Our Kids Are Growing

By Peter Galvin, MD

Obesity during adolescence (ages 10 to 19) is associated with health consequences that include prediabetes and type 2 diabetes, nonalcoholic fatty liver disease, dyslipidemia, polycystic ovary syndrome, obstructive sleep apnea, and mental health disorders and social stigma. It is also a risk factor for complications and death from coronary artery disease as well as death from any cause in adulthood, including early adulthood. This was confirmed by a study of 2.3 million persons in Israel which found that BMIs (body mass index: weight divided by height squared, measured in kilograms and meters) in late adolescence that were between the 84th and 94th percentiles were associated with hazard ratios of 2.2 for sudden death and 3.5 for stroke during adulthood.

The prevalence of obesity in adolescents has increased markedly since the 1980s, especially in low-income commu­nities and communities of color. Partly, this is due to less access to medical care and the consumption of unhealthy foods, especially sugary drinks and processed foods, which are aggressively marketed and targeted toward these communities (ever notice how TV ads for fast foods are almost exclusively targeted toward people of color? No? Then you haven’t been paying attention to ads for KFC, Popeye’s, McDonalds, and Burger King). In the U.S., the prevalence of obesity in adolescents was 20.6% in 2015-2016, as compared to 14.8% in 1999-2000. Worse yet, the rates were 22% among non-Hispanic blacks and 25.8% among Hispanic adolescents, as compared to 14.1% among whites and 11% among Asians. Rates of weight gain worsened during the Covid-19 lockdowns, when schools were shuttered for a prolonged period. Also, obesity was the most common underlying condition for Covid-19-associated death in persons younger than 21 years of age.

The evaluation of obesity in adolescents includes a complete medical history including family history, as it is often the case that other family members are also obese. Lifestyle factors including diet and exercise are important, as is a psychosocial assessment. Lab testing is done to assess liver function and prediabetes/diabetes. Management and treatment are difficult and require the use of a multidisciplinary long-term model that includes lifestyle modifications and consideration of pharmacologic and bariatric surgical therapies. Sugar-sweetened beverages that lack any nutritional value must be eliminated from the diet. Research has shown that over the course of one year, each daily 12-oz serving of a sugar-sweetened beverage increases the BMI by 0.06. Dietary recommendations emphasize plant-based foods (i.e., vegetables, fruits, and whole grains), lean sources of protein, high fiber intake, and low consumption of saturated fats. Ketogenic diets have shown short-term safety and efficacy, but these programs have substantial attrition rates. Physical activity recommendations include daily moderate-to-vigorous physical activity for 60 minutes.

Anti-obesity medications have had some success but must be part of the multidisciplinary approach that includes diet and exercise. Orlistat, which has been used successfully in adults, has unpleasant side effects such as flatus (gas), oily spotting, and fecal urgency and incontinence which make it unsuitable for adolescents. Anti-diabetic medications like Ozempic and metformin have been used successfully. As a last resort, bariatric surgery is sometimes necessary, although long-term complications include mineral deficiencies, bone loss, and weight re-gain. Unfortunately, costs and limited access to these therapies make them out of reach for some.

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