Playground Play Equipment

A Sober Look At Childhood Obesity And Its Relationship With Outdoor Play

Childhood Obesity And Outdoor Play

Childhood obesity is arguably at its most critical and alarming issues we face worldwide. According to the World Health Organisation (WHO), it’s one of the most severe public health challenges of the 21st century. This global epidemic is hitting low and middle-income countries, more significantly in urban settings. Globally in 2016, the number of overweight children under the age of five was 41 million. Furthermore, overweight and obese children tend to stay obese into adulthood and are prone to developing diseases like diabetes and cardiovascular ailments at a younger age.

Childhood obesity* and related diseases, such as diabetes are mostly preventable. For this reason, the WHO prioritises the prevention of these conditions in youth, especially because poor dietary habits and a sedentary lifestyle are among the leading causes of noncommunicable diseases. These conditions, including cardiovascular disease, type 2 diabetes and certain types of cancer, contribute substantially to the global burden of disease, death and disability. (1)

*To clarify, the terms ‘overweight and obesity’, as defined by The World Health Organisation is “abnormal or excessive fat accumulation that presents a risk to health”. (2)

Furthermore, many significant studies show that overweight and obesity in childhood can negatively influence a child’s executive function and academic performance. Children who are overweight and obese experience a higher level of bullying amongst peers as well as experiences that lower their confidence and esteem, therefore posing a risk of developing unhealthy or underdeveloped social and emotional factors in children. Social and emotional factors and poor academic experiences that can influence a child through to adulthood.

In response to these findings the UK government’s Chief Medical Officer, Dame Sally Davies, has issued a report ‘Time To Solve Childhood Obesity’, the report includes ten guidelines for potential solutions to the problem. Which include actions toward promoting healthy eating, and physical activity for all children. Dame Sally Davies calls for the cooperation of other organisations, including schools, politicians and industry, to help reach the goal of halving childhood obesity by 2030. (3)

All studies, and reports worldwide, including those from the World Health Organisation and UK government highlight a need to combine healthy eating with physical activity and education to combat the problem.

How they plan to do that follows in this paper along with ways that schools can support this worldwide mission to counter childhood obesity and give children the right to a healthy, happy life and a successful education through supporting all-year-round physical exercise and outdoor play.

What Are Physical Effects Of Childhood Obesity?

The ‘Time To Solve Obesity Report’ by Dame Sally Davies claims that six children in a class of thirty are obese in the last year of primary school, and four are overweight. Over the past thirty years, this number has nearly doubled. (3)

Obesity during childhood harms a child’s body in several ways. Children who have obesity are more likely to have asthma and other types of breathing problems like sleep apnea, high blood pressure and high cholesterol, musculoskeletal discomfort and joint issues. They are also exposed to gallstones, heartburn fatty liver disease and are at risk of type 2 diabetes, insulin resistance and impaired glucose tolerance. (4-10)

It’s a sombre outlook.

Furthermore, children who have obesity are more likely to become adults with obesity which leads to increased acute health issues and cancer. 11-12

Cardiovascular Disease

Doctor's StethoscopeChildhood obesity brings some concerning problems and risks, which are a consequence of excessive fat accumulation. Specifically, metabolic disturbances are a common risk factor which often leads to chronic diseases like type 2 diabetes, hypertension, and cardiovascular disease. (13-14)

Metabolic syndrome is the most common condition linked to childhood obesity.

The connection between metabolic syndrome and childhood obesity is new since traditionally, most medical practitioners associated metabolic and cardiovascular complications to be a risk factor reserved only with adults.

Metabolic syndrome (MS) is by far the most extensively described condition associated with childhood and adolescent obesity and has traditionally been supposed to be a risk factor for adult cardiovascular and metabolic complications. (15)

A patient must have obesity and two more risk factors to define metabolic syndrome in children, adolescents and adults. (15) These risk factors include:

  • High diastolic and/or systolic blood pressure – diastolic blood pressure highlights how much pressure your blood exerts against your artery walls between beats. Systolic blood pressure measures the same pressure, but it measures it when the heartbeats.
  • Low high-density lipoprotein cholesterol (HDL-C) – When there’s too much low-density lipoprotein in your blood, it can build up along the walls of your blood vessels, narrowing the passageways. When this occurs there is a risk of forming blood clots (which can cause a stroke or heart attack are higher), a common name for this risk factor is ‘bad cholesterol’.
  • High triglycerides (TG) – A type of fat in your blood. You need a healthy balance of fats to remain healthy, too many triglycerides can raise your risk of heart disease and can be a sign of metabolic syndrome.
  • Abnormal glucose homeostasis – A cell containing adipose tissue (body fat) that is circulating at increased levels in obesity. These cells impair glucose tolerance. (16 – 19)

Real cardiovascular studies at Princeton Lipid Research Clinic show that participants who have persistently have high triglycerides or high blood pressure from childhood which continues into adulthood have a three times higher risk of developing type two diabetes in adulthood than somebody who does not start out with these medical concerns. Furthermore, a child with persistently elevated triglycerides continuing into adulthood has a five times higher risk of developing cardiovascular disease. This study highlights how critical it is to consider the effects of obesity in children, especially when considering metabolic syndrome and its associated risks. (20)

Aside from the risk of developing type two diabetes and cardiovascular disease studies also show despite some being population-based and not solely focused on obese children that obese children and adolescents have higher cIMT* if they have metabolic syndrome or even just one component of metabolic syndrome they also show a connection between metabolic syndrome and left ventricular hypertrophy** (21-23)

It’s a bleak outlook.

* cIMT: Increased carotid intima-media thickness – the measurement of the thickness of the two layers of the carotid artery. If the thickness is above the normal range, it can lead to left ventricular hypertrophy (LVH).

**Left ventricular hypertrophy refers to the thickening of the heart’s pumping chamber which prevents the heart from pumping efficiently.

While these studies demonstrate the dire consequences of childhood and adolescent obesity as well as adult obesity, there are also promising studies indicating that it is possible to reverse the effects that obesity has on the onset of cardiovascular disease in children. But the way to change the prognosis is for children to recover from their obesity.

The Bogalusa, Muscatine, Cardiovascular Risk in Young Finns and Childhood Determinants of Adult Health studies on 6,328 subjects show that children and adolescents who recover from obesity show the same risks of developing increased cIMT, adult diabetes, or hypertension as children who never were obese. (24)

Diabetes and Glucose Intolerance

Metabolic syndrome prevalent in obese children (and discussed above) leads to type two diabetes, impaired glucose intolerance and insulin resistance.

However, type two diabetes is often considered an adult disease – at least it was until recent times. The first known cases of type two diabetes in children occurred in England in 2000. Fast track to today and there are over 700 children known to be living with type two diabetes and over 100 new child diagnoses every year.

When type two diabetes occurs in children, it’s more severe and rapidly progresses to severe complications like leg ulcers, sight damage and perhaps worse kidney failure. (25)

Respiratory Disease

If the picture we’re painting above wasn’t enough, there are further complications. Respiratory problems, such as asthma and sleep apnea, are known to be associated with childhood obesity. While a direct link between asthma and childhood obesity is still under research, many examples lead to the notion that there’s a connection yet to be discovered.

For example, asthma in children has paralleled the rise in obesity, and furthermore, obesity also appears to increase the severity of asthma. (25)

In obese children, excess fat burdens the respiratory system, especially during exercise, which could mean that the excess fat diminishes exercise tolerance in children. (26) Perhaps due to the onset of dyspnea on exertion – the feeling of running out of air during physical activity or not breathing fast or deeply enough. This theory could explain why many reports on obese children acknowledge an obese child’s low physical activity and fitness levels. It doesn’t take a scientist to realise dyspnea on exertion, and low physical activity in children does not equate to a happy, healthy childhood.

There is also a link between childhood obesity and sleep apnea – a condition where breathing stops and starts while you’re sleeping. Severe obesity and sleep apnea may lead to obesity-hypoventilation syndrome (a condition found in some people with obesity, whereby poor breathing leads to lower oxygen and higher carbon dioxide levels in the blood). (25) This condition also comes with further respiratory risk factors like:

  • Hypoxia – Commonly found in people who experience high altitudes, hypoxia is the name given for a person experiencing low oxygen levels in their blood. Symptoms include coughing, wheezing, shortness of breath, fast heartbeat, confusion and blue coloured skin and lips.
  • Hypercapnia – Excessive amounts of carbon dioxide building up in your bloodstream. People who suffer from COPD (chronic obstructive pulmonary disease) usually experience hypercapnia. Symptoms include daytime sluggishness or sleepiness, headaches, shortness of breath, anxiety and in extreme circumstances, seizures.
  • Reduced ventilatory drive – When the ventilatory drive reduces, it blunts the perception of danger and therefore decreases the alarm reaction to critical situations like severe airway obstruction or severe hypoxemia or hypercapnia.

While there appears to be a correlation between obesity and respiratory disease, and a steady rise in respiratory disease that parallels the increase of obesity in children, this is an emerging body of research. And one where much more work is required to fully understand the connection between respiratory disease and obesity in children.

Joint Problems and Musculoskeletal Discomfort

Human SkeletonAn interesting risk factor associated with childhood obesity. Children with obesity often experience joint problems and musculoskeletal discomfort. It seems glaringly obvious that a child who lives with obesity may experience these problems, perhaps due to the child’s excess weight to carry on their growing body every day. But the interesting thing is, childhood obesity doesn’t appear to have a direct link with joint and muscular discomfort – the excess weight doesn’t seem to be the cause of musculoskeletal or joint pain. Instead, the social and emotional problems that come from obesity in children appear to cause joint and musculoskeletal discomfort.

Problems like depression, social isolation, low self-esteem and loneliness are linked with cardiorespiratory fitness in obese children and young people. Cardiorespiratory fitness is the ability (or lack thereof) of the circulatory and respiratory systems to supply oxygen to skeletal muscles during sustained physical activity. 27,28. Because of this link, obesity in children can impact a child’s osteoarticular health, leading to chronic pain.

This link between obesity, cardiorespiratory fitness and osteoarticular health in children presents the same problems in adults with obesity as it does in obese children. It appears as though the majority of these studies focus on adults, which means that childhood obesity and osteoarticular health requires more research. But we can take what we know from adults with obesity and pose it as a potential risk for children with obesity.

Obesity in adults is linked to cardiovascular disease and diabetes (mentioned earlier in this paper), and some cancers. (1) Also, cartilage breakdown and osteoarthritis. (29)

Maybe you don’t need a study to confirm that this kind of damage to the body is going to be painful and will likely be detrimental to a person’s experience and quality of life, but many studies also confirm this notion. (30)

It’s not a risk many of us would wish to impose on children, which is why there is such an emphasis for all (politicians, manufacturers, retailers, schools, parents and communities) to tackle childhood obesity today.

Non-Alcoholic Fatty Liver Disease In Childhood

Finally, but probably not exclusively, non-alcoholic fatty liver disease is also present in children who live with obesity and are a risk to the child’s health. Non-alcoholic fatty liver disease includes gallstones and gastro-oesophageal reflux heartburn). (31)

According to the NHS non-alcoholic fatty liver disease is a group of conditions caused by high levels of fat in the liver’. It usually has no symptoms aside from some stomach pain, weakness and lethargy. There is no medicine to counter fatty liver disease, and the NHS cite weight loss, healthy eating and regular exercise to manage this problem. Diabetes, high blood pressure, high cholesterol and obesity are usually the cause of fatty liver disease.

So far, we have determined that a child who lives with obesity can be susceptible to a plethora of severe health conditions. Conditions that can lead to time off school, reduced exercise, an inability to concentrate, lethargy, sleepiness, headaches or confusion that can be symptoms of a respiratory and metabolic disorder. All of this while the child is obligated to attend school every day and perform academically. It is an equation that does not add up; obesity in children could and does take away the child’s right to thrive, be healthy and have a good education especially if these problems are undiagnosed. However, the problem does not stop there – while the child is sitting in class, dealing with all of these physical problems, they still have to encounter and live with the social and emotional problems that arise from living with obesity.

The Social, Emotional and Cognitive Implications Of Childhood Obesity In Children

Aside from medical problems, childhood obesity is also linked to low self-esteem, lower quality of life, depression, anxiety, social issues related to bullying, stigma and peer pressure. 32-34. Overweight and obese children may also develop academic problems, and a poor relationship with food, both due to their obesity and as a side effect linked to the social and emotional issues already highlighted. (35)

Bullying and Stigma

Social problems refer to the bullying and stigma often associated with childhood obesity.

Studies show that children with obesity have a 63% higher chance of being the target of bullying in school-aged children. These early life experiences can trigger immense negative feelings and even shape the child’s identity towards shame, depression, worthlessness, a lack of trust of the world and in others, low body image and even suicide. (36)

Perhaps most surprisingly, teachers can develop biased attitudes towards a child with obesity. As cited by the World Health Organisation, teachers have shown lower expectations from the obese child, a lack of understanding or patience and even the presumption of laziness. (36) Naturally, this experience can influence a child’s experience of life and sabotages their chance to develop healthily psychologically, emotionally, socially and academically all of which can lead to health and social inequities as the child grows into adulthood. While we recognise that it is most likely no teachers’ intention to make a child feel this way, it should be acknowledged and understood.

Low Self-esteem And Lower Self-reported Quality Of Life

As we saw earlier in this article, conditions like respiratory disease cause problems for children that can lead to social and emotional problems. For example, children with obesity may experience a compounding sense of failure when they cannot concentrate in school because they are too sleepy, anxious, uncomfortable, or have a headache. In this situation, how can they concentrate and do well? Especially if the child has an undiagnosed medical condition and is then at risk of teacher bias and weight biased attitudes from peers that do not correlate with supporting a child’s healthy development of a well-rounded sense of self-esteem.

Anxiety and Depression

Aside from the physical and social problems that lead to depression already mentioned in this paper, other conditions compound the problem. For example, an unhealthy diet, sleep disturbances and low physical activity are all associated with anxiety and depression in children. (37,38)

The problem is that anxiety and depression in both children and adults can be a compounding problem. 39. Sedentary activity caused by obesity in children leads to depression, and then depression causes an increase of sedentary activity secondary to a depressed mood, which leads to decreased motivation. It is a downward spiralling cycle that no child deserves to experience.

What Are The Long Term Effects Of Childhood Obesity On Academic Performance?

The psychosocial issues that children with obesity experience often relates to poor academic performance. (40) Studies in the USA, Asia and South America show significant and discouraging associations between childhood obesity and academic performance. (41 – 44)

Though the exact link between obesity and academic performance remains undefined, psychosocial factors like low esteem and altered peer relationships appear to influence the decline in academic success in obese children. (45) Additional research also shows how cognitive abilities like executive function in obese children can influence academic performance negatively. (46-47)

A study reveals an association between BMI and lower grades in a sample of adolescents (age 14 – 17) in America. (48) While another study in adolescents age 14 -15 found that children with obesity showed lower scores on math and reading tests than their peers who were not overweight 49. In this particular study, controls were set to counter any social-economical influences that may distort the outcomes.

Many similar studies demonstrate how obesity in childhood influences cognitive memory and other executive functions negatively. These issues are serious, they affect the quality of our children’s lives, education, and life chances. In later life, these can reduce their productivity, earnings and shorten their lives.

What Are The Causes Of Childhood Obesity?

The World Health Organisation discusses the ethical considerations necessary to avoid oversimplification of the cause of childhood obesity which can imply that a quick and easy approach is necessary to solve a seemingly simple problem – the need to encourage children to eat less, eat healthier and be more active. Nevertheless, managing the problem of childhood obesity is not as easy as it first seems. There are social-economical factors to consider – not all children have access to healthy foods. Some parents cannot afford to feed their children healthily, or do not understand how to provide healthy foods for their children. It is also essential to be very careful not to contribute further to the stigma associated with obesity. (2)

Children are usually not in control of the food they eat or the exercise they take. Moreover, when they exercise, the respiratory implications and body weakness discussed earlier in this paper can lead to embarrassment amongst their peers as they struggle to move.

However, it is necessary to encourage healthier eating, more exercise, and support a child who lives with obesity in fighting the depression, anxiety, stigma, and the health and academic implications associated with obesity, which is a task much more significant than it first appears.

We can break down some of the remedies Dame Sally Davies proposes in her report: Time To Solve Childhood Obesity into three factors. 3.

  • Children need to play outdoors.
  • Children need access to healthy foods.
  • Policies need to be implemented by schools, manufacturers, health services, town planners and politicians to create better opportunities for children to have access to outdoor play and healthy food regardless of their social-economic status.

The World Health Organisation appears to have the same ideas as Sally Davies, who cite:

“The fundamental cause of childhood overweight and obesity is an energy imbalance between calories consumed and calories expended.”

The World Health Organisation (WHO) recognises that the rise and prevalence of childhood obesity is a direct result of social change. While obesity is linked to low levels of physical activity and unhealthy eating, it is not solely the child’s behaviour at the root. Social and economic policies in the following areas appear to be the cause (and the secret to reversing the problem) today: education, marketing and distribution, agriculture, urban planning, transport, the environment and food processing.

The WHO claims that across the globe increases in overweight and obesity in childhood arises from several factors:

  1. A global shift in diet towards high sugar and high-fat foods which are, energy-dense and low in vitamins and minerals.
  1. Decreased physical activity levels, resulting from sedentary recreation time, urbanisation and transportation.

According to the WHO the problem is ”societal and demands a multisectoral, multidisciplinary and culturally relevant approach”. Children cannot choose the food they eat any more than they can choose the environment they live in. They are also limited in their ability to understand the long term consequences of their decisions or behaviour, which is why the WHO calls for special attention when fighting obesity in children.

Deprivation of Outdoor Play

It is well known that the opportunities that all children have to play outdoors are declining. A deprivation of outdoor play has a hugely detrimental impact on all children – it damages their early childhood development. It poses other significant consequences too, children who are deprived of outdoor play experiences frequently develop counterintuitive behaviours to both their healthy development and their academic performance. They can also demonstrate behaviours such as depression, aggression, impatience, and anti-social skills and can become obese. 50. Play deprivation also leads to reduced sensory stimulation, which reduces electrical brain activity. (51)

Factors that influence the reduced opportunities for outdoor play involve:

1. Inadequate and Unsafe Social Environments

Our outdoor environment is increasingly dominated by vehicles, limiting a child’s ability to explore their outdoor environment safely. It compromises their safety when participating in simple activities we often take for granted like being able to walk or cycle to school. The increase in traffic also reduces the air quality and can agitate any pre-existing respiratory problems a child may be living with making outdoor play undesirable. (3)

2. Parental Risk

Parents are increasingly, and understandably growing in concern for their child’s safety when they are away from home. The problem is so significant that parents often restrict their child’s independent access to local parks and streets that were once a familiar haunt for many children. (52) This change in parental behaviour appears to be linked to safety concerns, such as stranger danger and road traffic danger. (53) Though more research is necessary. There is also a possibility that children may constrain their active play themselves because of their own perceptions of risk and safety.

3. The Rise In Media Replacing Play

Today’s children play outdoors far less frequently than their preceding generations. (53,54) A problem can in some situations attribute to the increase of media available to children, such as computers, games and TV. All of which ”seduce” children away from playing outdoors.

4. Driving Children To School

Perhaps owing to parental risk factors, or perhaps busy lifestyles, more parents drive their children to school, friends and after school clubs than ever before. This action removes opportunities for a child to exercise daily.

The significant changes in our living environment combined with the type of food we eat and have access to is making it more difficult for everybody to maintain a healthy weight – adults and children. Perhaps it is a sign of the times, a time to reconsider how we live and plan our outdoor environment so that we may all children and adults alike have the opportunity to live healthily.

How Can Schools Help To Prevent Childhood Obesity?

Curbing the childhood “obesity epidemic requires sustained political commitment and the collaboration of many public and private stakeholders”, according to the World Health Organisation. According to the WHO and the UK’s Chief Medical Officer schools will need to introduce the following. (2)

Weight Victimisation Policies

Schools need to create policies to prevent weight victimisation in school, and parental advocacy on behalf of their children to express weight bias concerns and promote awareness. (37)

School Canteen Policies

The WHO recommends the following actions to prevent or reduce childhood obesity:

  • Increased consumption of fruit, vegetables, legumes, nuts and whole grains.
  • Remove saturated fats and replace with unsaturated fats.
  • Limit sugar intake.

Introducing this standard into the school canteens and replacing snacks with fruit and nuts can support a child while they are in school will be an admirable and proactive approach to tackling this problem. It also reduces the risk of weight victimisation because all children are eating the same foods.

Encourage Children To Spend More Time Outdoors

Playground shelter we designed for Old Church C of E Primary SchoolThe ‘Time To Solve Childhood Obesity Report’ and the WHO cites a need for all children to increase their physical activity. The WHO proposes an increase in physical activity of at least 60 minutes of moderate to vigorous age and developmentally appropriate activity. E.g., An obese child will not perform the same kind of activities that a healthy child can. However, this is not so easy in environments that are not adequate for a child to spend more time outdoors – a concern echoed by the UK Chief Medical Officer who cites a need in her report for schools to invest in and design an environment that creates opportunities for children to be active.

There are several opportunities for schools to play a significant role in encouraging children to spend time outdoors, and with Dame Sally Davies suggesting sponsorships and grants to help accomplish these tasks, there may be plenty of support for schools to do more to promote outdoor play and activity.

Here are a few suggestions.

Invest In and Design An Environment To Create Opportunities To Be Active

Dame Sally Davies encourages schools and town planners to invest in, prioritise and design an environment that allows children to be active, suggesting that adequate spaces for children to run, play and cycle are built, protected and maintained.

Covered MUGA we installed at Haileybury CollegeFor schools, this could mean creating outdoor classrooms or sheltered outdoor play environments that children can access in all weathers, like a school canopy or a sports canopy also known as a MUGA. School canopies and sports canopies are very easy to add heat and light too, and they also provide shade from harmful UV rays in the summertime. It could be a solution to many school problems as well as for tackling obesity in children.

It would be worthwhile for schools to reconsider how they structure their school day and teach because there are plenty of ways to incorporate teaching with physical activity. Some schools are already investing in their own versions of a forest school and other outdoor classroom types. The good news is that this type of learning is usually exceptionally beneficial to children and helps them grow and develop healthily while enhancing their working memory and cognitive function!

Promote Walking and Cycling To School

The Chief Medical Officer also suggests that schools, planners and parents work to create opportunities for children to run and cycle to school safely in all seasons.

Some of Dame Sally Davies’ suggestions involve:

  • Increased dedicated funding for active travel infrastructure towards walking and cycling.
  • Reducing the speed limit around schools to 20 mph.
  • Improve the potential of smart technology to limit the speed of cars in urban areas.
  • Take measures to improve the air quality around schools.
  • To tackle this last measure, Sally suggests ideas such as car-free zones around the schools, car-free weekends, health zones around schools, play streets to create safe spaces for children to play.
  • Sally also proposes provisions of support to schools and parents so they can encourage active travel to and from school. Some suggestions to support this are as follows:

Educate Staff, Children and Parents

There are so many ways schools can educate to bring more awareness to a problem that influences everybody. Some ideas include:

Engaging and teaching children in:

  • Health and exercise and its effect on their wellbeing through active outdoor play.
  • The detrimental impact of technology and games.
  • How to play outside. We take it for granted that children know how to play outside because we did. However, it is becoming a lost art. Nowadays, we need to teach children the things we took for granted.
  • Goal setting and how to create small wins to encourage confidence. This is something that some people learn as adults, but there is no reason why children cannot learn this. Mainly because it can encourage children with obesity to take a few extra steps, or to keep trying even when faced with bullying, it builds resilience and confidence and keeps the child on track to develop healthy habits and encourages all children without creating a bias for children with obesity.
  • About bullying, what it looks like and how to deal with it.
  • Kindness and understanding of others – suppose children can empathise with an obese child. In that case, the bullying will reduce, improving social and emotional development for all involved and encouraging obese children to experiment more outdoors.

Conclusion

Parents, caregivers and schools all have a responsibility in helping children fight obesity. However, they cannot do anything if they are uneducated or if there are inadequate facilities to encourage healthy eating and adequate exercise. There has never been a better time to step up and support the fight against childhood obesity. There is plenty of support available for schools to make it a priority to ensure all involved – including children, their parents, and teachers are educated in understanding how to help children fight obesity and are actively participating in the fight.

Furthermore, Dame Sally Davies proposes that schools and nurseries play a ‘central role’ in this effort which is supported by Ofsted monitoring. Working on this now may help you stay ahead of the curve.

References:

  1. The World Health Organisation. Global strategy on diet, physical activity and health. 2004. Link to article.
  2. The World Health Organisation. Noncommunicable diseases: childhood overweight and obesity. 2020. Link to article.
  3. Davies, S. Time to solve childhood obesity. 2019. Link to article
  4. Bacha F, Gidding SS. Cardiac abnormalities in youth with obesity and type 2 diabetes. Curr Diab Rep. 2016;16(7):62. Doi:10.1007/s11892-016-0750-6.
  5. Narang I, Mathew JL. Childhood obesity and obstructive sleep apnea. J Nutr Metab. 2012; doi: 10.1155/2012/134202.
  6. Cote AT, Harris KC, Panagiotopoulos C, et al. Childhood obesity and cardiovascular dysfunction. J Am Coll Cardiol. 2013;62(15):1309–1319.
  7. Africa JA, Newton KP, Schwimmer JB. Lifestyle interventions including nutrition, exercise, and supplements for nonalcoholic fatty liver disease in children. Dig Dis Sci. 2016;61(5):1375–1386.
  8. Lloyd LJ, Langley-Evans SC, McMullen S. Childhood obesity and risk of the adult metabolic syndrome: a systematic review. Int J Obes (Lond). 2012;36(1):1–11
  9. Mohanan S, Tapp H, McWilliams A, Dulin M. Obesity and asthma: pathophysiology and implications for diagnosis and management in primary care. Exp Biol Med (Maywood). 2014;239(11):1531–40.
  10. Pollock NK. Childhood obesity, bone development, and cardiometabolic risk factors. Mol Cell Endocrinol. 2015;410:52-63. doi: 10.1016/j.mce.2015.03.016.
  11. Magnussen CG, Et Al, Pediatric metabolic syndrome predicts adulthood metabolic syndrome, subclinical atherosclerosis, and type 2 diabetes mellitus but is no better than body mass index alone: the Bogalusa Heart Study and the Cardiovascular Risk in Young Finns Study. Circulation 2010;122:1604-1611.
  12. Hosseinpanah F, Asghari G, Barzin M, Ghareh S, Azizi F: Adolescence metabolic syndrome or adiposity and early adult metabolic syndrome. J Pediatr 2013;163:1663-1669.
  13. Franks PW, Hanson RL, Knowler WC, Sievers ML, Bennett PH, Looker HC: Childhood obesity, other cardiovascular risk factors and premature death. N Engl J Med 2010;362: 485-493.
  14. Park MH, Falconer C, Viner RM, Kinra S: The impact of childhood obesity on morbidity and mortality in adulthood: a systematic review. Obes Rev 2012;13:985-1000.
  15. Morandi A, Maffeis C: Predictors of Metabolic Risk in Childhood Obesity. Horm Res Paediatr 2014;82:3-11. doi: 10.1159/000362237
  16. Kassi E, Pervanidou P, Kaltsas G, Chrousos G: Metabolic syndrome: definitions and controversies. BMC Med 2011;9:48.
  17. Weiss R, Bremer AA, Lustig RH: What is metabolic syndrome, and why are children getting it? Ann NY Acad Sci 2013;1281:123-140.
  18. Marcovecchio ML, Chiarelli F: Metabolic syndrome in youth: chimera or useful concept? Curr Diab Rep 2013;13:56-62.
  19. Goodman E, Daniels SR, Meigs JB, Dolan LM: Instability in the diagnosis of metabolic syndrome in adolescents. Circulation 2007;115:2316-2322.
  20. Morrison JA, Glueck CJ, Woo JG, Wang P: Risk factors for cardiovascular disease and type 2 diabetes retained from childhood to adulthood predict adult outcomes: the Princeton LRC Follow-up Study. Int J Pediatr Endocrinol 2012;2012:6.
  21. Reinehr T, Wunsch R: Intima media thickness-related risk factors in childhood obesity. Int J Pediatr Obes 2011;6(S1):46-52.
  22. Mangge H, Zelzer S, Puerstner P, Schnedl WJ, Reeves G, Postolache TT, Weghuber D: Uric acid best predicts metabolically unhealthy obesity with increased cardiovascular risk in youth and adults. Obesity (Silver Spring) 2013;21:E71-E77.
  23. Di Bonito P, Moio N, Scilla C, Cavuto L, Sibilio G, Forziato C, Sanguigno E, Saitta F, Iardino MR, Capaldo B: Preclinical manifestations of organ damage associated with the metabolic syndrome and its factors in outpatient children. Atherosclerosis 2010;213:611-615.
  24. Juonala M, Et al: Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med 2011;365:1876-1885.
  25. National Paediatric Diabetes Audit, Royal College of Paediatrics and Child Health, 2018
  26. Fiorino EK, Brooks LJ. Obesity and respiratory diseases in childhood. Clin Chest Med. 2009 doi: 10.1016/j.ccm.2009.05.010.
  27. U.S National Library Of Medicine. Respiratory effects of obesity in children. 2017.
  28. Puhl RM, Latner JD. Stigma, obesity and the health of the nation’s children. Psychol Bull. 2007;133:557–580.
  29. Shomaker LB, Tanofsky-Kraff M, Zocca JM, Field SE, Drinkard B, Yanovski JA. Depressive symptoms and cardiorespiratory fitness in obese adolescents. J Adolesc Health. 2012;50:87–92.
  30. Mazzuca SA, Brandt KD, Lane KA, Chakr R. Malalignment and subchondrial bone turnover in contralateral knees of overweight/obese women with unilateral osteoarthritis: implications for bilateral disease. Arthritis Care Res. 2011;63:1528–1534.
  31. Marcus D. Obesity and the impact of chronic pain. Clin J Pain. 2004;20:186–191.
  32. Morandi A, Maffeis C: Predictors of Metabolic Risk in Childhood Obesity. Horm Res Paediatr 2014;82:3-11. doi: 10.1159/000362237
  33. Morrison KM, Shin S, Tarnopolsky M, et al. Association of depression and health related quality of life with body composition in children and youth with obesity. Journal of Affective Disorders 2015;172:18–23.
  34. Halfon N, Kandyce L, Slusser W. Associations between obesity and comorbid mental health, developmental, and physical health conditions in a nationally representative sample of US children aged 10 to 17. Academic Pediatrics. 2013;13.1:6–13.
  35. Beck AR. Psychosocial aspects of obesity. NASN Sch Nurse. 2016;31(1):23–27. Childhood Obesity and Academic Performance: The Role of Working Memory. 2017. DOI=10.3389/fpsyg.2017.00611
  36. The World Health Organisation. World obesity day: understanding the social consequences of obesity. 2017. Link to article
  37. Berk M, Williams LJ, Jacka FN, O’Neil A, Pasco JA, Moylan S, et al. So depression is an inflammatory disease, but where does the inflammation come from? BMC Med. 2013;11:200.
  38. Beck AR. Psychosocial aspects of obesity. NASN Sch Nurse. 2016;31(1):23–27. Childhood Obesity and Academic Performance: The Role of Working Memory. 2017. DOI=10.3389/fpsyg.2017.00611
  39. Reeves GM, Postolache TT, Snitker S. Childhood obesity and depression: connection between these growing problems in growing children. Int J Child Health Hum Dev. 2008;1(2):103–14.
  40. Datar, A., Sturm, R., and Magnabosco, J. L. (2004). Childhood overweight and academic performance: national study of kindergartners and first-graders. Obes. Res. 12, 58–68. doi: 10.1038/oby.2004.9
  41. Mikkila, V., Lahti-Koski, M., Pietinen, P., Virtanen, S. M., and Rimpela, M. (2003). Associates of obesity and weight dissatisfaction among Finnish adolescents. Public Health Nutr. 6, 49–56. doi: 10.1079/phn2002352
  42. Campos, A. L., Sigulem, D. M., Moraes, D. E., Escrivao, A. M., and Fisberg, M. (1996). Intelligent quotient of obese children and adolescents by the Weschler scale. Rev. Saude Publica 30, 85–90.
  43. Mo-suwan, L., Lebel, L., and Puetpaiboon, A. (1999). School performance and weight status of children and young adolescents in a transitional society in Thailand. Int. J. Obes. Relat. Metab. Disord. 23, 272–277. doi: 10.1038/sj.ijo.0800808
  44. Wang, F., and Veugelers, P. J. (2008). Self-esteem and cognitive development in the era of the childhood obesity epidemic. Obes. Rev. 9, 615–623. doi: 10.1111/j.1467-789x.2008.00507.x
  45. Tsal, C. L., Chen, F. C., Pan, C. Y., and Tseng, Y. T. (2016). The neurocognitive performance of visuospatial attention in children with obesity. Front. Psychol. 7, 1033. doi: 10.3389/fpsyg.2016.01033
  46. Mond, J. M., Stich, H., Hay, P. J., Kraemer, A., and Baune, B. T. (2007). Associations between obesity and developmental functioning in preschool children: a population-based study. Int. J. Obes. 31, 1068–1073. doi: 10.1038/sj.ijo.0803644
  47. Sabia, J. J. (2007). The effect of body weight on adolescent academic performance. South. Econ. J. 73, 871–900. doi: 10.2307/20111933
  48. Sigfúsdóttir, I. D., Kristijánsson, A. L., and Allegrante, J. P. (2007). Health behavior and academic achievement in Icelandic school children. Health Edu. Res. 22, 70–80. doi: 10.1093/her/cyl044
  49. Huttenmoser M., and Deiger-Zimmerman, D, (1995), Lebensträume für Kinder. Zurich: Swiss Science Foundation
  50. Tobin, A., (1997). Asking About Life. Harcourt Brace College
  51. Karsten L. It all used to be better? Different generations on continuity and change in urban children’s daily use of space. Children’s Geographies. 2005;3(3):275–290. doi: 10.1080/14733280500352912.
  52. Valentine G, McKendrick J. Children’s outdoor play: Exploring parental concerns about children’s safety and the changing nature of childhood. Geoforum. 1997;28(2):219–235. doi: 10.1016/S0016-7185(97)00010-9.
  53. Hillman M. Children’s rights and adults’ wrongs. Children’s Geographies. 2006;4(1):61–67. doi: 10.1080/14733280600577418.