Defining Obesity
One of the greatest struggles the fight on childhood obesity has seen is
the inability to agree on when a child is to be declared obese and how best
to measure obesity. The two most common practices for determining obesity
are the measuring of skinfold thickness and the calculation of BMI. BMI (body
mass index) is derived using height and weight. A BMI test will provide
consistent results for the same patient as they progress through life. A
skinfold test is usually done at the bicep and gives a more accurate measure
of adiposity in a child. However, there is more room for inconsistency using
this method. While the cutoff for obesity in adults is a BMI of 30 or greater,
there is debate about whether or not it is appropriate to use the same scale
for children because of the immaturity of their bodies (Pediatr, 2003). The
average BMI at birth is 13, it then rises to 17 at age 1 and drops again by
age 6 to around 15.5. Because children go through varying growth cycles, it
is not appropriate to use the same cutoffs as are used on adults. Preferably
there would be a standard table established that could correlate BMI to very
specific ages (Cole, 2000).
Because of the varying cutoffs for which children may be considered
obese, most studies will use BMI in relation to other study participants. This
is why population also plays a role in many studies and why many have
chosen to take participants from across the country as well as multinational
studies. For example, the average BMI in America would be higher than an
impoverished country, making it hard to use the same defining brackets. In a
population that is generally more obese to begin with, the data would show
that early onset of puberty has little to do with BMI, whereas in a community
featuring more extremes the age difference will be more noticeable (Cole,
2000).
each year). This went on at regular intervals until 1993 (See table 1).
Participants were taken out of three counties near the Dayton, Ohio
metropolitan area.
In this study the IOTF (International Obesity Task Force) standards of
obesity were used in addition to those of the CDC (Center for Disease
Control). The two differ slightly, with the IOTF standards focusing more on
appropriate cutoffs for childhood obesity. The IOTF has higher standards of
obesity, while the CDC has lower ones. A child may be considered normal by
the CDC, but overweight by the IOTF. What was found was that indeed, over
time, the FLS research subjects had become more obese. Between the birth
cohorts of 1930 and 1993, the prevalence of obesity rose from 0% to 14%
among FLS boys and from 2% to 12% among FLS girls. The prevalence of
overweight children rose from 10% to 28% among boys and from 9% to 21%
among girls. The trend towards obesity began starting in birth year 1970 for
boys and 1980 for girls (Hippel, Nahhas 2013). The study did find issues with
consistency of ethnicity of the cohorts because there was a large influx of
children of Hispanic heritage beginning in the 60s, where there was almost
none prior to that. Because of this, data of 20 Hispanic children was omitted.
Also omitted were 7 pairs of twins and 9 girls who became pregnant during
throughout the study. The ultimate conclusion of the study was that
childhood obesity is a fairly recent phenomenon. (where BMI was stable
throughout the 60s and 70s and began to rise steadily in the 80s, until the
present) The data of this study is consistent with national data.
concluded that in order for puberty to begin, a critical mass of ~42 kg must
be reached. An even higher ~46 kg must be reached in order for puberty to
be maintained. After reviewing longitudinal (a study that looks at continuous
data over time, versus single points of data) growth data for 181 normal
girls, Frisch and Revelle observed that the average weight at menarche was
consistently at 48 kg for girls who reached menarche before age 12,
between 12 and 13, between 13 and 14, and after age 14; however, average
height at menarche increased progressively the older the girls were at the
time of menarche. This data may imply that when a young girl reaches the
critical weight or ~48 kg, she is more likely to enter puberty than her peers.
The study also shows that height has very little to do with the onset of
menarche and that rather overall weight and fat percentage plays a larger
role (Kaplowitz, 2008).
Another study looked directly at the relationship between BMI and
skinfold thickness and timing of puberty. The National Heart, Blood, and Lung
Association did its National Growth and Health study using a cohort of 2379
girls. The cohort was equally black and white girls. They were recruited at
age 9, from Richmond, California, Washington, D.C. and Cincinnati, Ohio.
Each year the girls were measured for height, weight, skinfold thickness,
BMI, and stage of puberty. The average of menarche in white girls was 12.7
and the average age for black girls was 12. Upon completion of the study the
girls were divided into three groupings, based on age of menarche as
recorded. It was found that the girls who first entered menarche had, on
average, a higher BMI than others in the study. Subsequently those in the
mid-range group also had higher BMIs than those who were last to get their
periods (Biro, 2001).
Interestingly enough, a study conducted by the Girls-Health
Enrichment Multi-Site Study, found that amongst 147 black girls, those in
>95th% were found to develop breasts far before pubic hair and having their
first period (Himes, 2004). In the Bogalusa Heart Study, cross-sectional
studies (studies that compare single data points taken at different times)
were done; one in 1973-1974 and another in 1992-1993. The study consisted
of girls ages 5-17 who lived in a somewhat rural area of Louisiana. What the
study found was that over the course of 20 years the average age menarche
decreased ~9.5 months for black girls and ~2 months for white girls. Greater
than this though, is that it was found that girls in the >75th% were 1.79 times
more likely to experience menarche early, which was defined in this study as
before age 11 (Freedman et. al, 2002). This study specifically highlights that
while childhood obesity has been on the steady incline for the past 30 years,
the age of menarche has been decreasing. The timing of this study was also
fortunate because the first cross sectional was done before the 1980s, where
childhood obesity first began to spike. The second cross sectional shows a
more recent data set that accurately reflects how the rise in obesity has
decreased the age of menarche.
Another study also concluded that the age at which girls develop
breasts has decreased significantly. Before the 1980s, the average age of
healthy weight, but puberty and fertility were restored. In female rats that
had not yet undergone puberty, leptin helped lower the age of puberty as
well as accelerate it. Those rats that had higher initial body weights
responded even better to the leptin treatments because they already had a
high level of leptin being produced by their own adipose (fat) cells. The rats
eating a higher fat diet tended to enter puberty sooner than those on a low
fat diet (Ahima, Dushay, Flier, Prabakaran, J. Flier, 1997).
In females, levels of leptin rise throughout puberty, in correlation with
estrogen. In general, this is due to the increase of fat that occurs in the
female body during puberty. Women also have less leptin-binding proteins
than men, which means there is more free leptin within the body at any
given time. Patients with chronically low levels of leptin are unable to enter
puberty due to leptins association with the hypothalamus. Leptin may be the
messenger that tells the hypothalamus that fat store is adequate to enter
puberty. Therefore, if that level of fat is achieved at a younger age, the
hypothalamus engages pubertal hormones at a younger age. It was found
that girls with precocious puberty had twofold the amount of plasma leptin,
and higher rates of obesity, as compared to their peers. Consequences of
this include functional ovarian hyperandrogenism and polycystic ovary
syndrome due to an even higher increase of fat on top of the already existing
obesity (Shalitin, Phillip, 2003).
The Newcastle thousand family study was able to find a link between
obesity rates in children and adulthood. 1147 children were in the initial
cohort, however only 529 were able to be followed until past the age of 50. It
was noted that the socioeconomic situation of the remaining participants
was slightly better than the average of the collective group in the beginning.
However, since all socioeconomic classes are equally susceptible towards
obesity, this made no difference in the final data. What was found was that,
at age 50, those who had been in the >90th% at ages between 9-13 were
between 5 and 9 times as likely to be obese. As is standard for adults,
obesity is defined as having a BMI of 30 or more. Similarly, children in the top
10% of their weight class at the age of 13 were twice as likely to be
overweight or obese. Interestingly enough, it is around age 13 that children
enter puberty, implying that especially the ages 9-13 are critical for setting
weight for the rest of adulthood. The journal mentions that thin or children of
average weight are no less susceptible to become overweight or obese
adults (Wright, Parker, Lamont, & Craft, 2001).
Precocious puberty (puberty beginning before age 8 in girls and age 9
in boys) has been linked to multiple health risks (Mayo Clinic Staff, 2014). In
the past 50 years the age of the onset of breasts has decreased even more
than the onset of menarche. Breast development is enough to diagnose a
patient with PP (precocious puberty). In the Pediatric Research in Office
Settings study (PROS) it was found that 6.7% of all white girls and 27.7% of
all black girls could be diagnosed with PP. What differentiated this study from
several similar ones, is that all subjects in the study had their breasts
palpitated, rather than just observed. This has been an issue faced by other
studies, because it is difficult to differentiate between simple fat distribution
and development of breast tissue. Parents were also asked to rate the
developmental stage of the childs body.
Conclusion:
The age of menarche and onset of puberty has decreased over past
200 years. As humans have better access to nutrition, the rate of obesity,
and childhood obesity, has increased. Overweight children have long been
observed to develop faster than children of a normal weight. Specifically, in
girls, a higher BMI between the ages of 9 and 13 has been linked to an
increased likelihood of entering puberty at a younger age than that of her
peers. Multiple studies have concluded that girls in the >85th% for weight
mature sooner. This may be due to the increased levels of leptin in the body,
which has been linked to triggering an early puberty in rats. Other than early
puberty, being overweight as a child has health implications for the entire
adult life. Obesity leads to heart disease, hypertension, arthritis, joint
damage, and diabetes.
Tables
Table 1:
Participation in the Fels Longitudinal Study
a. Boys
Birth Year
Participant
s
Measurements
Mean
Minimum
Maximum
1930 to 1934
34
799
10.48
3.00
18.08
1935 to 1944
76
1612
10.37
3.00
18.30
1945 to 1954
88
1856
10.47
3.00
18.65
1955 to 1964
113
1874
10.36
3.00
18.70
1965 to 1974
106
1544
10.25
3.00
18.57
1975 to 1984
65
979
11.67
3.00
18.64
1985 to 1993
88
956
10.73
3.00
18.89
Birth Year
Participant
s
Measurements
Mean
Minimum
Maximum
1930 to 1934
42
956
10.30
3.00
18.15
1935 to 1944
73
1477
10.40
3.00
18.99
1945 to 1954
66
1283
10.47
3.00
18.60
1955 to 1964
132
2168
10.19
3.00
18.91
1965 to 1974
90
1345
10.03
3.00
18.80
1975 to 1984
60
890
11.03
3.01
18.85
1985 to 1993
83
992
9.91
3.00
18.97
b. Girls
Table 2:
References
Biro FM, McMahahon RP, Striegel-Moore R, et al. Impact of timing of
pubertal maturation on growth in black and white female adolescents: the
National Heart, Lung, and Blood Institute Growth and Health Study. J
Pediatr.2001.
Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Berenson
GS. Relation of menarche to race, time period, and anthropomorphic
dimensions: the Bogalusa Heart Study. Pediatrics.2002.
Cole, Tim J., Mary C. Bellizzi, Katherine M. Flegal, and William H. Dietz.
"Establishing a Standard Definition for Child Overweight and Obesity
Worldwide: International Survey." 6 May 2000. Web. 13 May 2016.
Kaplowitz, Paul B. "Link Between Body Fat and the Timing of Puberty."
Feb. 2008. Web. 13 May 2016.
Shaltin, S., and M. Philip. "Role of Obesity and Leptin in the Pubertal
Process and Pubertal Growtha Review." 2003. Web. 13 May 2016.
Wright, Charlotte M., Louise Parker, Douglas Lamont, and Alan W. Craft.
"Implications of Childhood Obesity for Adult Health: Findings from Thousand
Families Cohort Study." 1 Dec. 2000. Web. 13 May 2016.
The thousand familys cohort study and the long term effects of
being obese as a child into adulthood.