Current Obesity Reports

https://doi.org/10.1007/s13679-018-0320-0

METABOLISM (M DALAMAGA, SECTION EDITOR)

Risk Factors and Implications of Childhood Obesity

Susann Weihrauch-Blüher1 & Susanna Wiegand 2

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review This review summarizes our current understanding of factors associated with childhood obesity, including
latest prevalence rates, effectiveness of intervention strategies, and risk for concomitant disease later in life.
Recent Findings Obesity has reached global dimensions, and prevalence of childhood obesity has increased eightfold since 1975.
Interventions for obesity prevention have mainly focused on behavioral settings to date, i.e., interventions that have focused on
behavioral changes of the individuum such as increasing daily physical exercise or optimizing diet. However, effects have been
very limited worldwide and could not stop the increase of obesity prevalence so fare. Thus, community-based/environment-
oriented measures are urgently needed, such as promotion of healthy food choices by taxing unhealthy foods, mandatory
standards for meals in kindergarten and schools, increase of daily physical activity at kindergartens, and schools as well as
ban on unhealthy food advertisement for children.
Summary Restructuring obesity interventions towards community-based/environment-oriented measures to counteract an
obesogenic environment is mandatory for sustainable success and to stop the obesity epidemy. There is need to move fast, as
already moderate overweight before the start of puberty is associated with significantly increased risk for type 2 diabetes and
cardiovascular disease in midlife.

Keywords Obesity . Childhood . Adolescence . Prevention . Cardio-metabolic disease . Risk factor . Type 2 diabetes

Introduction: Prevalence of Childhood obesity prevalence in younger children until adolescence, a

Obesity
Childhood overweight and obesity have emerged to a public
health crisis. The prevalence of obesity has doubled in more
than 70 countries since 1980, as analyzed in a systematic
evaluation within the Global Burden of Disease Study. A total
of 107.7 million children and 603.7 million adults were obese
in 2015 [1]. Thus, obesity prevalence was as high as 5%
among children worldwide in 2015, and overweight and obe-
sity prevalence taken together was even as high as 23% [1, 2].
Although there seems to be a stabilization or even decrease in
This article is part of the Topical Collection on Metabolism
* Susann Weihrauch-Blüher
susann.weihrauch-blueher@uk-halle.de
1
Department of Pediatrics I/Pediatric Endocrinology, University
Hospital of Halle-Wittenberg, Ernst-Grube-Strasse 40, 06120 Halle/
Saale, Germany
2
Center for Social-Pediatric Care/Pediatric Endocrinology and
Diabetology, Charité Universitätsmedizin Berlin, Berlin, Germany
sharp increase is seen afterwards with many youths presenting
already with extreme or morbid obesity [3•, 4, 5]. Alarmingly,
the increase in childhood obesity in meanwhile exceeding the
increase in adult obesity in many countries [1].
In 2015, excess body weight accounted for about four mil-
lion deaths worldwide, and almost 70% of these deaths were
due to cardiovascular disease [3•]. Other chronic sequelae of
obesity—in addition to cardiovascular disease—include dia-
betes mellitus, increased risk for malignancies or
musculosceletal disorders, and many others [3•]. The inci-
dence of cardio-metabolic comorbidities is already consider-
ably higher for obese teens than for normal weight peers
[6–9].
On the one hand, therapeutic interventions for childhood
obesity have shown only very limited success to date, with
achievable weight loss of 0.05–0.42 BMD-SDS units (stan-
dard deviation of the body mass index) over 12–24 months,
and success rates clearly correlate with age with younger kids
having significantly better outcome [10, 11]. On the other
hand, a recent cohort study from Denmark has clearly shown
that even any effort and even small steps towards a normal
body weight during childhood reduce the risk for obesity-

related cardio-metabolic disease later in life significantly:
obese boys who could reduce their BMI towards normal body
weight between 7 and 13 years of age, i.e., before puberty, and
who could maintain a normal weight into early adulthood had
a risk to develop type 2 diabetes that was similar to that among
boys who had a normal body weight throughout their life
[12••].
Prevention of Childhood Obesity: Goals Have
to Be Reset Towards
Community-/Environment-Based Measures
Obesity prevention has been classified into behavior-oriented
(individual-based) interventions and community-based or
environment-oriented (context-related) interventions.
Whereas behavior-oriented prevention programs have aimed
to change individual life style factors, such as increase phys-
ical activity or optimizing diet, environment-oriented pro-
grams aim to support the implementation of health-relevant
decision-making and environmental factors like residential
neighborhood in order to positively influence weight status
by health-related behavior [13, 14].
Obesity prevention programs have to date mainly focused
on behavioral interventions with only marginal effects on chil-
dren’s body weight in the long term [15, 16]. Large random-
ized controlled trials have shown that current prevention strat-
egies for childhood overweight and obesity are insufficient in
terms of reducing body weight in the long term and inadequate
in daily life or clinical practice in most countries of the world.
In addition, available data are very heterogeneous in terms of
type, duration, and intensity of the interventions as well as
long-term follow-up [16]. In addition, certain groups at risk
for the development of obesity are not reached effectively by
most programs [16].
International stakeholders and scientific organizations
agree that there needs to be a shift towards community-
based/environment-oriented preventions strategies to stop
the global obesity epidemy. However, there are almost no
studies available to date that have investigated effectiveness
and long-term outcome of such interventions.
However, available data that have studied the impact of
(social) environment on long-term weight development are
interesting and point towards the direction we need to move:
one study has evaluated several different environmental fac-
tors (including social factors) on the risk of childhood obesity
over a 4-year period and including a total of 500 children. The
most important determinants of children’s body weight were
the length of the street the children lived on (with longer
streets having more impact on elevated body weight), acces-
sibility of the nearest playground by foot, frequency of busses/
trains passing the street, and the socioeconomic status (SES)
of the neighborhood. However, the SES had the greatest
Curr Obes Rep
impact; the BMI-SDS of children living in socioeconomically
disadvantaged neighborhoods ranged 0.31 SDS points above
the reference group [17].
Given the small number of available studies towards long-
term outcome of environmental prevention on body weight
regulation, it is too early to draw conclusions on the individual
effect of changes in environmental conditions.
Additional measures for environment-based obesity pre-
vention have been recommended by several groups and sci-
entific associations. These measures are increasingly
discussed to be mandatory for a sustainable success to fight
the obesity epidemic and are closely connected to the Global
Action Plan for the prevention and control of noncommunica-
ble diseases of the WHO. Such measures include restriction of
the advertisement of unhealthy foods to children, improving
school meals by development of binding quality standards for
the catering offers in kindergartens and schools, implementa-
tion of a sugar—or fat tax to reduce consumption of unhealthy
foods, and increase in daily physical activity by offering more
physical activity/sports in schools and kindergartens [18•].
However, the effectiveness, feasibility of widespread im-
plementation, and sustainability of such measures need to be
evaluated in different settings and in the long term [1]. Some
countries have already started to implement some of these
measures or policies; however, no major success in terms of
decreasing obesity prevalence in the population could be
shown to date as long-term date are not available yet [19].
Obesity During Childhood and Risk
for Concomitant Disease Later in Life
Obesity-related comorbidities start as early as in childhood:
more than half of obese children and adolescents have at least
one biochemical or clinical cardiovascular risk factor and one
quarter have more than two [20]. Many obese adolescents
remain obese into adulthood, with increased morbidity and
mortality due to cardiovascular, metabolic, or oncological dis-
orders [21].
The NICHD Study of Early Child Care and Youth
Development was one of the first studies that have investigat-
ed the ability of body mass index trajectories during childhood
to predict cardiovascular risk in adolescence. In this study,
growth and weight (BMI) curves were established for 657
children aged 1 to 10 years, separately for girls and boys.
Predictors of cardiovascular risk at the age of 15 years were
determined and controlled for confounding factors: children
who were obese at the age of 15 months and who remained
obese throughout infancy and early and middle childhood had
significantly elevated risk for the development of cardiovas-
cular disease in adolescence [22]. However, some obese
youngsters are never affected by any cardio-metabolic comor-
bidities. Therefore, the concept of metabolically healthy
Curr Obes Rep
obesity (MHO) has been implemented. The prevalence of
MHO in obese youths is estimated between 4.2 [23] and
25% [24]. We are far from understanding underlying patho-
genetic mechanisms and physiology of MHO; however, high
birth weight and increased weight gain during infancy have
been increasingly discussed as predictors for insulin sensitiv-
ity and even adipose tissue metabolism later in life and might
therefore contribute to the development of metabolic and car-
diovascular disease [25].
What about “healthy” obese children and cardiovascular
risk later in life? The Bogalusa Heart Study has addressed this
question within a large cohort study involving 1098 individ-
uals, both as children (aged 5–17 years) and adults (aged 24–
43 years). The study revealed that obese children without
metabolic/cardiovascular comorbidity during childhood were
more likely to retain this healthy status in adulthood despite
being obese. Moreover, they showed a cardio-metabolic pro-
file comparable to that of non-obese children and non-obese
adults [23]. These results suggest that a favorable cardio-
metabolic risk profile may be retained later in life, indepen-
dent of weight status during childhood.
However, interpretation of results is not as simple as we are
far away from understanding underlying mechanism, i.e., why
some patients retain good cardio-metabolic health despite be-
ing obese and others do not. In addition, the concept of MHO
seems only to be true for a minority of patients: a study in-
volving more than 6000 subjects and a follow-up period of
more than 20 years have clearly shown that reduction of body
weight towards normal weight range, i.e., decreasing severity
if obesity, between childhood and adulthood, is associated
with significant reduction of features of the metabolic syn-
drome such as type 2 diabetes, arterial hypertension, or dys-
lipidemia [26]. On the other hand, if obesity persists until
adolescence, the risk of coronary heart disease in midlife is
significantly increased [27]. Large prospective cohort studies
could clearly show that the duration of obesity is independent-
ly associated with an increased risk of type 2 diabetes and that
each-year increment in the duration of obesity increases the
risk of diabetes by as much as 14% [28]. These findings have
been supported by a recent study from Denmark, showing that
an increase in BMI between 7 years of age and early adult-
hood is associated with a significantly higher risk of type 2
diabetes later in life, even if body weight had been normal at
age of 7 [12••]. However, there is also good news: obese boys
who could reduce their BMI towards normal body weight
between 7 and 13 years of age, i.e., before puberty, and who
could maintain a normal weight into early adulthood, had a
risk to develop type 2 diabetes that was similar to that among
boys who had a normal body weight throughout their life
[12••]. Boys who had reduced their body weight into normal
range between 13 years of age and early adulthood had a risk
to develop type 2 diabetes that was higher than that among
boys who had never been overweight but lower than that
among boys who had been overweight since childhood
[12••]. So, every effort towards normalization of BMI counts
and is important to prevent concomitant disease later in life, as
already (mild) overweight during childhood seems to be asso-
ciated with increased cardiovascular risk in midlife: a large
cohort study from Israel has analyzed data sets from 2.3 mil-
lion adolescents between 1967 to 2010. The authors could
show that a BMI between 50 and 74th percentiles (which
would be regarded as normal weight) was already associated
with significantly increased risk for cardiovascular disease
and death from coronary heart disease compared to those with
BMI values between the 5th and 24th percentile during
40 years of follow-up. The lowest rates of cardiovascular
deaths were observed in the group with BMI values between
25th and 49th percentile during adolescence. Thus, not only
obesity, but also (mild) overweight during adolescence seems
to be associated with substantially increased risk of cardiovas-
cular disease in midlife. The association is similar in both
sexes. However, a distinct BMI threshold that is associated
with increased risk remains to be determined [29••]. Baker
et al. found that the BMI at 7 years of age is already associated
with increased risk for mortality from cardiovascular disease
in adulthood, and this association became stronger until the
age of 13 [30].
Transferring these findings to adults, the lowest risk of
death (taking into account several confounding factors) seems
to be between BMI values between 20 and 25 kg/m2 as shown
by the Global Burden of Disease Study [3•].
Discussion
The Hippocratic principle “primum non nocere” (above all do
not harm) is one of the keystones of medicine. However, def-
initions of good health and disease often overlap, and the need
for feasible but also effective prevention or intervention strat-
egies for maintaining good health has frequently been the
focus of controversial discussion among different professions.
This is especially true for the field of obesity and associated
sequelae.
The medical dilemma that physicians and health-care pro-
viders increasingly have to face is that on the one hand, child-
hood obesity das dramatically increased since 1975, namely
8- to 8.7-fold [31].This increase in obesity prevalence is asso-
ciated with increased morbidity and mortality later in life:
Overweight or obesity in adolescence may account for as
much as 20% of cardiovascular deaths and 25% of deaths
from coronary heart disease when affected youths reach mid-
life [29••].
On the other hand, although effective interventions for pre-
vention and therapy of childhood and adolescent obesity are
available as shown in systematic reviews of the Cochrane
database, effects of such interventions have been rather small

Fig. 1 Childhood obesity:
controllable influencing factors
Influencing factors:
and selected effects on health
Physical Inactivity
Dietary Habits
Sedentary Behaviour
Socio-Economic Status
Sleep Duration and Intensity
Obesogenic Environment
Marketing Strategies for
Energy-Dense Foods
to date [11, 32]. Additional difficulties include the failure to
maintain reduced body weight in the long term due to poor
compliance to lifestyle changes as well as the failure of many
programs and interventions in daily life and clinical practice as
adherence of affected children and adolescents is rather low
and many patients do not see a need to seek medical care due
to subjective well-being [33].
However, cardio-metabolic, orthopedic, psychological,
and other comorbidities are clearly associated with dramati-
cally increased body weight, as shown by numerous cohort
studies and systematic reviews and as discussed earlier in this
manuscript. The alarming message we have to face is that
already moderate increase of BMI, between 7 and 13 years
of age, is associated with a significantly higher risk for type 2
diabetes and cardiovascular disease in midlife [12••, 29••].
High BMI has emerged to one of the leading health risks as
assessed in the Global Burden of Disease 2015 study. As both
industrialized and developing countries are affected by an in-
creasing obesity prevalence in all age groups, the problem is
not simply attributable to income or wealth [1]. However, an
association between socioeconomic status (SES) and body
weight as well maintenance of good health is well established
and widely accepted [14, 15].
The longitudinal IDEFICS study included 2401 European
children between 2 and 10 years of age and has investigated
the association between socioeconomic disadvantages (chil-
dren from families with low income, low education, migrant
origin, unemployed parents, parents who lacked a social net-
work, and from non-traditional families) and children’s total
metabolic syndrome (MetS) score at baseline and follow-up
after 2 years. For the calculation of MetS risk score, the sum of
z-scores of waist circumference, blood pressure, lipids, and
insulin resistance was applied. At both time points, the authors
could clearly show a significant correlation between socioeco-
nomic disadvantage and higher MetS score compared to non-
Curr Obes Rep
Effects:
Cardiovascular
Disease
Impaired Glucose
Tolerance / Type 2 DM
CHILDHOOD
OBESITY
Psychosocial Problems
/ Stigmatisation
Malignancies
Orthopaedic Problems
socioeconomically disadvantaged children. This has led to the
conclusions that children from socioeconomically disadvan-
taged families have a high metabolic risk independently of
diet, physical activity, sedentary behaviors, and well-being
[34••].
Existing evidence suggests that socioeconomic determi-
nants may influence different levels from macro-economic
factors and the capacity to make individual health decisions
to microlevel factors such as epigenetic alterations [35, 36].
Factors leading to the individual increase in body weight
are very complex and far from completely being understood.
Many conditions and predispositions play in concert and are
responsible for the worldwide obesity epidemy. Important
drivers are changes in the food environment, such as 24/7
availability, accessibility, and affordability of energy-dense
foods and sugary drinks as well as marketing strategies of
such foods, which have led to excess energy intake and weight
gain, starting as early as in infancy and early childhood [37].
On the other hand, another driver for the obesity epidemy is
the reduced opportunity for physical activity during childhood
and adolescence as a result of urbanization as well as increas-
ing use of new media during leisure time [37]. This also results
in shorter sleep duration and lower sleep efficiency, associated
with a poorer cardio-metabolic risk profile in early adoles-
cence, independent of other obesity-related factors [38].
Thus, the impact of sleep quantity and quality on cardiovas-
cular risk profile, circadian rhythms across development (in-
fancy to adulthood), and other factors such as body weight
regulation/obesity in childhood and adolescence needs to be
assessed in addition to the factors discussed above [39]
(Fig. 1).
Obesity interventions have to date mainly focused on indi-
vidual behavioral changes, and we have clearly seen that these
measures do not lead to effective reduction of obesity preva-
lence and sustainable success in the long term in most
Curr Obes Rep
countries. Thus, we have to move fast towards community-/
environment-based approaches to stop the ball rolling.
Especially in the field of obesity prevention in childhood,
all community-based or environment-oriented interventions
would lead to health and development support for all children
and adolescents. Not focusing on certain risk groups further-
more may reduce social stigma of obesity. However, measures
for obesity prevention implemented to date cannot counteract
the obesity epidemic alone in our complex obesogenic envi-
ronment. Additional and distinct measures, as outlined in the
Global Action Plan for the prevention and control of
noncommunicable diseases of the WHO, have to be deter-
mined at the level of educational and health policy decision-
makers. To stop the global obesity epidemy, it is crucial that
political decision-makers are involved.
Conclusions
Intervention strategies for overweight and obesity in child-
hood and adolescence have been shown only limited effects
to date and are inadequate for long-term success in most coun-
tries of the world. Thus, a rethinking and revision of available
guidelines and recommendations is mandatory: community-
based or environment-oriented approaches as outlined above
are urgently needed to stop the global obesity epidemy and
improve individual health as well as the health of future
generations.
As many obese youngsters stay obese until adulthood and
as obesity is associated with significantly increased morbidity
and mortality later in life, normalization of body weight dur-
ing childhood and before puberty is becoming more and more
important. Every effort should be made to counteract the obe-
sity epidemy that we are facing and that has emerged towards
a global health crisis during the past decades.
Compliance with Ethical Standards
Conflict of Interest Susann Weihrauch-Blüher and Susanna Wiegand
declare they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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