Clinical Context

Obesity among children and adolescents is a major public health problem in the United States, and a new study by Goto and colleagues published June 21 in JAMA Pediatrics examines trends in pediatric obesity based on parental education and income levels.^[1] Researchers used data from the National Health and Nutrition Examination Survey from 1999 to 2018, with a specific focus on adolescents between the ages of 10 and 19 years. The main study outcome was the trend in obesity (age- and sex-adjusted body mass index [BMI] ≥ 95th percentile) over time, with household income and education as the principal variables.

A total of 21,296 participants provided study data. The mean age was 14.5 ± 2.8 years, and 49.3% of participants were female. Overall, living in a household below 138% of the federal poverty level was associated with a 4.2-percentage point increase in the prevalence of obesity, and the respective increase associated with parents not achieving a college degree was 9%. Importantly, there were trends that both household income and parental education became more strongly correlated with adolescent obesity during the period from 1999 to 2018.

Behavioral training is an important component of weight management among children and adolescents. Another new article compares traditional family-based behavioral treatment (FBT) with guided self-help (GSH) in treating pediatric obesity.

Study Synopsis and Perspective

Lower levels of household income and education in the United States are associated with higher rates of adolescent obesity. These socioeconomic disparities "have widened during the last two decades," new research shows.

Because obesity in adolescence has immediate and long-term health consequences, this phenomenon "may exacerbate socioeconomic disparities in chronic diseases into adulthood," according to study author Ryunosuke Goto, MD, of University of Tokyo Hospital, Tokyo, Japan, and colleagues.

Groups with higher rates of obesity may also be less likely to access treatment, said Kyung E. Rhee, MD, professor of pediatrics at University of California San Diego School of Medicine, who was not involved in the new analysis.

"These are the families who have a harder time getting to the doctor's office or getting to programs because they are working multiple jobs or they don't have as much flexibility," Rhee told Medscape Medical News.

A recent study^[2] showed a relationship between socioeconomic status (SES) and weight in adults. Research examining current trends in adolescents has been limited, however, according to the authors of the new study.

To address this gap, Goto and colleagues looked at obesity trends among more than 20,000 US children aged 10 to 19 years using cross-sectional data from the 1999-2018 National Health and Nutrition Examination Surveys.

They compared the prevalence of obesity among participants whose household income was 138% of the federal poverty level or less vs participants with higher levels of household income. They also examined obesity prevalence according to whether the head of household had graduated college.

Relative to higher-income households, adolescents from lower-income households were more likely to be non-Hispanic Black (21.7% vs 10.4%) or Hispanic (30.6% vs 13.4%) and to have an unmarried parent (54.5% vs 23%). They also were more likely to have obesity (22.8% vs 17.3%).

The prevalence of obesity likewise was higher among adolescents whose head of household did not have a college degree (21.8% vs 11.6%).

In an analysis that adjusted for race, ethnicity, height, and marital status of the head of household, the prevalence of obesity increased over 20 years, particularly among adolescents from lower-income homes, the researchers reported.

Lower income was associated with an increase in obesity prevalence of 4.2 percentage points, and less education was associated with an increase in obesity prevalence of 9 percentage points.

By 2015-2018, the gap in obesity prevalence between low-income households and higher-income households was 6.4 (95% CI: 1.5, 11.4) percentage points more than it had been during 1999-2002.

"When we assessed linear trends, the gap in obesity prevalence by income and education increased by an average of 1.5 (95% CI: 0.4, 2.6]) and 1.1 (95% CI: 0, 2.3) percentage points every 4 years, respectively," according to the researchers.

Separately, researchers are studying ways to help treat patients with obesity and increase access to treatment. To that end, Rhee and colleagues developed a new program called Guided Self-Help Obesity Treatment in the Doctor's Office (GOT Doc).

The GSH program was designed to provide similar resources as a leading treatment approach -- family-based treatment -- but in a less intensive, more accessible way.

Last week, they published in Pediatrics^[3] results from a randomized trial comparing this GSH approach with FBT.

The trial included 159 children and their parents. The children had an average age of 9.6 years and body mass index BMI z-score (BMIz) of 2.1. Participants were primarily Latinx and from lower-income neighborhoods.

Whereas FBT included hour-long sessions at an academic center, the GSH program featured a 20-minute session in the office where patients typically see their primary care provider.

Both programs covered how to self-monitor food intake, set healthy goals, and modify the home environment to promote behavioral change. They also discussed body image, bullying, and emotional health. The program is framed around developing a healthy lifestyle rather than weight loss itself, Rhee said.

Children in both groups had significant reductions in their body mass index (BMI) percentiles after the 6-month treatment programs. The reductions were largely maintained at 6-month follow-up.

Families in the GSH program, however, had a 67% lower risk of dropping out of the study and reported greater satisfaction and convenience. They attended more than half of the treatment sessions whereas participants assigned to FBT attended 1 in 5 sessions, on average.

The trial was conducted before the COVID-19 pandemic. Next, the researchers plan to test delivery of a GSH program via video calls, Rhee said.

Having options readily available for families who are interested in treatment for obesity proved valuable to clinicians, Rhee said. "They could then just refer them down the hall to the interventionist who was there, who was going to then work with the family to make these changes," she said.

The study by Goto and colleagues was supported by grants from the Japan Society for the Promotion of Science. The trial by Rhee et al was supported by a grant from the Health Resources and Services Administration. Neither research team had conflict of interest disclosures.

Clinical Implications

• In a new study by Goto and colleagues, both lower parental income and education levels were associated with higher rates of adolescent obesity. This trend increased over time from 1999 to 2018.
• The current study by Rhee and colleagues of children with obesity found that GSH had greater attendance vs FBT, but there was no difference in BMIz between groups.
• Implications for the healthcare team: The healthcare team can consider GSH as an alternative approach to FBT in cases of pediatric obesity. Healthcare team members should encourage how to self-monitor food intake, set healthy goals, and modify the home environment to promote behavioral change to develop healthy lifestyle changes rather than just focus on weight loss itself.

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