa, and Europe.2,3 Although Peru has experienced significant economic growth over the past few decades, there are still inequalities across the country: the 24% national poverty rate conceals a great deal of variation because poverty rates reach 48% in rural areas. Poor families would benefit from food assistance programs (FAPs). July 2016, Vol 106, No. 7 AJPH Unfortunately, studies in the United States have linked FAPs with obesity, particularly for women.6 However, the evidence regarding children is less conclusive. Infants whose mothers participate in FAPs have higher odds of being overweight,7 but for older children, the association is not as clear as that observed in the United States and Mexico.8–10 Studies in Chile have reported increasing rates of obesity as well as excess energy intake among beneficiary children.11–14 A study in Peru found a 29% higher obesity prevalence among women participating in these programs.15 However, this study combined FAPs as the exposure, precluding an assessment of the impact of specific FAPs. Two programs with great impact in Peru are Vaso de Leche (Spanish for Glass of Milk) and Comedores Populares (Spanish for Community Kitchens; File A, available as a supplement to the online version of this article at Most of the existing evidence of the association between FAPs and obesity comes from cross-sectional studies in developed countries.6–8,10,16 Previous studies have been unable to discriminate in detail the exposure of interest because of the broad use of participation in FAPs or the focus on only 1 program. The present study includes the frequency of participation in 2 specific programs, and the outcomes were measured separately for mothers and children. This study improves upon previous studies that have put together FAPs instead of singling them out. We aimed to assess the obesity risk of mothers and children who are beneficiaries of 2 FAPs: Community Kitchens for mothers and Glass of Milk for children. METHODS This is a secondary analysis of prospective data from the Young Lives study,17 which is a prospective cohort following children in 4 developing countries: Ethiopia, India, Peru, and Vietnam. The study began in 2002 and included 2 cohorts at baseline: a younger cohort with children aged 6 to 18 months and ABOUT THE AUTHORS All authors are with the CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru. J. Jaime Miranda is also with the Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia. Antonio Bernabe´-Ortiz is also with Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima. Correspondence should be sent to Rodrigo M. Carrillo-Larco, CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av Armendáriz 497, 2do Piso, Miraflores, Lima 18, Peru (e-mail: Reprints can be ordered at by clicking the “Reprints” link. This article was accepted March 13, 2016. doi: 10.2105/AJPH.2016.303191 Carrillo-Larco et al. Peer Reviewed Research 1301 AJPH RESEARCH an older cohort with children aged 7 to 8 years. The follow-up rounds were conducted in 2006–2007 and 2009–2010.17 This study only includes the data from the younger Peruvian cohort, specifically the first (hereafter known as baseline) and second follow-up (hereafter known as follow-up) rounds, conducted in the years 2006–2007 and 2009–2010, respectively. We did not include the 2002 assessment because there was not complete information about the FAPs. Furthermore, at such time children were aged 6 to 18 months, preventing us from using the same obesity definition as for older children. Moreover, when aged 6 to 18 months, children are still breastfeeding making it difficult to talk about obesity as a misbalance between energy intake and expenditure like with older children. Local and contextual knowledge regarding FAPs is required to appropriately interpret the results; thus, we focused on information from our country: Peru. Although the study is not nationally representative, it is informative of mothers and children living in constrained settings in a middle-income country. Furthermore, the sampling procedure focused on poor areas where most of the FAPs are set. Thus, our results could be of particular interest for individuals in resource-constrained settings. For this study, we included participants with complete data at baseline on child age, sex, body mass index (BMI), and information regarding participation in FAPs (Figure A, available as a supplement to the online version of this article at Variables Outcomes. Outcomes were overweight and obesity defined according to BMI cut-off points. For children, we used the International Obesity Task Force sex- and age-specific cutoff points,18 whereas for mothers, we used the traditional cut-offs (weight in kilograms divided by the square of height in meters [kg/m2]): overweight was defined as BMI greater than or equal to 25 kg/m2 but less than 30 kg/m2, obesity as BMI 30 kg/m2 or greater, and underweight as BMI < 18.5 kg/m2.19 Exposure. There were 2 exposure variables assessed at baseline: being a beneficiary of the Glass of Milk or the Community Kitchens program (File A). Information was retrieved 1302 Research Peer Reviewed Carrillo-Larco et al. from mothers with the following questions: “In the last 12 months, have your children benefited from the Glass of Milk program?” and “In the last 12 months, did you go to the Community Kitchens program in your area?” Possible answers were “Yes, almost every month”; “Yes, some months”; “Yes, only 1 or 2 months”; and “No.” We collapsed these answers into 3 categories: No (reference); Yes, some months (“Yes, some months” and “Yes, only 1 or 2 months”); and Yes, almost every month. Although some mothers in the study could have been beneficiaries of the Glass of Milk program, we did not include this program as an exposure variable for mothers because the question was assessing children in particular. Other variables. For children, we included sex and age (4 and 5–6 years). For mothers we included age (< 30 years and ‡ 30 years) and education level (none or primary and high school or higher). With regard to the household, we included location (urban and rural), wealth index in tertiles (bottom, middle, and top), and household food security (food security and food insecurity) assessed with a locally adapted version of the US Department of Agriculture’s Food Insecurity and Hunger Module. We assessed all of these variables at baseline. We chose these variables on the basis of previous studies and because they have been shown to be associated with the exposure and outcomes of interest. For example, a previous study with the same population showed that higher wealth index was associated with higher risk of obesity in children.20 Likewise, a study with Peruvian women proved that wealthier women were more likely to be obese, although the opposite was found for women with higher education.21 Statistical Analysis We conducted analyses with Stata version 13.0 (StataCorp LP, College Station, TX). We used means and standard deviations to describe numerical variables. We described categorical variables by using proportions and 95% confidence intervals (CIs). To compare categorical variables, we used the c2 test. We calculated incidence rate per 100 person-years and relative risk (RR), each with its associated 95% CI, per 100 person-years. We calculated the RR by using generalized linear models with Poisson family and log link, including robust standard errors to account for the cluster effect. When the outcome was children overweight, we excluded children with either overweight or obesity at baseline; when the outcome was obesity, we excluded children with obesity at baseline. We made similar exclusions with the mothers. The adjusted models for children included child sex, age, household location, wealth index, food security, and maternal education. The models for mothers were adjusted by household location, wealth index, food security, and maternal education and age. We conducted further analyses with mothers to understand if the risk effect differed according to socioeconomic status: we stratified the adjusted model for mothers by wealth index. RESULTS At baseline, there were 2052 children, and we excluded 103 because of missing values. There were no differences between included and excluded participants regarding child age and sex, participation in either FAP, children nutritional status, and mother nutritional status. The mean age of the children was 5.3 (SD = 0.4) years, and 50.5% were boys. The mean age of the mothers was 31.1 (SD = 6.7) years. Regarding the nutritional status of the children, 4.7% (95% CI = 3.7%, 5.6%) were underweight, 15.5% (95% CI = 13.9%, 17.1%) were overweight, and 5.1% (95% CI = 4.2%, 6.1%) were obese. At baseline, most of the children with obesity received the Glass of Milk program almost every month (37%; P < .001). For the mothers, 1.0% (95% CI = 0.3%, 1.0%) were underweight, 40.5% (95% CI = 38.3%, 42.7%) were overweight, and 14.6% (95% CI = 13.0%, 16.2%) were obese. At baseline, most mothers with obesity had high-school or higher education (66.1%; P < .001). For both children and mothers with obesity, most lived in urban areas and were in the top tertile of wealth index (P < .001). We excluded underweight children or mothers from further analyses. In general, 62% of the children who participated almost every month in the Glass of Milk program were in the bottom wealth index tertile, whereas 61% of the children in the top tertile reported not participating in AJPH July 2016, Vol 106, No. 7 AJPH RESEARCH this program (P < .001). However, such a discrepancy across socioeconomic strata was not observed in mothers in the Community Kitchens program. Nearly 85% of women across wealth index categories reported not participating in this program, and 10% of all women reported using it once or twice a month; 4% of all mothers reported participating almost every month (P = .334). Sociodemographic variables of children and mothers according to their nutritional status are shown in Tables 1 and 2. Incidence and Risk of Overweight or Obesity Among Children When the outcome was childhood overweight and obesity, we included 4010 and 4772 children-years, respectively. The overall incidence rate of overweight and obesity was 4.3 (95% CI = 3.7, 5.0) and 1.1 (95% CI = 0.9, 1.5) per 100 children-years, respectively; Table 3 shows the incidence rate by each category of the exposure variable. Children exposed nearly every month to the Glass of Milk program had a 65% lower risk of becoming obese compared with children not participating in the program (Table 4). When we further adjusted these regression models for maternal age, the risk estimates did not change. Incidence and Risk of Overweight or Obesity Among Mothers When the outcome was mother overweight and obesity, we included 2419 and 4341 mother-years, respectively. The incidence rate of overweight and obesity was 9.8 (95% CI = 8.6, 11.1) and 3.3 (95% CI = 2.8, 3.9) per 100 mother-years, respectively. Mothers in households participating in the Community Kitchens program had a higher incidence of overweight and obesity (Table 3). Mothers participating frequently in the Community Kitchens program had almost twice the risk of becoming obese versus those who did not participate in this program (Table 4). When we stratified the adjusted model by each tertile of wealth index, there was a higher obesity risk for mothers across strata: in the bottom tertile, those who reported using the Community Kitchens TABLE 1—Sociodemographic Variables of Children and Mothers According to Nutritional Status at Baseline: The Young Lives Study, Younger Cohort, Peru, 2006–2007 Variable Overall Sex, no. 1949 Normal Weight Overweight Obesity Pa Children 1456 302 100 Boys, % 50.5 50.0 53.0 54.0 Girls, % 49.5 50.0 47.0 46.0 1949 20.9 1456 21.1 302 23.5 100 13.0 Age, no. 4 y, % 5–6 y, % 79.1 Glass of Milk, no. 1949 No, % 35.6 78.9 1456 33.0 76.5 302 41.4 .51 .08 87.0 100 < .001 54.0 Yes, some months, % 16.4 17.6 14.2 9.0 Yes, almost every month, % 48.0 49.4 44.4 37.0 Mothers Age, no. 1941 820 751 271 18–27 y, % 28–37 y, % 35.7 45.4 40.4 44.3 30.6 49.5 27.7 44.7 38–47 y, % 17.4 14.0 18.2 26.6 48–53 y, % 1.3 1.3 1.6 Education, no. 1943 817 747 1.1 271 None or primary school, % 44.7 50.2 42.0 34.0 High school or higher, % 55.3 49.8 58.0 66.1 a 2 c test when comparing nutritional status. July 2016, Vol 106, No. 7 AJPH < .001 < .001 program for some months had a 250% higher risk of obesity. In the middle tertile, mothers who used the program some or almost every month had a 200% and 250% higher obesity risk, respectively. In the top tertile, only mothers who used the program almost every month had a 279% higher obesity risk. DISCUSSION In households participating in FAPs in resource-limited settings in a middle-income country, children and mothers have different obesity risk profiles: children who frequently participate in the Glass of Milk program had a 64% lower risk of developing obesity, but mothers frequently participating in the Community Kitchens program had a 93% higher risk of becoming obese. These results were independent of food security and wealth index, suggesting that the effect of the assessed FAPs cannot be explained by socioeconomic status, nor by lack of access to nutritional food. Thus, other variables could explain the association between FAPs and weight outcomes, warranting further studies to disentangle the implied mechanism linking FAPs and weight profiles. Comparison With Other Studies The risk of obesity in middle-income countries seems to be higher among those who are better off relative to those who are worse off, particularly for children and women.22 This could explain why our children were not at higher obesity risk. However, in developed countries, people in the lowest socioeconomic level are at higher risk of obesity, and this could explain the different results obtained in the United States.7–9 We report that children and mothers who have the same socioeconomic status have different obesity risk profiles. We hypothesize that mothers are moving faster toward rates of obesity similar to those observed in developed countries, but children are still somehow protected. We found that mothers participating in the Community Kitchens program have a higher risk of obesity. Previous studies also reported that FAPs increase the prevalence and risk of Carrillo-Larco et al. Peer Reviewed Research 1303 AJPH RESEARCH TABLE 2—Household Variables According to Nutritional Status of Children and Mothers at Baseline: The Young Lives Study, Younger Cohort, Peru, 2006–2007 Children Mothers Variable Overall Normal Weight Overweight Obesity Pa Normal Weight Overweight Obesity Pa Household location, no. Urban, % 1949 69.4 1456 66.8 302 72.5 100 86.0 < .001 820 61.3 751 73.6 271 85.6 < .001 < .001 820 Rural, % 30.6 Household wealth index, no. 1949 33.2 1456 27.5 302 14.0 100 38.7 26.4 751 14.4 271 Bottom, % 33.2 35.0 31.8 19.0 42.6 28.8 14.3 Middle, % 33.5 35.0 30.1 15.0 30.4 35.7 41.0 Top, % 33.3 30.0 38.1 66.0 27.0 35.5 44.7 Household food security, no. Food security, % 1949 1456 27.7 Food insecurity, % Community Kitchens No, % 72.3 1949 302 26.4 73.6 1456 31.1 68.9 302 87.1 100 .03 37.0 26.3 63.0 100 85.9 85.5 Yes, some months, % 9.8 10.2 8.3 8.0 Yes, almost every month, % 4.3 4.3 4.6 1.0 820 73.7 .37 91.0 820 86.6 751 29.8 70.2 751 271 < .001 .25 26.2 73.8 271 86.7 81.2 8.9 9.2 13.3 4.5 4.1 5.5 .20 a 2 c test. obesity, mostly for women.6,15 Overall, there seems to be a paradox when one compares these results with those of the children. A possible explanation includes the nutritional composition of the offer of each FAP. The Community Kitchens program, for example, provides meals with an excess of carbohydrates and few servings of fruits and vegetables. If physical activity is insufficient, there will be a positive energy balance leading to obesity. This seems a possible scenario because women in resource-limited settings in Peru appear to have high rates of physical inactivity.23 On the other hand, children in the Glass of Milk program receive a more balanced diet. Moreover, presumably children have higher rates of physical activity, thus leading to a negative energy balance and fewer new obesity cases. Studies in Latin America have reported mixed results. In Brazil, an evaluation of the program Bolsa Familia revealed that the beneficiaries have a higher intake TABLE 3—Incidence Rate per 100 Person-Years of Overweight and Obesity of Children and Mothers According to Food Assistance Programs at Baseline:The Young Lives Study, Younger Cohort, Peru, 2006–2007 of calorie-rich food with less nutritional value, which would lead to obesity.24 In Mexico, the assessment of 2 assistance programs aimed at school-aged children did not yield higher obesity rates.10 Studies from Chile report that there was an increasing trend in obesity rates with a FAP with a plateau in 2001.11 Statistics from 2002 to 2004 showed that the obesity prevalence was between 11% and 20% in preschool children,13 and in 2006, an assessment of central obesity revealed a prevalence of 16%.14 It has also been reported that beneficiaries of the FAP in Chile have better diet profiles when they consume what is provided by the program, but there is positive energy balance mostly when they eat at home and on the weekends.11,12 Incidence Rate (95% CI) Program Overweight Obesity Children Glass of Milk No 6.1 (4.9, 7.6) 2.4 (1.7, 3.3) Yes, some months Yes, almost every month 2.8 (1.8, 4.4) 3.6 (2.9, 4.5) 0.6 (0.3, 1.5) 0.5 (0.3, 0.8) Mothers Community Kitchens No Yes, some months 9.8 (8.5, 11.2) 3.1 (2.6, 3.7) 11.2 (7.3, 16.8) 4.3 (2.6, 6.9) 7.9 (4.0, 15.9) 6.2 (3.4, 11.2) Yes, almost every month Note. CI = confidence interval. 1304 Research Peer Reviewed Carrillo-Larco et al. Interpretation of the Results The higher obesity risk observed among mothers could be attributable to unhealthy diets. Relative to Supplemental Nutrition Assistance Program (SNAP) nonbeneficiaries, beneficiaries have poorer quality diets8,25–27 and consume more sweetened beverages.8,16,28,29 Although the Community Kitchens program does not deliver sweetened beverages, they provide diets with lots of carbohydrates and few servings of fruits and vegetables. The FAPs such as the Community Kitchens program are located in poor AJPH July 2016, Vol 106, No. 7 AJPH RESEARCH TABLE 4—Relative Risk of Overweight or Obesity Among Children and Mothers According to Food Assistance Programs at Baseline: The Young Lives Study, Younger Cohort, Peru, 2006–2007 Overweight, RR (95% CI) Program Crude Glass of Milk, children, no. Adjusted Obesity, RR (95% CI) Crude 417 No (Ref) Adjusted 1450 1 1 1 1 0.52 (0.33, 0.82) 0.62 (0.43, 0.90) 0.84 (0.58, 1.22) 0.96 (0.66, 1.38) 0.25 (0.08, 0.73) 0.19 (0.10, 0.37) 0.44 (0.15, 1.33) 0.35 (0.18, 0.66) 1 1 1 1 Yes, some months 1.23 (0.97, 1.55) 1.25 (0.97, 1.60) 1.51 (0.93, 2.43) 1.47 (0.93, 2.36) Yes, almost every month 0.85 (0.40, 1.77) 0.90 (0.43, 1.86) 1.70 (0.93, 3.12) 1.93 (1.18, 3.15) Yes, some months Yes, almost every month Community Kitchens, mothers, no. No (Ref) 767 746 Note. CI = confidence interval; RR = relative risk. Models for children adjusted by sex, age, household location, wealth index, food security, and maternal education; all assessed at baseline. Models for mothers adjusted by household location, wealth index, food security, maternal education, and maternal age; all assessed at baseline. neighborhoods, where the built environment or much traffic may prevent people from engaging in physical activity and where healthy food choices may not be available.6,23,30,31 Although the United States represents a different epidemiological context, the following example sheds further light on the environmental effect. Children who grew up in well-off neighborhoods and participated in SNAP have higher BMI values at adulthood than their peers who did not participate in the program, and this difference decreases when one compares children raised in less-advantaged settings.32 In terms of socioeconomic profiling, the “food stamp cycle” and the “income effect” have been proposed to explain the association between SNAP participation and obesity in the United States6; however, these effects may not explain our results. Participation in SNAP provides monthly benefits to purchase food,33 whereas the programs assessed in this study directly provide food. As a consequence, alternative explanations could be proposed: (1) households receiving food assistance really do not need it15 or (2) the assistance distribution within households is not equitable. With regard to the first possible explanation, authorities should efficiently select beneficiaries by assessing socioeconomic and nutritional variables at the household and individual levels. Although our results showed that there may be a higher obesity risk for mothers across all wealth index tertiles, these estimates could have July 2016, Vol 106, No. 7 AJPH a limitation because of lack of statistical power for subgroups analysis. This is different from what had previously been reported in Peru, where, in a cross-sectional study, the investigators only found a higher obesity prevalence in women with no poverty indicators.15 The second possible explanation could be supported by the fact that the distribution of energy and macronutrients within a family may vary for each member and according to their relationship with the household head.34 In middle-income countries, obesity, particularly for children and women, is more frequent among people who are better-off22; however, such a trend may have changed in the past year, as well as by country and according the indicator used.21,35 Our results indicate how low-resource settings in Peru are moving toward the obesity profiles of developed countries. Thus, FAPs may offer an excellent venue for obesity prevention programs and for overall better nutritional status at the household level.11 Strengths and Limitations This study presents the results of a prospective cohort study, which rules out reverse causation. This study explored the association of interest according to the frequency of participating in FAPs. In addition, our study explored the participation in FAPs during the past year, whereas other studies did not define a time frame; however, it could also be a limitation as the development of obesity may require a longer exposure to these programs. It could be argued that not including the other countries of the Young Lives study is a limitation. We believe it is not a limitation but a conservative decision: FAPs between these countries may not be comparable because of differences between populations as well as in the objectives, methods, and procedures of each FAP. Further limitations should be highlighted. First, we did not include some variables that had been explored in other studies. For example, we did not include the characteristics of the neighborhood, which seem to be important determinants of the association of interest (e.g., access to healthy food options).32 Future studies in developing settings should include this variable, as these settings are becoming filled with fast-food restaurants and other unhealthy food choices. In addition, we did not have data on food intake. Future studies should include food intake assessed with valid methods and clearly identifying food consumed as part of the program and otherwise. Second, the questions regarding the exposures of interest referred to the previous year. If a participant’s economic status improved, they could have become ineligible for food supply programs, whereas if a participant’s economic status worsened, they could have faced further difficulties in meeting the nutritional requirements. Nevertheless, the wealth index used in this study did not vary much between baseline and follow-up. Third, we could not assess whether a given family participated in both programs at the same time, or if they participated in any other. Thus, the influence of other programs could have influenced our results. However, the programs assessed in this study are strictly related to food assistance, whereas other initiatives such as cash transfer programs can be used for any purposes. Therefore, the effect of any other program on the nutritional status of the household member could have had a minor impact on our results. Fourth, we excluded a significant number of mothers from the incidence analysis as they were already overweight or obese at baseline, possibly adding selection bias to our results. This would be particularly true if they were overweight or obese when they entered the FAP. We cannot determine the nutritional Carrillo-Larco et al. Peer Reviewed Research 1305 AJPH RESEARCH status of the mothers when they first participated in the program. Future studies could address this limitation by following the mothers beginning the first time they received the FAP. Furthermore, another source of selection bias is the inclusion criteria for each FAP and where these are located: a FAP based in a low or low–middle income setting with participants who have low-salary jobs may be different from those based in a poor rural setting. Fifth, the ascertainment of the exposure variables could have been affected by social desirability bias. If social desirability influenced the answers to the exposure questions, participants could have answered “no, they do not participate” as this would have made them appear to be in a better socioeconomic position; alternatively, they could have answered “yes, they participate very often” to sustain their eligibility status. However, in the overall distribution of, for example, the Glass of Milk program, 35.5% answered “no [participation]” and 47.9% answered “almost every month.” As a consequence, we believe social desirability did not skew the results, thus having little impact in the overall results. A sixth limitation is the low prevalence of childhood obesity and the short follow-up time. Subsequent rounds of the Young Lives study, and other prospective cohorts including families, would help to assess whether our results sustain in time. Conclusions In resource-limited settings in a middle-income country, participation in 2 specific FAPs, measured by self-report, is associated with a lower risk of developing obesity for children (Glass of Milk program) but a higher risk of developing obesity for mothers (Community Kitchens program). Strategies to improve the nutritional status of either mothers or children could be conducted through specific FAPs. Interventions conducted in this population could have important implications in improving the overall nutritional status at the household level. CONTRIBUTORS R. M. Carrillo-Larco conceptualized the idea, conducted the analysis under the supervision of A. Bernabé-Ortiz, and drafted the article. All authors interpreted the results, participated in writing the article, provided important 1306 Research Peer Reviewed Carrillo-Larco et al. intellectual content, and gave their final approval of the version submitted for publication. ACKNOWLEDGMENTS The data used in this publication come from Young Lives, a 15-year study of the changing nature of childhood poverty in Ethiopia, India (Andhra Pradesh), Peru, and Vietnam (, which is funded by UK aid from the Department for International Development, with co-funding from 2010 to 2014 by the Netherlands Ministry of Foreign Affairs, and from 2014 to 2015 by Irish Aid. R. M. Carrillo-Larco, J. J. Miranda, A. Bernabé-Ortiz, and the CRONICAS Center of Excellence in Chronic Diseases were supported by the National Heart, Lung, and Blood Institute Global Health Initiative under the contract Global Health Activities in Developing Countries to Combat Non-communicable Chronic Diseases (project 268200900033C-1-0-1). A. Bernabé-Ortiz is currently supported by a Wellcome Trust Research Training Fellowship in Public Health and Tropical Medicine (grant 103994/Z/14/Z). The authors are thankful to Lorena Saavedra Garcia for her comments that helped define the study. Note. The views expressed here are those of the author(s). They are not necessarily those of Young Lives, the University of Oxford, Department for International Development, or other funders. HUMAN PARTICIPANT PROTECTION This study is a secondary analysis of publicly available data from the Young Lives study. The Young Lives study received ethical approval as a whole as well as in each study site. Only de-identified data were used in this study. No personal information was available or is presented. REFERENCES 1. Kain J, Hernandez Cordero S, Pineda D, et al. Obesity prevention in Latin America. Curr Obes Rep. 2014;3(2): 150–155. 2. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766–781. 9. Simmons S, Alexander JL, Ewing H, Whetzel S. SNAP participation in preschool-aged children and prevalence of overweight and obesity. J Sch Health. 2012;82(12): 548–552. 10. Cuevas-Nasu L, Hernandez-Prado B, Shamah-Levy T, Monterrubio EA, Morales-Ruan Mdel C, MorenoMacias LB. Overweight and obesity in school children aged 5 to 11 years participating in food assistance programs in Mexico. Salud Publica Mex. 2009;51(suppl 4): S630–S637. 11. Rojas PJ, Uauy DR. Evolving standards of food and nutrition of the food program and changes in the nutritional status of preschool JUNJI beneficiaries in the past 3 decades [in Spanish]. Rev Chil Nutr. 2006;33: 91–101. 12. Vásquez VF, Salazar RG, Andrade SM, Díaz BE, Rojas J. Dietary intake of obese preschool children attending kindergartens of JUNJI [in Spanish]. Rev Chil Nutr. 2004;31:100–108. 13. Kain J, Lera ML, Rojas PJ, Uauy DR. Obesity among preschool children of Santiago, Chile [in Spanish]. Rev Med Chil. 2007;135(1):63–70. 14. Gutiérez-Gómez Y, Kain J, Uauy R, Galván M, Corvalán C. Nutritional status of preschool children attending the Chilean National Nursery Schools Council Programs (JUNJI): assessment of the agreement among anthropometric indicators of obesity and central obesity [in Spanish]. Arch Latinoam Nutr. 2009;59(1):30–37. 15. Chaparro MP, Bernabe-Ortiz A, Harrison GG. Association between food assistance program participation and overweight. Rev Saude Publica. 2014;48(6):889–898. 16. Leung CW, Villamor E. Is participation in food and income assistance programmes associated with obesity in California adults? Results from a state-wide survey. Public Health Nutr. 2011;14(4):645–652. 17. Barnett I, Ariana P, Petrou S, et al. Cohort profile: the Young Lives study. Int J Epidemiol. 2013;42(3):701–708. 18. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes. 2012;7(4):284–294. 3. Rivera JÁ, de Cossio TG, Pedraza LS, Aburto TC, Sanchez TG, Martorell R. Childhood and adolescent overweight and obesity in Latin America: a systematic review. Lancet Diabetes Endocrinol. 2014;2(4):321–332. 19. National Institutes of Health, National Heart, Lung, and Blood Institute, North American Association for the Study of Obesity. The Practical Guide Identification, Evaluation and Treatment of Overweight and Obesity in Adults. 2000. Available at: docs/guidelines/prctgd_c.pdf. Accessed April 8, 2016. 4. Álvarez-Dongo D, Sanchez-Abanto J, Gomez-Guizado G, Tarqui-Mamani C. Overweight and obesity: prevalence and determining social factors of overweight in the Peruvian population (2009–2010) [in Spanish]. Rev Peru Med Exp Salud Publica. 2012;29(3):303–313. 20. Carrillo-Larco RM, Miranda JJ, Bernabe-Ortiz A. Wealth index and risk of childhood overweight and obesity: evidence from four prospective cohorts in Peru and Vietnam. Int J Public Health. 2015; Epub ahead of print. 5. Pajuelo-Ramírez J, Sanchez-Abanto J, Alvarez-Dongo D, Tarqui-Mamani C, Aguero-Zamora R. Overweight, obesity and chronic malnutrition in 6 to 9 year-old children in Peru, 2009–2010 [in Spanish]. Rev Peru Med Exp Salud Publica. 2013;30(4):583–589. 21. Poterico JA, Stanojevic S, Ruiz-Grosso P, BernabeOrtiz A, Miranda JJ. The association between socioeconomic status and obesity in Peruvian women. Obesity (Silver Spring). 2012;20(11):2283–2289. 6. DeBono NL, Ross NA, Berrang-Ford L. Does the food stamp program cause obesity? A realist review and a call for place-based research. Health Place. 2012;18(4):747–756. 7. Watt TT, Appel L, Roberts K, Flores B, Morris S. Sugar, stress, and the Supplemental Nutrition Assistance Program: early childhood obesity risks among a clinicbased sample of low-income Hispanics. J Community Health. 2013;38(3):513–520. 8. Leung CW, Blumenthal SJ, Hoffnagle EE, et al. Associations of food stamp participation with dietary quality and obesity in children. Pediatrics. 2013;131(3):463–472. 22. Dinsa GD, Goryakin Y, Fumagalli E, Suhrcke M. Obesity and socioeconomic status in developing countries: a systematic review. Obes Rev. 2012;13(11): 1067–1079. 23. Miranda JJ, Carrillo-Larco RM, Gilman RH, et al. Patterns and determinants of physical inactivity in rural and urban areas in Peru: a population-based study. J Phys Act Health. 2016; Epub ahead of print January 18, 2016. 24. Cotta RM, Machado JC. The Bolsa Familia cash transfer program and food and nutrition security in Brazil: a critical review of the literature [in Portuguese]. Rev Panam Salud Publica. 2013;33(1):54–60. AJPH July 2016, Vol 106, No. 7 AJPH RESEARCH 25. Nguyen BT, Shuval K, Njike VY, Katz DL. The Supplemental Nutrition Assistance Program and dietary quality among US adults: findings from a nationally representative survey. Mayo Clin Proc. 2014;89(9): 1211–1219. 26. Leung CW, Ding EL, Catalano PJ, Villamor E, Rimm EB, Willett WC. Dietary intake and dietary quality of low-income adults in the Supplemental Nutrition Assistance Program. Am J Clin Nutr. 2012;96(5):977–988. 27. Hilmers A, Chen TA, Dave JM, Thompson D, Cullen KW. Supplemental Nutrition Assistance Program participation did not help low income Hispanic women in Texas meet the dietary guidelines. Prev Med. 2014;62: 44–48. 28. Bleich SN, Vine S, Wolfson JA. American adults eligible for the Supplemental Nutritional Assistance Program consume more sugary beverages than ineligible adults. Prev Med. 2013;57(6):894–899. 29. Andreyeva T, Luedicke J, Henderson KE, Tripp AS. Grocery store beverage choices by participants in federal food assistance and nutrition programs. Am J Prev Med. 2012;43(4):411–418. 30. Gustafson A, Lewis S, Perkins S, Wilson C, Buckner E, Vail A. Neighbourhood and consumer food environment is associated with dietary intake among Supplemental Nutrition Assistance Program (SNAP) participants in Fayette County, Kentucky. Public Health Nutr. 2013; 16(7):1229–1237. 31. Han E, Powell LM, Isgor Z. Supplemental Nutrition Assistance Program and body weight outcomes: the role of economic contextual factors. Soc Sci Med. 2012;74(12): 1874–1881. 32. Vartanian TP, Houser L. The effects of childhood SNAP use and neighborhood conditions on adult body mass index. Demography. 2012;49(3):1127–1154. 33. US Department of Agriculture Food and Nutrition Service. Supplemental Nutrition Assistance Program (SNAP). Available at: supplemental-nutrition-assistance-program-snap. Accessed September 16, 2015. 34. Ardila VA, Prada GE, Herran OF. Intra-household distribution of energy and macronutrients in Colombian households [in Spanish]. Biomedica. 2013;33(2):163–174. 35. Monteiro CA, Moura EC, Conde WL, Popkin BM. Socioeconomic status and obesity in adult populations of developing countries: a review. Bull World Health Organ. 2004;82(12):940–946. July 2016, Vol 106, No. 7 AJPH Carrillo-Larco et al. Peer Reviewed Research 1307 Copyright of American Journal of Public Health is the property of American Public Health Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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