Author + information
- Received June 13, 2013
- Accepted July 3, 2013
- Published online February 4, 2014.
- Charlotte A. Pratt, PhD∗ (, )
- Sonia Arteaga, PhD and
- Catherine Loria, PhD
- Clinical Applications and Prevention Branch, Prevention and Population Sciences Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- ↵∗Reprint requests and correspondence:
Dr. Charlotte A. Pratt, Prevention and Population Sciences Program, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Suite 10118, Bethesda, Maryland 20892-7936.
This paper describes ongoing National, Heart, Lung, and Blood Institute (NHLBI)-initiated childhood obesity research. It calls on clinicians, researchers, and cardiologists to work with other healthcare providers, community agencies, schools and caregivers to foster better cardiovascular health in children by intervening on multiple levels of influence on childhood obesity.
Can the high prevalence of childhood obesity be reversed? More important, can childhood obesity be curtailed to reduce associated increases in future cardiovascular morbidity and mortality? In the past 30 years, the prevalence of obesity has more than doubled in children and tripled in adolescents; >12 million or ∼17% of U.S. children and adolescents are now obese (1–3). Although the overall childhood obesity prevalence may be stabilizing (1), in nonwhite children and adolescents, particularly Hispanic boys and African-American girls, and those of low socioeconomic status, it continues to be disproportionately high (1–3). Obese youths have higher prevalence of vascular abnormalities, including left ventricular hypertrophy and atherosclerosis, but also hypertension, dyslipidemia, and type 2 diabetes, than normal-weight youths (4,5). For the cardiologist and other healthcare professionals, this raises major concerns regarding children's risk of the development of heart disease in adulthood as well as concerns that the marked reductions in heart disease morbidity and mortality over the past decades will halt or even reverse. Today's obese children and adolescents are much more likely to be tomorrow's obese adults and, perhaps, tomorrow's cardiac patients (5,6).
The purpose of this article is to describe ongoing National Heart, Lung, and Blood Institute (NHLBI)-initiated childhood obesity research as examples of efforts to foster better cardiovascular health in children. Strategies for improving clinical care of obese children and adolescents are discussed.
There is increasing consensus among childhood obesity researchers that interventions that include multiple components across multiple settings have the potential to be more effective than single-component interventions because obesity development appears to depend on multiple factors: biological and physiological (e.g., genetic predisposition, appetite, and satiety mechanisms), personal (e.g., physical activity patterns, taste preferences, and dietary intake patterns), social (family, siblings, peer influences), psychological (e.g., motivations, attitudes, self-efficacy), environmental (e.g., home, school, and community), societal (e.g., school and institutional policies and food advertising), and healthcare-related (e.g., pediatric care access, insurance and provider counseling) (7). In addition, children and adolescents spend time in multiple settings (e.g., school, home, and community environments) that may promote poor dietary intakes, sedentary behaviors, and physical inactivity.
In August 2010, the NHLBI launched the Childhood Obesity Prevention and Treatment Research (COPTR) Consortium and the Healthy Communities Study (HCS), in collaboration with other National Institutes of Health branches and offices. COPTR comprises 4 research centers and multiple randomized, controlled trials that intervene on children and adolescents, where they live, learn, and play. Two of the 4 centers focus on obesity prevention and target 2- to 5-year-olds; the other 2 focus on the treatment of overweight or obese 7- to 13-year-olds. With a planned total of 1,700 children and adolescents, the studies are testing innovative multilevel, multicomponent interventions that include involvement of primary care physicians in pediatric care units, parks and recreational centers, family advocates, and schools, consistent with the socioecological model (Fig. 1) (7).
Figure 1 illustrates the multilevel linkages, interactions, and relationships among multiple factors that affect diet and physical activity, the key drivers of obesity. Individual factors (e.g., child and parent lifestyles, attitudes, beliefs, skills, behaviors, and biology), social environments (e.g., network of family, friends, and peers), physical environments (e.g., home, school, child care, fast food restaurants), and societal factors (e.g., advertising, government assistance, and healthcare system) all interact and influence childhood obesity. Figure 1 also shows how COPTR studies are intervening on multiple levels within the model framework. For example, at the individual level, behavioral interventions enhance diet and physical activity and modify food preferences; at the social environment level, social network and support from pediatric care units, healthcare providers, family, friends, and peers enhance the interventions; at the physical environment level, modifications in the home food and physical activity environments and after-school sports are encouraged; and at the macro-level, school wellness policies and involvement of parks and recreation departments and boys and girls clubs support physical activity interventions.
In addition to COPTR, the NHLBI is supporting the HCS, a large observational study of community programs and policies that target childhood obesity and are being implemented across the country. There is natural variation in many aspects of these programs and policies, including their intensity, duration, target population, implementation procedures, and how aspects of community programs and policies are related to childhood obesity outcomes. The HCS aims to: 1) determine the associations between characteristics of community programs/polices and body mass index (BMI), diet, and physical activity in children; 2) identify the community, family, and child factors that modify or mediate the associations between community programs/policies and BMI, diet, and physical activity in children; and 3) assess the associations between programs/policies and BMI, diet, and physical activity in children in communities that have a high proportion of African-American, Latino, and/or low-income residents. More than 200 communities, defined as high school catchment areas, and ∼20,000 elementary and middle school children and their parents/caregivers will be sampled. Following the ecological framework (7), HCS will collect data on multiple levels of influence. Individual-level data include parents' and children's height and weight and children's waist circumference, diet, and physical activity behaviors. School-level data include policies and food and activity environments. Community-level data include programs and policies targeting obesity and captured through interviews with key informants. Details of the HCS are available at http://www.nhlbi.nih.gov/resources/obesity/popstudies.htm.
In addition to these 2 studies, and based on studies suggesting that obesity begins in utero and excessive gestational weight gain predicts obesity in both mother and child (8), the NHLBI is collaborating with other institutes to test behavioral and lifestyle interventions in overweight and obese pregnant women to improve weight and metabolic outcomes in pregnant women and their offspring (Lifestyle Interventions for Expectant Moms [LIFE-Moms] at http://www.clinicaltrials.gov/ct2/show/NCT01812694?term=The+Lifestyle+Interventions+for+Expectant+Moms&rank=1).
Among older children, longitudinal epidemiological research in high school–age youths is limited. The NHLBI is collaborating with the Eunice Kennedy Shriver National Institute of Child Health and Human Development to conduct the NEXT Generation Health Study, a nationally representative cohort of 2,700 U.S. 10th graders randomly selected from 81 schools to examine longitudinal trends in cardiovascular risk factors and health behaviors among a cohort (N = ∼ 550) of obese and normal-weight youths (NEXT Plus) as they transition from middle school through high school. Details of other NHLBI-led studies that target children or young adults for obesity prevention are available at http://www.nhlbi.nih.gov/resources/obesity/clinicaltrials.htm.
Forging Better Cardiovascular Health in Children and Adolescents
Childhood obesity prevention and treatment are a national and international public health priority. Clinicians, cardiologists, researchers, along with others can forge the way toward better cardiovascular health in children by addressing multiple levels of influence (child, parent, family, home, healthcare provider, schools, child recreational facilities) and by using multiple components of interventions in multiple settings. Similarly, clinicians and cardiologists should recognize the importance of community environments, resources, programs, and policies for improving diet, physical activity, and BMI in children. The NHLBI-initiated WeCAN (Ways to enhance Children's Activity and Nutrition) program (http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/health-professionals/index.htm) provides additional resources to clinicians and researchers. Other resources include the Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm) and those at the National Collaborative for Childhood Obesity Research (www.nccor.org). In addition, because of the knowledge of early origins of obesity, intervening on pregnant women to modify dietary and physical activity patterns for appropriate weight gain during pregnancy could improve adiposity in early childhood.
COPTR, HCS, and other National Institutes of Health obesity studies have implications for the cardiologist. Obese children and adolescents are more likely to be obese as adults, and maternal obesity increases the risk of having children with congenital heart defects (4,5). Adult obesity is associated with abnormalities of the cardiac structure and function including heart failure and left ventricular hypertrophy (4). These abnormalities can begin in childhood, occur long term, and may be exacerbated when obesity begins in childhood and continues into adulthood. There is some evidence of modest beneficial effects of childhood obesity prevention interventions on BMI and on children's nutrition and physical activity behaviors (9). We believe that the childhood obesity epidemic can be reversed as research identifies the key elements of effective prevention strategies for at-risk children, families, schools, communities, and the healthcare system. It is likely that the adoption and integration of evidence-based prevention strategies into healthcare systems and community programs will be needed to achieve long-lasting and sustainable effects. These prevention efforts will likely involve concerted efforts among multiple partners including children at risk and their families, the medical system (e.g., pediatricians, primary care physicians, and cardiologists), and collaboration with various institutions and community settings to tackle the obesity problem.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- body mass index
- Childhood Obesity Prevention and Treatment Research
- Healthy Communities Study
- National Heart, Lung, and Blood Institute
- Received June 13, 2013.
- Accepted July 3, 2013.
- American College of Cardiology Foundation
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