JPediatr(RioJ).2015;91(2):105---107
www.jped.com.br
EDITORIAL
Preventing
childhood
overweight
and
obesity
夽
,
夽夽
Prevenc
¸ão
do
sobrepeso
e
da
obesidade
infantis
Mercedes
de
Onis
GrowthAssessmentandSurveillanceUnit,DepartmentofNutrition,WorldHealthOrganization,Geneva,Switzerland
Childhood obesity is widely recognized as a major public health problem of global significance.1 In Latin America, the ever-rising rates of overweight and obesity observed overthe pastthreedecadeshavenotsparedchildren and adolescents.Themostrecent dataestimatethatbetween 42.4and51.8millionchildrenandadolescents(0-18years) areoverweightor obese,representing20-25%of thetotal population of children and adolescentsin the region.2 In children younger than 5 years, the estimated prevalence ofoverweightandobesitybasedontheWHOChildGrowth Standards3 was reportedto be 6.9% (95% CI:5.8-8.0%) in 2010.4 In school-aged children, national combined preva-lencesof overweightand obesity reportedinthe lastfive yearsusingtheWHOgrowthreference5rangedfrom18.9%in Colombia(bothgenders)to36.9%inMexicanboys.2Although notavailablefor thepast fiveyears,prevalencesin Brazil (2009)andinChile(1997)werealmostashighasthosefound in2012inMexico,suggestingthatthemagnitudeofexcess BMIinthesetwocountriesissimilartoorevenhigherthan inMexico.2
Awareness of the high rates of overweight and obe-sity during childhood together with the range of health consequences associated with these conditions from
DOIoforiginalarticle:
http://dx.doi.org/10.1016/j.jped.2014.06.004
夽
Pleasecitethisarticleas:deOnisM.Preventingchildhood over-weightandobesity.JPediatr(RioJ).2015;91:105---7.
夽夽
SeepaperbyFariasetal.inpages122---9. E-mail:[email protected]
psychosocial consequences to adverse metabolic effects on blood pressure, cholesterol, triglycerides, and insulin resistance6---8 haspromptedthedevelopmentofanumber ofaction plansandtheestablishmentofglobal targetsfor thepreventionofobesityinchildrenandadolescents. Cen-traltotheLatinAmericanregionisthePlanofactionforthe preventionofobesityinchildrenandadolescentsfor 2014-2019,whichthePanAmericanHealthOrganization(PAHO) approvedinJuneof2014atthe154th sessionofits
Execu-tiveCommittee.9TheregionalPlanfocusesontransforming thecurrentobesogenicenvironmentintoahealthyonethat providesopportunities forconsumption ofnutritious foods andphysicalactivity,andalignsitselfwithearlier interna-tionalmandatesemergingfromtheWorldHealthAssembly, inparticulartheWHOglobalstrategyondiet,physical activ-ity,andhealth,10thePoliticaldeclarationofthehigh-level meeting of the general assembly on the prevention and controlofnon-communicablediseases,11andtheWHO com-prehensiveimplementation planonmaternal,infant,and youngchildnutrition.12
Alltheseplansofactionemphasizetheessentialroleof physicalactivityinthecontrolofchildhoodobesity,thereby underscoring the relevance in this issue of the Jornal de Pediatria of the contribution of Farias et al.13 reporting ontheimpactofprogrammedphysicalactivityinreducing bodyfatinpost-pubertalschoolchildren.Theauthors com-pared a control group of 191 students aged 15-17 years attendingconventionalphysicaleducationclassesatschool with a study group comprising 195 students of the same agewhoparticipatedindailyprogrammedphysicalactivity, including 30minutes of aerobic activity (exercises for
http://dx.doi.org/10.1016/j.jped.2014.10.002
106 deOnisM
flexibility,muscularstrength,jumpingrope,walking, alter-natingrunning, continuous jumping, recreational games), 20minutesofsportsgames(volleyball,soccer,handball)and 10minutesofstretching.Attheendoftheschoolyear,there wasa significant decrease in fat mass and percentage of bodyfatinthestudygroupcomparedtothecontrolgroup.13 Theprogrammedphysicalactivityimplementedinthestudy groupisconsistentwithinternationalrecommendationsfor theagegroup5-17yearsold.14ArecentWHOguideline con-cluded that the scientific evidence available for this age group supportsthe overall conclusion that physical activ-ityprovidesfundamentalhealthbenefits.Thedocumented healthbenefitsincludeincreasedphysicalfitness(both car-diorespiratoryfitnessandmuscularstrength),reducedbody fat, enhanced bone health, favorable cardiovascular and metabolichealthbiomarkers,andreducedsymptomsof anx-ietyanddepression.14 The specificrecommendations from theguidelinegroupare:
1 Children and young people aged 5-17 years old should accumulateatleast60minutesofmoderate-to vigorous-intensityphysicalactivitydaily;
2 Physicalactivitylastinglongerthan60minutesdailywill provideadditionalhealthbenefits;
3 Mostdailyphysicalactivityshouldbeaerobic. Vigorous-intensity activities should be incorporated, including those that strengthen muscle and bone, at least three timesperweek.
For children and adolescents 5 to 17 years old, phys-ical activity includes play, games, sports, transportation, recreation,physicaleducation,orplannedexercise,inthe context of family, school, and community activities. For inactivechildrenandyouth,aprogressiveincreasein activ-itytoeventuallyachievethetargetsaboveisrecommended. It is appropriate to start with small amounts of physical activity and gradually increase duration, frequency, and intensityovertime.14
Whileschool-basedprogramsthatpromoteplanned phys-icalactivitysuchasthatdescribedbyFariasetal.13playan importantrole,itisalsoessentialtobeawarethat contem-porarychildren establish a sedentarylifestyle at an early age.15Themodernenvironmentencouragesinactivityatall levelsandinallsettings(e.g.,work,school,transportation, home),andyoungchildrenarenotimmunetothistrend.As youngchildrenestablishasedentarylifestyle,theyalmost certainlypredisposethemselvestooverweightandobesity. Thisisreflectedinobservedtrendsfortheseconditionsin children aged 0-5 years. Worldwide, in the period 1990-2010,therewasarelativeincreaseof21%(firstdecade)and 31%(second decade) inthe prevalenceof early childhood overweightand obesity,whereasthe forecast for the rel-ativeincrease in the present decade (2010-2020) is 36%.4 About 50% of the countries with available national data showrising trendsfor overweightin pre-schoolers(50out of102 countries).16 These data confirm theneed to com-bineschool-basedapproacheswitheffective interventions startingasearlyasinfancytoreverseanticipatedtrends.
What does all this meanfor Latin America? The avail-abledata for the regionare eye-opening andcry out for urgent action. Rates of overweight and obesity in youths suchasthosereportedforBrazil, Chile, andMexicocarry
vast health andeconomic consequences.2 As governments becomemoreawareofthecostofoverweightandobesity forindividualsandsociety,policyoptionsarebeingdiscussed andimplementedlocallyandnationallyinsomeLatin Amer-icancountries.2,9ThePlanofactionforthepreventionof obesity in children and adolescentsfor 2014-2019, which the PAHOapproved in June 2014, providescountrieswith a useful framework for taking action at the highest lev-elstodealwiththissignificantpublichealthproblem.The Plandrawsattentiontothevast,robustscientificand pub-lichealthknowledgeaboutthemechanismsinvolvedinthe current obesity epidemic and the public action required to control it; and promotes coordination between public institutions primarilyinthesectorsofeducation, agricul-ture,finance,trade,transportation,andurbanplanning to achievenationalconsensusandsynergiestohaltprogression oftheobesityepidemicamongchildren.9Italsoestablishes an integrated monitoring, evaluation, and accountability system for policies, programs, legislation, and interven-tions, which willmake itpossible toassess the impactof implementingthePlan.Assessingtheimpactofpoliciesand programs is crucial to building evidence of cost-effective interventionsforcontrollingtheobesityepidemic.
In the light of circumstances, however, it is essential toconsider thefact that mostcountries in Latin America faceadoubleburdenofnutritionaldeficits(mainlystunting andmicronutrientdeficiencies)andexcessbodyweight.17,18 Addressing theproblemofchildhoodobesity intheregion willhave thisaddedcomplexity,asmanyof thecountries have notyet attunedtheirnutritionandfoodpoliciesand programs designed decades ago with a focus on the control of undernutrition to their new epidemiological profiles. Contrary to the belief of some decision-makers, undernutrition and obesity are not unrelated problems requiring separate solutions. For example, undernutrition fromconceptiontotheendofthefirst2yearsoflifeisarisk factor for overweight andobesity,and non-communicable diseases.19 Thepromotionofappropriatefeedingpractices forinfantsandyoungchildrenwillthuseffectivelyprevent both undernutrition and excess bodyweight. In contrast, overweight childrenandadolescentsarea high-risk group forirondeficiency20andothermicronutrientdeficiencies.21 This ‘‘nutrition paradox’’, the coexistence of nutritional deficit and excess in individuals and populations, should be taken into consideration when Latin American gov-ernments design national strategies to control childhood obesity.
Preventingchildhoodoverweightandobesity 107
internationalconsensusisthatpreventionisthemost realis-ticandcost-effectiveapproachforcontrollingtheproblem ofchildhoodobesity.Thepreventionofexcessweightgain willrequireabroad publichealth policyperspective,with multisectoralmeasuresinvolvingmanystakeholders,asthe PAHOandtheWHOhaveproposed.9,10,12Thisapproachwill requiresubstantialpolitical will andfinancial investment, but it will yield a richer dividend to society in the long term.
In addition to multisectoral approaches that focus on transformingthecurrentobesogenicenvironmentintoone promoting healthy diets and physical activity, the early recognition of excessive weight gain relative to linear growth is essential. Routine assessment of all children usingappropriatemethodsandequipmentneedstobecome standardclinicalpracticefromveryearlychildhood.Recent studiesshowthatthetrendtowardschildhoodobesitystarts as early as 6 months of age,22,23 and that the choice of growth standard is essential for identifying the onset of excess weight gain in both infants23 and school-age chil-drenandadolescents.24Earlyinterventionwhenanincrease inweight-for-height orBMI percentileshas beenobserved should provide parents and caregivers with guidance and supporttopromotehealthyeatinghabitsandroutine phys-icalactivity.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
References
1.WorldHealthOrganization(WHO).Globalstatusreportof non-communicablediseases2010.Geneva:WHO;2011.
2.RiveraJÁ,deCossíoTG,PedrazaLS,AburtoTC,SánchezTG, MartorellR.Childhoodandadolescentoverweightandobesityin LatinAmerica:asystematicreview.LancetDiabetesEndocrinol. 2014;2:321---32.
3.WHOMulticentreGrowthReferenceStudyGroup.WHOChild GrowthStandardsbasedonlength/height,weightandage.Acta PaediatrSuppl.2006;450:76---85.
4.deOnisM,BlössnerM,BorghiE.Globalprevalenceandtrends ofoverweightandobesityamongpreschoolchildren.AmJClin Nutr.2010;92:1257---64.
5.deOnisM,OnyangoAW,BorghiE,SiyamA,NishidaC,Siekmann J.Developmentof a WHOgrowth reference for school-aged childrenand adolescents.Bull WorldHealth Organ.2007;85: 660---7.
6.DietzWH.Healthconsequencesofobesityinyouth:childhood predictorsofadultdisease.Pediatrics.1998;101:518---25.
7.Lobstein T, Baur L, Uauy R. IASO International Obesity Task Force.Obesityinchildrenandyoungpeople:acrisisinpublic health.ObesRev.2004;5:4---104.
8.deOnisM,Martínez-CostaC,Nú˜nezF,Nguefack-TsagueG, Mon-talA,BrinesJ.AssociationbetweenWHOcut-offsforchildhood overweightandobesityandcardiometabolicrisk.PublicHealth Nutr.2013;16:625---30.
9.Plan ofaction for the preventionof obesity inchildren and adolescents.ResolutionCE154.R2.In:154thSessionofthePan
AmericanHealthOrganizationExecutiveCommittee. Washing-ton,D.C.,USA,16-20June2014.
10.WorldHealthOrganization(WHO).Globalstrategyondiet phys-icalactivityandhealth.Geneva:WHO;2004.
11.PresidentoftheGeneralAssembly.Politicaldeclarationofthe high-levelmeetingoftheGeneralAssemblyontheprevention and control ofnon-communicable diseases(A/66/L. 1).New York:UnitedNationsGeneralAssembly;2011.
12.WorldHealthOrganization(WHO).Resolution WHA65.6.WHO comprehensiveimplementationplanonmaternal,infant,and youngchildnutrition.Maternal,infantandyoungchild nutri-tion.In:Sixty-fifthWorldHealthAssembly,Geneva,21-26May. Resolutionsanddecisionsannexes.Geneva:WHO;2012.
13.FariasES,Gonc¸alvesEM,MorcilloAM,Guerra-JúniorG,Silverio AmancioOM.Effectsofprogrammedphysicalactivityonbody compositioninpost-pubertalschoolchildren.JPediatr(RioJ). 2015;91:122---9.
14.WorldHealthOrganization(WHO).Globalrecommendationson physicalactivityforhealth.Geneva:WHO;2010.
15.Reilly JJ, Jackson DM, Montgomery C, Kelly LA, Slater C, GrantS,etal.Totalenergyexpenditureandphysicalactivity inyoung Scottish children:mixed longitudinalstudy.Lancet. 2004;363:211---2.
16.World Health Organization (WHO). WHO Global Database on ChildGrowthandMalnutrition.Geneva:WHO;2014.
17.DuranP,CaballeroB,deOnisM.Theassociationbetween stunt-ingandoverweightinLatinAmericanandCaribbeanpreschool children.FoodNutrBull.2006;27:300---5.
18.BlackRE, Victora CG, WalkerSP, BhuttaZA, ChristianP, de Onis M, et al. Maternal and child undernutrition and over-weight in low-income and middle-income countries. Lancet. 2013;382:427---51.
19.VictoraCG,AdairL,FallC,HallalPC,MartorellR,RichterL, etal.Maternalandchildundernutrition:consequencesforadult healthandhumancapital.Lancet.2008;371:340---57.
20.NeadKG,HaltermanJS,KaczorowskiJM,AuingerP,Weitzman M.Overweightchildrenandadolescents:ariskgroupforiron deficiency.Pediatrics.2004;114:104---8.
21.Pinhas-HamielO,Doron-PanushN,ReichmanB,Nitzan-Kaluski D,ShalitinS,Geva-LernerL.Obesechildrenandadolescents: a riskgroupfor lowvitaminB12concentration.Arch Pediatr AdolescMed.2006;160:933---6.
22.McCormick DP, Sarpong K, Jordan L, Ray LA, Jain S. Infant obesity: are we ready to make this diagnosis? J Pediatr. 2010;157:15---9.
23.vanDijkCE,InnisSM.Growth-curvestandardsandthe assess-ment of early excess weight gain in infancy. Pediatrics. 2009;123:102---8.
