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San Diego County Childhood Obesity Initiative (COI)

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San Diego County Childhood Obesity Initiative (COI)

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This seems to be a credible information source. I linked their website, but they do have an instagram page where they share the same information! This COI is a public-private partnership thats mission is to reduce/prevent childhood obesity through policy. This could be through government, school, healthcare, community, media policies, etc. They are facilitated by the University of California San Diego Center for Community Health and funded by County of San Diego Health and Human Services Agency (HHSA). I think that this makes this a credible and reliable source to get information regarding childhood obesity from.

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The COI is a public-private partnership. Its mission is to reduce and prevent childhood obesity through policy, systems, and environmental change. The COI is facilitated by the University of California San Diego Center for Community Health and is funded by the County of San Diego Health and Human Services Agency (HHSA). Established in 2006, the COI engages a diverse group of regional stakeholders with committed public leadership from the County Board of Supervisors and program-level involvement of HHSA staff.

The Childhood Obesity Action Plan (COAP) is the guiding document for COI activities. By offering a reference of environments and policies that support healthy eating and active living, COAP guides the broader community in reducing and preventing childhood obesity in San Diego County. The COI has adopted a Collective Impact model to create, support, and mobilize 200+ partners from multiple domains (i.e., sectors); provide leadership, vision, education, and advocacy; and coordinate and sustain countywide efforts to prevent and reduce childhood obesity. To assure effective implementation of the strategies outlined in the COAP, partners from the following domains collaborate to fulfill the COI mission:

The COI has established active workgroups in each of these domains to develop, leverage, and replicate best practices and resources throughout San Diego County. Together, they work toward shaping a healthy future for children.

These efforts support the County of San Diego's comprehensive chronic disease prevention approaches, which are collectively referred to as Healthy Works.

To learn more about the COI, visit the San Diego County Childhood Obesity Initiative web site.

Back to Chronic Disease and Health Equity Unit.

Webpage last updated 9/28/2023.

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The COI is a public-private partnership. Its mission is to reduce and prevent childhood obesity through policy, systems, and environmental change. The COI is facilitated by the University of California San Diego Center for Community Health and is funded by the County of San Diego Health and Human Services Agency (HHSA).

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National Collaborative on Childhood Obesity Research 

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National Collaborative on Childhood Obesity Research 

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The National Collaborative on Childhood Obesity Research seems credible because they compile peer reviewed articles by doctors and scientists, webinars and other tools to help the prevention of childhood obesity as well as bring awareness to. They have a Facebook group that they also post tools and resources at which is what I linked. From what I found in the Facebook group and their website, I would say that this could be considered credible information.

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National Collaborative on Childhood Obesity Research

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National Collaborative on Childhood Obesity Research. 714 likes · 1 talking about this. NCCOR brings together four of the nation’s leading research funders to halt—and reverse—childhood obe

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This isn't a credible source and is misinformation. This is the story of a woman and struggled with childhood obesity and how it lead into her adult years. She explains in her blog how this helped her find a passion for exercise and eating paleo, which lead her to finding the WHOLE30 cookbook. This is a diet or program that says taking out certain foods in an individuals diet and slowly reintroducing them after the 30 days is healthy. I researched the WHOLE30 diet and there wasn't any credible information to support this diet. This is a great story but isn't back up by any credible information or references that are credible which makes it misinformation.

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How It All Started & About Paleo Bailey - Whole Kitchen Sink

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Brief background on Paleo Bailey and how I went from 300lbs to losing 125 of them through Paleo. A short history lesson to help us get to know each other

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Mary's Story- Childhood Obesity Awareness Month 

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Mary's Story- Childhood Obesity Awareness Month 

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This isn't a credible source and could be considered as misinformation. This blog shows the story of a woman that struggled with childhood obesity and how she slowly started to overcome it. The things that she explained that helped her overcome obesity may not be what others need to overcome theirs which is why this could be considered as misinformation. The things that she said she did weren't backed up by any reputable information or has any links to credible sources which makes it misinformation as well. But overall a very inspiring story.

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Hello, Keep reading to hear Mary's heart wrenching story of a young girl who missed out on a happy, joyous childhood as no one in her life knew there was a way out, no one knew there was a clear path to recovery...a path to a life that every child on this earth deserves. Let's make sure kids today aren't robbed of this life because the adults around them don't know about food addiction and the proper treatment. I believe that as a recovered food addict it is my I am heading to Florida soon (won't feel so much like Fall there) as we have a Primary Intensive starting October 6

Wow, I can't believe we are in the third week of September already...I was a little shocked when I looked at the calendar today and realized we are only 3 weeks away from Thanksgiving (don't panic, I am talking about the Canadian Thanksgiving). Fall is certainly evident all around me. I am currently in New Jersey having just participated in the "A Vision 4 You" OA conference - which was truly amazing, inspiring and hopeful - where the leaves are falling and changing colours (that's Canadian for colors). What a beautiful time of year!!

As we continue to highlight Childhood Obesity Awareness Month, our amazing and brilliant Mary, shares her story (see below) of growing up as an obese child and the lifelong scars that the bullying and oppression she suffered have left. Mary talks about how in the third grade she already weighed more than many of her teachers and that she started praying that she would die as the pain was far too much to bear as a young girl. These blunt statements can be hard to read, however we must face the reality and not turn a blind eye. In Mary's case we also get to see a miraculous recovery...let's continue to share our stories of pain and recovery in hopes that young people no longer need to suffer the ugly consequences of compulsive eating and food addiction.

obligation to share this message!

th. It's a great time to recommit to your program, and I would love to see you there. Peace & abstinence,
Amanda
Dear ACORN Family,
I hope you have enjoyed our emphasis on National Childhood Obesity Awareness Month. Obviously it is a topic that several of your ACORN staff wanted to write on, and I am no exception. I am going to share a little of my personal story growing up with childhood obesity.

As an obese child, life was very hard. In fact, I can honestly say that it was brutal and something that I wouldn't wish upon anyone. I know that many of you can relate.

I was born a healthy weight of just over seven pounds. I was a cute little girl with curly blonde hair and bright blue eyes. I was the second child born in my family and my sister and I were loved and cherished. I was a "normal" weight until around three years old when I became "chubby."

My first memory of sensing that I was "different" because of my size was when I was five years old. One of my young friends and I sang, "My Bonnie Lies over the Ocean," at a summer neighborhood talent show. As I stood on the stage singing my little heart out, proud as I could be, I sensed that some people in the audience were laughing at me because I was fat.

By the time I was in third grade I weighed 130 pounds which was more than some of the teachers. Throughout my school years I was subjected to daily teasing, mocking, jokes, stares from people of all ages, bullying on the playground, exclusion from gym teams and being ostracized by my peers. With each passing year my weight increased approximately 30 pounds and my self-esteem and self-worth plummeted. The pain was too great for me to bear and, as a young girl, I prayed many nights that I would die in my sleep. I hated myself. I hated my life. But even more so, I hated having to face yet another day with its painful repetition of the day before.

I felt vulnerable to constant negative attention every time I was out in public. One time, with tears rolling down my chubby cheeks, I told my father that I felt sad and hurt by all the kids teasing me. He told me that he had been a fat kid too and that he knew how I felt. With sadness in his eyes, he offered his young daughter the only comfort that he had known which was to simply tell myself that "Sticks and stones may break my bones but words will never hurt me." I believed my daddy and tried his advice. When kids teased me, I told myself what he had said. It didn't help. I still felt sad and lonely and hurt. That was the last time I remember telling anyone about the pain.

In seventh grade I weighed 270 pounds and by the time I was a junior in high school I weighed 290. The experience of obesity during my teen years was excruciating. I was never asked to a dance or attended a prom. I was kicked, tripped and spat at in the hallway. Every day was a matter of survival until, at the end of each day, I could walk into my home and fill myself with my favorite "comfort foods" which consisted of cookies, chips, and other snack foods that gave me that much-needed sense of relief.

As an adult, people have asked me why my parents allowed me to get so fat. Why didn't they help me? Why did they let me eat so much? In fact, by today's standards, I might have been removed from my family home, my parents accused of abusing me.

I am quite clear about one thing: I do not blame my parents. My obesity was not their fault. They had no control over my mental obsession with sugary foods and had little, if any, control over my consumption of them. I hid food. I stole food. I snuck food. I lied about food. I know today that my parents did their absolute best to support a daughter who, without their understanding, was suffering with the disease of food addiction.

Both of my parents were overweight and did not have access to recovery prior to their early deaths. Of my four siblings, one sister and one brother have weight issues but they do not identify with my experience of bingeing on addictive foods. I do not know if they are addicted to food; it is not for me to determine. Even more to the point, however, my other brother and sister - who were raised in the same household, with the same parents, and with access to the very same foods - have never had an eating or weight problem. So, I do not subscribe to the belief that obesity is entirely a problem of family or environment.

I have learned a great deal since growing up as an obese child and adult. I first heard about compulsive eating and food addiction while attending a food-related twelve step fellowship in the mid 80s. I learned that some people have an abnormal reaction to certain foods - for me, primarily sugar, flour and volume - and that those with this addictive disease and/or predisposition cannot safely eat certain foods in any quantity.

About that same time I attended my first inpatient food addiction treatment program. I was 34 years old and weighed 340 pounds. While there I discovered that my obesity was a symptom of the disease of food addiction. I worked hard in treatment and wholeheartedly surrendered to their direction. Upon leaving, I continued a multi-faceted recovery journey that lasted well over a year.

As the weight came off, I began to think that I had somehow overcome this addiction and that I didn't need to do so many of the actions that had given me a sense of freedom from the weight and from the obsession. This thinking led to four years of relapse where my will to live was of no match for my will to binge. My last binge lasted 42 days and I gained 56 pounds, during which time I decided that I would eat until I died. I knew that I could not stop; and I knew that life would not be worth living without sugar. I was done.

Yet, deep inside of me, there was a little spark of hope, and in January 1990 I recommitted myself to a residential treatment program that used the addictive model. This time I stayed for five weeks followed by three months in a halfway house for food addicts. Pain had become a huge motivator.

I surrendered to their direction and did whatever I was told were the recommendations for treating advanced food addiction: putting my abstinence first, no matter what; weighing and measuring my food without exception; structuring my daily life around what I need to do to be abstinent and in recovery; surrendering to rigorous participation in a food-related, twelve step fellowship; cultivating a spiritual life; building a strong network of support; getting professional counseling as needed; committing to helping others who suffer with this disease.

All of these actions - and more - have enabled me to live free of food bingeing and the mental obsession of addictive foods and for over 27 years maintaining a 195-pound weight loss for over 25 years.

The internal scars of growing up as an obese child are, to some extent, still with me, and I continue to experience ongoing healing as a result of the daily actions that I am guided to take.

In reflecting upon my story, my thoughts turn to the hundreds of thousands of obese children all around us who may be suffering in silence and don't yet know how to get out of their excruciating pain.

While I am grateful for the heightened awareness of bullying in recent years, I also know that bullying and oppression against fat kids and adults continue. As I perused a few websites specific to Childhood Obesity Awareness Month, I did not come across one article that addressed the possibility of food addiction in our youth and the need for abstinence from addictive foods. I support the work of organizations like the Food Addiction Institute and others who seek to promote education and treatment for food addiction.

My hope and prayer is that every food addict have the strength and courage to continue their abstinence journey such that our voices and our very beings may share a resounding message of hope, of recovery, and of healing from food addiction and obesity.
What will you do this month to share your awareness of childhood obesity and offer hope to those who still suffer? Having an abstinent day today is one positive step. I commit to do that. Will you?
Upcoming Events:
I offer you my love and prayers for ongoing abstinence and recovery,

Mary
Dear ACORN Family,

September 30 - Eating, eating and more eating...Why can't I STOP? - East Greenwich, Rhode Island - Space is still available!

October 6 - 11 - Primary Intensive - Bradenton, Florida

October 14 - 16 - "3-Days with Phil" - Bradenton, Florida

November 3 - 5 - Alumni Retreat - Vancouver, Canada (details to follow)

November 10 - 15 - Primary Intensive - Vancouver, Canada

Hello, Keep reading to hear Mary's heart wrenching story of a young girl who missed out on a happy, joyous childhood as no one in her life knew there was a way out, no one knew there was a clear path to recovery...a path to a life that every child on this earth deserves. Let's make sure kids today aren't robbed of this life because the adults around them don't know about food addiction and the proper treatment. I believe that as a recovered food addict it is my I am heading to Florida soon (won't feel so much like Fall there) as we have a Primary Intensive starting October 6

Wow, I can't believe we are in the third week of September already...I was a little shocked when I looked at the calendar today and realized we are only 3 weeks away from Thanksgiving (don't panic, I am talking about the Canadian Thanksgiving). Fall is certainly evident all around me. I am currently in New Jersey having just participated in the "A Vision 4 You" OA conference - which was truly amazing, inspiring and hopeful - where the leaves are falling and changing colours (that's Canadian for colors). What a beautiful time of year!!

As we continue to highlight Childhood Obesity Awareness Month, our amazing and brilliant Mary, shares her story (see below) of growing up as an obese child and the lifelong scars that the bullying and oppression she suffered have left. Mary talks about how in the third grade she already weighed more than many of her teachers and that she started praying that she would die as the pain was far too much to bear as a young girl. These blunt statements can be hard to read, however we must face the reality and not turn a blind eye. In Mary's case we also get to see a miraculous recovery...let's continue to share our stories of pain and recovery in hopes that young people no longer need to suffer the ugly consequences of compulsive eating and food addiction.

obligation to share this message!

th. It's a great time to recommit to your program, and I would love to see you there. Peace & abstinence,
Amanda

I hope you have enjoyed our emphasis on National Childhood Obesity Awareness Month. Obviously it is a topic that several of your ACORN staff wanted to write on, and I am no exception. I am going to share a little of my personal story growing up with childhood obesity.

As an obese child, life was very hard. In fact, I can honestly say that it was brutal and something that I wouldn't wish upon anyone. I know that many of you can relate.

I was born a healthy weight of just over seven pounds. I was a cute little girl with curly blonde hair and bright blue eyes. I was the second child born in my family and my sister and I were loved and cherished. I was a "normal" weight until around three years old when I became "chubby."

My first memory of sensing that I was "different" because of my size was when I was five years old. One of my young friends and I sang, "My Bonnie Lies over the Ocean," at a summer neighborhood talent show. As I stood on the stage singing my little heart out, proud as I could be, I sensed that some people in the audience were laughing at me because I was fat.

By the time I was in third grade I weighed 130 pounds which was more than some of the teachers. Throughout my school years I was subjected to daily teasing, mocking, jokes, stares from people of all ages, bullying on the playground, exclusion from gym teams and being ostracized by my peers. With each passing year my weight increased approximately 30 pounds and my self-esteem and self-worth plummeted. The pain was too great for me to bear and, as a young girl, I prayed many nights that I would die in my sleep. I hated myself. I hated my life. But even more so, I hated having to face yet another day with its painful repetition of the day before.

I felt vulnerable to constant negative attention every time I was out in public. One time, with tears rolling down my chubby cheeks, I told my father that I felt sad and hurt by all the kids teasing me. He told me that he had been a fat kid too and that he knew how I felt. With sadness in his eyes, he offered his young daughter the only comfort that he had known which was to simply tell myself that "Sticks and stones may break my bones but words will never hurt me." I believed my daddy and tried his advice. When kids teased me, I told myself what he had said. It didn't help. I still felt sad and lonely and hurt. That was the last time I remember telling anyone about the pain.

In seventh grade I weighed 270 pounds and by the time I was a junior in high school I weighed 290. The experience of obesity during my teen years was excruciating. I was never asked to a dance or attended a prom. I was kicked, tripped and spat at in the hallway. Every day was a matter of survival until, at the end of each day, I could walk into my home and fill myself with my favorite "comfort foods" which consisted of cookies, chips, and other snack foods that gave me that much-needed sense of relief.

As an adult, people have asked me why my parents allowed me to get so fat. Why didn't they help me? Why did they let me eat so much? In fact, by today's standards, I might have been removed from my family home, my parents accused of abusing me.

I am quite clear about one thing: I do not blame my parents. My obesity was not their fault. They had no control over my mental obsession with sugary foods and had little, if any, control over my consumption of them. I hid food. I stole food. I snuck food. I lied about food. I know today that my parents did their absolute best to support a daughter who, without their understanding, was suffering with the disease of food addiction.

Both of my parents were overweight and did not have access to recovery prior to their early deaths. Of my four siblings, one sister and one brother have weight issues but they do not identify with my experience of bingeing on addictive foods. I do not know if they are addicted to food; it is not for me to determine. Even more to the point, however, my other brother and sister - who were raised in the same household, with the same parents, and with access to the very same foods - have never had an eating or weight problem. So, I do not subscribe to the belief that obesity is entirely a problem of family or environment.

I have learned a great deal since growing up as an obese child and adult. I first heard about compulsive eating and food addiction while attending a food-related twelve step fellowship in the mid 80s. I learned that some people have an abnormal reaction to certain foods - for me, primarily sugar, flour and volume - and that those with this addictive disease and/or predisposition cannot safely eat certain foods in any quantity.

About that same time I attended my first inpatient food addiction treatment program. I was 34 years old and weighed 340 pounds. While there I discovered that my obesity was a symptom of the disease of food addiction. I worked hard in treatment and wholeheartedly surrendered to their direction. Upon leaving, I continued a multi-faceted recovery journey that lasted well over a year.

As the weight came off, I began to think that I had somehow overcome this addiction and that I didn't need to do so many of the actions that had given me a sense of freedom from the weight and from the obsession. This thinking led to four years of relapse where my will to live was of no match for my will to binge. My last binge lasted 42 days and I gained 56 pounds, during which time I decided that I would eat until I died. I knew that I could not stop; and I knew that life would not be worth living without sugar. I was done.

Yet, deep inside of me, there was a little spark of hope, and in January 1990 I recommitted myself to a residential treatment program that used the addictive model. This time I stayed for five weeks followed by three months in a halfway house for food addicts. Pain had become a huge motivator.

I surrendered to their direction and did whatever I was told were the recommendations for treating advanced food addiction: putting my abstinence first, no matter what; weighing and measuring my food without exception; structuring my daily life around what I need to do to be abstinent and in recovery; surrendering to rigorous participation in a food-related, twelve step fellowship; cultivating a spiritual life; building a strong network of support; getting professional counseling as needed; committing to helping others who suffer with this disease.

All of these actions - and more - have enabled me to live free of food bingeing and the mental obsession of addictive foods and for over 27 years maintaining a 195-pound weight loss for over 25 years.

The internal scars of growing up as an obese child are, to some extent, still with me, and I continue to experience ongoing healing as a result of the daily actions that I am guided to take.

In reflecting upon my story, my thoughts turn to the hundreds of thousands of obese children all around us who may be suffering in silence and don't yet know how to get out of their excruciating pain.
Upcoming Events:
While I am grateful for the heightened awareness of bullying in recent years, I also know that bullying and oppression against fat kids and adults continue. As I perused a few websites specific to Childhood Obesity Awareness Month, I did not come across one article that addressed the possibility of food addiction in our youth and the need for abstinence from addictive foods. I support the work of organizations like the Food Addiction Institute and others who seek to promote education and treatment for food addiction.

My hope and prayer is that every food addict have the strength and courage to continue their abstinence journey such that our voices and our very beings may share a resounding message of hope, of recovery, and of healing from food addiction and obesity.
What will you do this month to share your awareness of childhood obesity and offer hope to those who still suffer? Having an abstinent day today is one positive step. I commit to do that. Will you?

I offer you my love and prayers for ongoing abstinence and recovery,

Mary

September 30 - Eating, eating and more eating...Why can't I STOP? - East Greenwich, Rhode Island - Space is still available!

October 6 - 11 - Primary Intensive - Bradenton, Florida

October 14 - 16 - "3-Days with Phil" - Bradenton, Florida

November 3 - 5 - Alumni Retreat - Vancouver, Canada (details to follow)

November 10 - 15 - Primary Intensive - Vancouver, Canada

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Mary's Story - Childhood Obesity Awareness Month

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Hello, Keep reading to hear Mary's heart wrenching story of a young girl who missed out on a happy, joyous childhood as no one in her life knew there was a way out, no one knew there was a clear path to recovery...a path to a life that every child on this earth deserves.

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Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

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Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

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This is a credible information source because it is an official peer-reviewed journal of the American Academy of Pediatrics (AAP).

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Asheley C. Skinner, Amanda E. Staiano, Sarah C. Armstrong, Shari L. Barkin, Sandra G. Hassink, Jennifer E. Moore, Jennifer S. Savage, Helene Vilme, Ashley E. Weedn, Janice Liebhart, Jeanne Lindros, Eileen M. Reilly; Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions. Pediatrics February 2023; 151 (2): e2022060642. 10.1542/peds.2022-060642

Download citation file:

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Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

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The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity.

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This is a credible information source that is a nonprofit organization that has been committed to clinical practice education and research as well as being top ranked for quality more frequently than any other health care agency.

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Childhood obesity can lead to various conditions, including type 2 diabetes and high blood pressure. Learn how to protect your child’s health.

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This information is credible because it comes from our nations leading health experts and from the American Academy of Pediatrics.

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Obesity is a disease that can be treated, much like asthma and other chronic conditions.Childhood obesity often lasts into adulthood if it is not treated. It can result in other diseases such as type 2 diabetes, nonalcoholic fatty liver disease, high cholesterol, high blood pressure, sleep apnea and orthopedic (bone & joint) problems, to name a few. Learn more here.

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The Association Between Sugar-Sweetened Beverages and Child Obesity: Implications for US Policy

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The Association Between Sugar-Sweetened Beverages and Child Obesity: Implications for US Policy

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This is credible scientific information that has been peer reviewed as well as reviewed by doctors and other scientists.

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Abstract

Background: The prevalence of overweight and obesity among children and adolescents has increased worldwide and has reached alarming proportions. Currently, sugar-sweetened beverages (SSBs) are the primary source of added sugar in the diet of children and adolescents. Contradictive findings from studies and reviews have fueled an endless debate on the role of SSBs in the development of childhood obesity.

Methods: The primary aim of the present review of reviews was to assess how review- and study-level methodological factors explain conflicting results across reviews and meta-analyses by providing an up-to-date synthesis of recent evidence regarding the association between SSB consumption and weight gain, overweight, and obesity in a population of 6-month-old to 19-year-old children and adolescents. The secondary aim was to assess the quality of included reviews using the Assessment of Multiple SysTemAtic Reviews (AMSTAR) measurement tool. Systematic literature reviews and meta-analyses were included. The literature search was performed through the platforms Pubmed/Medline, Cinahl, and Web of Knowledge.

Results: Thirteen reviews and meta-analyses were included. Nine reviews concluded that there was a direct association between SSBs and obesity in children and adolescents and four others did not. The quality of the included reviews was low to moderate, and the two reviews with the highest quality scores showed discrepant results.

Conclusions: The majority of reviews concluded that there was a direct association between SSB consumption and weight gain, overweight, and obesity in children and adolescents. However, recent evidence from well-conducted meta-analyses shows discrepant results regarding the association between SSB and weight gain, overweight, and obesity among children and adolescents. Improving methodological quality of studies and reviews as well as ensuring responsible conduct of research and scientific integrity is essential for the provision of objective results.

Introduction

The prevalence of overweight and obesity among children and adolescents has increased all over the world and has reached alarming proportions, especially in industrialized countries.1,2 Obesity during childhood and adolescence is of major concern given that obese children and adolescents are at higher risk of being obese adults and developing comorbidities, such as diabetes and cardiovascular diseases.3-7

Evidence suggests that the consumption of sugar-sweetened beverages (SSBs) has increased in parallel to overweight and obesity trends.8-11 Currently, SSBs contribute between 10% and 15% of youth's caloric intake and are the primary source of added sugar in the diet of children and adolescents.12 Approximately 25% of US adolescents consume more than 750 mL of SSBs per day, which represents more than 350 calories.10,13

Numerous studies, reviews, and meta-analyses evaluating the association between SSBs and weight gain, overweight, and obesity in childhood and adolescence have been published, with some finding a positive association and others finding none. These contradictive findings have fueled intense debates, as illustrated in a pro versus con debate regarding the role of SSBs in obesity published in 2013, highlighting divergent expert opinions.8,14 Some experts argued that evidence supporting a causal relation between SSB intake and weight outcomes was sufficient,8 whereas other experts considered it to be weak.14 More recently, a systematic review showing mixed findings supplemented to the ongoing debate.15 These conflicting results may be owing to methodological issues in original studies and reviews.

Three reviews of reviews regarding SSB consumption and health outcomes among children and adults have previously been published.11,16,17 Two of these reviews11,16 studied different health outcomes, and their aims were not toward critically assessing the association between SSB consumption and obesity. Indeed, Weed and colleagues assessed the quality of reviews on SSBs and health outcomes and found that most reviews lacked comprehensive reporting of epidemiological evidence and use of systematic methodologies. The aim of the review by Althuis and Weed was to show the usefulness of evidence mapping among primary studies of SSBs and four health outcomes. Their findings showed great study-level methodological variability.11,16 The third review,17 examining SSBs and body weight, assessed how reviews' conclusions relate to their quality and source of funding. The results showed that quality scores were not correlated with reviews' conclusions or with the source of funding. However, industry-funded reviews were more likely to report weak evidence between SSB consumption and weight gain.

The primary aim of the present review of reviews was to assess how review- and study-level methodological factors explain conflicting results across reviews and meta-analyses by providing an up-to-date synthesis of recent evidence regarding the association between SSB consumption and weight gain, overweight, and obesity in a population of 6-month-old to 19-year-old children and adolescents. The secondary aim was to assess the quality of included reviews using the Assessment of Multiple SysTemAtic Reviews (AMSTAR) measurement tool.

Methods

Search Methods and Terms Used

The literature search was performed through the platforms Pubmed/Medline, Cinahl, and Web of Knowledge. Reference lists of articles and other reviews were cross-searched in order to include eventual nonidentified reviews. One article search combining the following key terms was performed: Adiposity; Body Weight; Body Mass Index; Adipose Tissue; Carbonated Beverages; Dietary Sucrose; Sucrose; Fructose; Sweetening Agents; Glucose; Energy Drinks; Beverages.

Selection of Articles

The selection of articles was performed in three steps. First, one researcher selected articles by title in the three databases mentioned above. Second, two researchers independently selected reviews published up to August 31, 2013, based on information available in the abstracts. Third, selected reviews were combined, duplicates were removed, and full texts of articles were screened for relevance. During the selection process, when opinion discrepancy occurred regarding the inclusion of an article, the two researchers individually proceeded to a second evaluation of the article and further discussed it until agreement was reached. There was only one discrepancy where reaching consensus was required.18

The following criteria were used to include or exclude articles of systematic reviews.

Exposure

The exposure of interest was SSB consumption. There is no official definition for SSBs. However, as a convention, SSBs are defined as beverages with added sugar, such as carbonated or noncarbonated sodas, fruit drinks (non-100% fruit juices), and sport drinks.18,19

Study design

Systematic literature reviews and meta-analyses were included. To be considered systematic, as a minimum criterion, a description of the literature search performed had to be presented in the method section of the article or online supplementary data Articles without literature search description were considered nonsystematic and were excluded. Only systematic literature reviews and meta-analyses of primary studies were included. Reviews of reviews were excluded.

Outcome

Systematic reviews and meta-analyses evaluating SSB consumption in regard to weight gain, overweight, and obesity among 6-month-old to 19-year-old children and adolescents were included.

Population

The population was defined as children and adolescents less than 19 years of age. Restriction to children and adolescents was made on the basis that BMI values during childhood and adolescence are important risk factors for the presence of adult overweight and obesity. Further, efforts to prevent overweight and obesity in the pediatric population might contribute to preventing adult morbidity and mortality.3-7,20,21

Only few reviews focused solely on children and adolescents; therefore, mixed systematic literature reviews, including both children and adults, were also included. However, data extraction and analysis exclusively considered studies on children and adolescents. Reviews including adults only were excluded. Article types were systematic reviews and meta-analyses in English published from 1990 up to August 2013.

Statistical Analysis

Descriptive information for each published review was extracted ( i. e., design, number, and type of studies summarized, age range, and geographical origin) using a structured form developed for this review. Each review was summarized and described with regard to design, population, number of included studies, authors' conclusions, and funding ( Table 1 ). The evaluation of dietary assessment methods and tools used in original studies was beyond the scope of the present review. However, information regarding dietary assessment tools mentioned in the included reviews was collected. In addition, the standardized instrument AMSTAR was used to assess the methodological quality of included reviews. The AMSTAR tool was developed by Shea and colleagues by combining previous tools, empirical evidence, and expert consensus to easily evaluate the quality of systematic literature reviews.22 The AMSTAR is a 1-page tool with 11 questions (see Supplementary Table 1) (see online supplementary material at http://www.liebertpub.com). Questions answered by "yes" give 1 point and the maximum score is 11 for meta-analyses and 9 for reviews. Scores of 0-4 indicate low quality, 5-8 moderate quality, and 9-11 high quality.11,16,23 The AMSTAR instrument was completed independently by two researchers. The researchers agreed on the final score of each included review.

Table 1.

No. of included studies

Reference (author and date)

Country

Study design

Population

Databases searched

Children

Adultsa

Authors' conclusion

Funding and conflict of interest (COI)

AMSTAR scoreb

Clabaugh K, Neuberger GB, 2011

USA

Review

Children

CINAHL, PubMed, Trip database, Cochrane Library

L (3)
CS (4)
IN (2)

N/A

(+)

Unknown
COI not mentioned

5

Forshee RA, Anderson PA, Storey, 2008

USA

Meta-analysis

Children

MedLine

L (8) (two more not included in meta-analysis)
IN (2)

N/A

(x)

Private c
no COI

7

Gibson S, 2008

UK

Review

Children and adults

PubMed, Google scholar, Cochrane Library

L (11)
CS (20)
IN (3)

L (6)
CS (3)
IN (1)

(x)

Commissioned by the UNESDA d
COI not mentioned

3

Harrington S, 2008

USA

Review

Children

CINAHL, MedLine

L (5)
IN (2)

N/A

(+)

Unknown
COI not mentioned

2

A Kaiser and colleagues, 2013

USA

Meta-analysis

Children and adults

PubMed, PsycINFO, Cochrane Collaborative Website, SCOPUS, Dissertation Abstracts (PROQUEST)

IN (3)

IN (3)

(o)

Unknown
Reported COI e

9

B Malik VS, Schulze MB, Hu FB, 2006

USA and Germany

Review

Children and adults

MedLine

L (6)
CS (13)
IN (2)

L (4)
CS (2)
IN (3)

(+)

Public f
No COI

2

B Malik and colleagues, 2013

USA and Singapore

Review and Meta-analysis

Children and adults

PubMed, Embase, Cochrane Library

L (14)
IN (5)

L (7) (6) a
IN (5) (2) a

(+)

Public f
No COI

9

A Mattes and colleagues, 2011

USA

Review and Meta-analysis

Children and adults

PubMed, PsycINFO, Cochrane Collaborative Website, Web of Science, Dissertation Abstracts

IN (6)

IN (6)

(o)

Public f
Reported COI e

7

Olsen NJ, Heitmann BL, 2009

Denmark

Review

Children and adults

MedLine, Scirus

L (11)
IN (2)

L (3)
IN (3)

(+)

Unknown funding
No COI

4

Osei-Assibey and colleagues, 2012

UK

Review

Children

MedLine, Embase,CCTR, DARE, CINAHL, Psycho-Info

L (3)
IN (1)

N/A

(+)

Public
No COI

6

Perez-Morales E, Bacardi-Gascon M, Jimenez-Cruz A, 2013

Mexico

Review

Children

PubMed, MedLine, SciELO, EBSCO

L (7)

N/A

(+)

Unknown

4

Vartanian LR, Schwartz MB, Brownell KD, 2007

USA

Review and Meta-analysis

Children and adults

MedLine, PsycINFO

L (7)
CS (13)
IN (2)

L (2)
CS (5)
IN (5)

(+)

Public g
COI not mentioned

6

Woodward-Lopez G, Kao J, Ritchie L, 2011

USA

Review

Children and adults

PubMed

L (19)
CS (25)
IN (4)

L (5)
CS (7)
IN (3)

(+)

Public h
COI not mentioned

4

At first, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was considered. However PRISMA has not been developed as a quality assessment instrument to assess the quality of systematic reviews per se.24 Therefore, AMSTAR was preferred over PRISMA.

Results

The literature search resulted in 13 reviews and meta-analyses ( Supplementary Fig. 1) (see online supplementary material at http://www.liebertpub.com). Eight were systematic reviews,18,25-31 three were combined systematic reviews and meta-analyses,32-34 and two were meta-analyses.14,35 The erratum by Forshee and colleagues36 was included as part of the review by Forshee and colleagues.35 In addition, four of the included reviews came from two authors' groups. The reviews by Malik and colleagues and Malik and colleagues are from the same group of authors as well as the reviews by Mattes and colleagues and Kaiser and colleagues. The review by Kaiser and colleagues is an update of Mattes and colleagues. The characteristics of each included study are presented in Table 1 . See Supplementary Table 2 (see online supplementary material at http://www.liebertpub.com) for the list of excluded articles after full-text screening and reasons for exclusion.

Of the 13 included reviews, nine concluded that there was a direct association between SSB intake and weight gain, overweight, and obesity in children and adolescents.7,12-18,20 Two reviews concluded that there was no association25,35 and two others, from the same group of authors, reported that no conclusion could be drawn and that more studies were needed.19,22 No reviews concluded that there was an inverse association.

Of the 13 included reviews, five14,32-35 assessed effect sizes of included longitudinal or intervention studies. The effect size of increasing SSB intake was comprised between 0.03 (95% confidence interval [CI], −0.01, 0.07) BMI unit change per serving of SSB and 0.14 (95% CI, −0.15, 0.42)14 (standardized mean difference) BMI increase. The effect size of decreasing SSB consumption was comprised between 0.007 (95% CI, −0.073, 0.086)33 and 0.329 (95% CI, 0.13, 0.53) (positive numbers showing that studies favored the treatment group).

Malik and colleagues32 reported effect sizes between 0.05 (95% CI, 0.03, 0.07) and 0.16 (95% CI, 0.15, 0.16) on BMI and body weight for a daily increase of one serving of SSB intake in prospective studies and an effect size of −0.12 (95% CI, −0.22, −0.02) (negative numbers showing that studies favored the treatment group) of reducing SSB intake between intervention and control groups.32

In the meta-analysis by Vartanian and colleagues,34 the effect size of increasing SSB consumption was r=0.03 (95% CI, 0.01, 0.04) in prospective studies and r=0.29 (95% CI, 0.22, 0.35) (positive numbers showing that studies favored the treatment group) in intervention studies aiming at decreasing SSB intake. In the review by Forshee and colleagues,35 the effect size was ≈0.03 (95% CI, −0.01, 0.07) unit change per serving of SSB. In the meta-analyses by Kaiser and colleagues14 and Mattes and colleagues,33 the effect of adding mandatory SSB consumption to a person's diet was 0.14 (95% CI, −0.15,0.42),14 whereas the effect of reducing SSB consumption on body composition/adiposity was between 0.007 (95% CI, −0.073, 0.08633 and 0.329 (95% CI, 0.13, 0.53)14 (positive numbers showing that studies favored the treatment group).

Within the 13 reviews, a total of 30 longitudinal, 12 intervention, and 34 cross-sectional studies on SSB intake and weight gain, overweight, and obesity in children and adolescents were included. The list of studies within each review is presented in Supplementary Tables 3-5 (see online supplementary material at http://www.liebertpub.com). All reviews concluding that there was a direct association between SSB intake and weight gain, overweight, and obesity in children and adolescents included longitudinal studies, eight included intervention studies, and four included cross-sectional studies as well.26,29,31,34 Among the four reviews that did not find a direct association between SSB intake and weight gain, overweight, and obesity in children and adolescents, all included intervention studies,14,25,33,35 two further included longitudinal studies,25,35 and one also included cross-sectional studies25 ( Table 1 ). No clear pattern between inclusion of different study designs and reviews' conclusion could be established.

Most reviews25-28,31-33,35 mentioned measurement limitations in the dietary assessment tools used to measure beverage consumption, such as self-reported data, use of a single 24-hour recall or noninclusion of weekend days. Heterogeneity in dietary measurement tools used and lack of homogeneity regarding SSB definition between studies were also reported. Other limitations inherent to study designs mentioned in reviews30-32,35 were related to small sample sizes, short follow-ups, and convenience samples. Whether or not measurement limitations were mentioned did not influence reviews' conclusions.

The population of interest for the present review of reviews was children and adolescents. The mean age of children and adolescents among the included reviews was 9.37 (±standard deviation [SD] 7.23) ranging from 0.5 to 19 years. The mean age within studies included in reviews was 9.62 (±SD 5.0) ranging from 0.5 to 19 years ( Supplementary Graphs 1 and 2) (see online supplementary material at http://www.liebertpub.com). Most reviews included children from the age of 2 to 18-19, and only one review solely focused on younger children.28 The age ranges analyzed in the reviews were not related to their conclusions.

Five reviews did not state their source of funding, six26,29,30,32-34 were publicly funded, and two25,35 were funded by the industry. Conflict of interest was not reported in six reviews,18,25,28,29,31,34 authors of five reviews reported not having any conflict of interest, and authors of two reviews14,33 reported having conflict of interest ( Table 1 ).

Quality

Among the 13 included reviews, none received the maximum score of 9 for reviews and 11 for meta-analyses. The mean quality score was 3.75 (SD±1.39) for reviews, 7.3 (SD±1.52) for the combined reviews and meta-analyses, and 8 (SD±1.41) for meta-analyses. The overall mean quality score was 5.23 (SD±2.26), ranging from 2 to 9. Based on the AMSTAR score, all reviews were classified as low quality, reviews combined with a meta-analysis were of moderate quality, and the two meta-analyses were of high quality. The two reviews/meta-analyses with the highest quality scores (=9) had discrepant results. The review by Kaiser and colleagues concluded that "the currently available randomized evidence for the effects of reducing SSB intake on obesity is equivocal," whereas Malik and colleagues concluded that "our systematic review and meta-analyses provide additional evidence that SSB consumption is associated with weight gain in both children and adults." Questions 11 ("was conflict of interest stated?") of the AMSTAR tool scored the lowest, only 17%, compared to the other questions for which percentage scores were comprised between 31% and 100% ( Supplementary Table 1) (see online supplementary material at http://www.liebertpub.com).

Discussion

Overall, the majority of reviews concluded that there was a direct association between SSB consumption and weight gain, overweight, and obesity in children and adolescents. These findings are in agreement with expert opinion, including primary studies, reviews, and meta-analyses on children and adults, which mentioned that there is sufficient evidence to conclude that SSB intake causes excess weight gain and that limiting its consumption will have significant impact on the prevalence of obesity and obesity-related diseases.8

However, recent evidence from well-conducted meta-analyses shows discrepant results. Contradictory results from studies, reviews, and meta-analyses might occur owing to differences in study design, inclusion criteria, and data analyses.

To illustrate, the discrepant results from the two highest-quality reviews/meta-analyses14,32 might be explained by the fact that one14 included intervention studies ( n=3) only, whereas the other32 included both intervention ( n=5) and cohort studies ( n=14). In the meta-analysis by Kaiser and colleagues, intervention studies had, on average, a shorter duration than in the review by Malik and colleagues. In addition, one of the three included randomized, controlled trials (RCTs) was not designed to assess the association between SSB intake and weight outcome.38 In comparison, all five RCTs included in the review by Malik and colleagues were testing the effect of reducing SSB intake on weight among children and adolescents. Reviews and meta-analyses based on RCTs that assess short-term weight loss might not be appropriate to identify dietary determinants of long-term weight change and prevention of weight gain.8 Further, the inclusion of studies not primarily designed to assess the association between SSB consumption and weight outcome might bias findings. Additionally, cross-sectional studies were included in 5 of the 13 reviews. Owing to the high risk of reverse causation, longitudinal studies should be privileged.39,40 Hence, reviews based on cross-sectional studies do not provide strong evidence.

Another factor influencing studies and reviews' results is linked to problems in exposure measurements, such as the use of single-day dietary assessments (insufficient to take into account large within-person variability), under-representation of weekend days, self-reported data, the use of nonquantitative food frequency questionnaires, as well as heterogeneity regarding SSB definition. For example, the inclusion of chocolate milk, which contains protein or 100% fruit juice and which contains vitamins and minerals, in some studies might change the results. Reliable assessment of dietary intake is difficult, especially among children and adolescents.41 Participants' age might influence misreporting owing to recall bias and cognitive abilities that may limit the reliability of dietary intake assessment methods. Evidence suggests that involvement of a parent for children under the age of 8 improves the reliability of dietary assessment, and for younger children, ages 0.5-4.0 years, weighted food records have been reported to provide the best estimates.41,42

In addition, different practices regarding total energy intake adjustments are likely to influence the direction of the association between SSBs and weight and change research results. In regard to best practice for meta-analyses of the association between SSBs and body weight, divergent expert opinions are present in the literature.43 On the one hand, adjustment for total energy intake is performed by some researchers in order to control for confounding factors, reduce extraneous variation, and predict the effect of dietary interventions.14,15,44 On the other hand, because SSBs are a source of calories, it has also been argued that adjusting for total energy intake might result in underestimating the effect of SSBs on body weight, given that total energy intake mediates the association between SSBs and BMI.43

Discrepant results regarding effect sizes in the included meta-analyses were found. Indeed, effect sizes of increasing SSB consumption on BMI change (increase) was statistically significant in half of the four meta-analyses evaluating effect sizes from both prospective (cohort) and intervention studies. Whereas effect sizes of decreasing SSB consumption on BMI change (decrease) was statistically significant in two of the three meta-analyses evaluating effect sizes from intervention studies. These discrepant findings might be explained by the factors mentioned above, such as heterogeneity in SSB definition, as well as analytical disparities in calculating effect sizes. Comparing effect sizes found in meta-analyses was also limited by the different inclusion criteria used. Some meta-analyses evaluated effect sizes from intervention studies only33 and other from both intervention and prospective studies.14,32,34,35 In addition, some meta-analyses evaluated the effect of increasing35 versus decreasing33 SSB consumption on BMI change or both.14,32,34 Hence, discrepant results across reviews and meta-analyses evaluating the association between SSB consumption and weight gain, overweight, and obesity in children and adolescents are likely to be owing to heterogeneity in research methods and design as well as analytical disparities.

Reviews not showing a direct association between SSB intake and weight outcomes were either funded by the food and beverage industry25,35 or conflict of interest14,33 was reported. The source of funding for reviews concluding that there was an association between SSB consumption and weight outcomes was either unknown18,27,28,31 or public. In accord with our results, Massougbodji and colleagues17 also reported differences regarding the nature of reviews' results between nonindustry- and industry-funded research. This suggests that reviews' conclusions might be influenced by funding sources as well as authors' conflict of interest.

Overall, reviews that concluded that there is a direct association emphasized the public health importance of identifying dietary determinants of obesity and the great potential of recommendations aiming at limiting the consumption of SSBs to prevent weight gain, especially among high-risk populations, such as overweight children. Reviews that did not conclude that there was a direct association underlined the importance of overall diet quality and physical activity and argued that evidence to reduce SSB intake to prevent weight gain or induce weight loss are equivocal.

Quality

The overall mean AMSTAR quality score (combining reviews and meta-analyses) was 5.23 (SD±2.26), which is slightly higher than another review that assessed the quality of reviews and meta-analyses on SSBs and weight, obesity, coronary heart disease, and diabetes, which had an average AMSTAR score of 4.4.4

These average low-to-moderate AMSTAR scores are likely to influence the conclusions of reviews and meta-analyses. This suggests that the methodology of reviews regarding SSB intake, as well as other exposures, in relation to weight outcomes could be improved.

Most reviews did not fulfill the criteria for question 11 ("was conflict of interest stated?"). Some reviews did not disclose their source of funding or conflict of interest, and most reviews that did so did not provide information on the source of funding of the cited studies, which is required to score "yes." The AMSTAR instrument does not distinguish between reviews providing partial information regarding funding sources and conflict of interest and reviews that do not provide any information. Another limitation of the AMSTAR measurement tool relates to the 11 questions being equally weighted. Therefore, questions that are more important for the reviews integrity are not given more weight than less-fundamental ones. As with any assessment tool, the quality criteria present some limitations, and our quality assessment approach may hence also have introduced some errors. However, the AMSTAR tool is validated and the clear guidance for each question limits interpretation bias and was found to be highly reliable.

Strengths and Weaknesses

The main strength of this review of systematic reviews and meta-analyses is the use of a validated quality assessment tool, AMSTAR, as well as the systematic approach used, which provides a more critical evaluation.

Of course, quality assessment remains subject to interpretation, but having two researchers performing the evaluation independently and using a validated tool should improve reliability. A limitation of our study is the inclusion of only published studies and restriction to English language. Publication bias cannot be excluded, given that studies with positive results tend to be published more easily.45

Conclusions

The majority of reviews concluded that there was a direct association between SSB consumption and weight gain, overweight, and obesity in children and adolescents. However, recent evidence from well-conducted meta-analyses shows discrepant results regarding the association between SSB and weight gain, overweight, and obesity among children and adolescents.

Our findings suggest that review- and study-level bias, such as the use of inappropriate study and review design, energy adjustment, as well as the acknowledged limitations linked to dietary assessment methods may impair the assessment of SSB consumption and its impact on weight gain among children and adolescents. Improving methodological quality of studies and reviews as well as ensuring responsible conduct of research and scientific integrity is essential for the provision of objective results.

Acknowledgment

The authors thank Birgitte Marie Skogstad for proofreading the manuscript.

Author Disclosure Statement

No competing financial interests exist.

References

3. Deckelbaum RJ, Williams CL. Childhood obesity: The health issue. Obes Res 2001;9(Suppl 4):239S-243S [[ PubMed] Google Scholar]

30. Osei-Assibey G, Dick S, Macdiarmid J, et al.. The influence of the food environment on overweight and obesity in young children: A systematic review. BMJ Open 2012;2 pii: . doi: 10.1136/bmjopen-2012-001538 [[ PubMed] [ CrossRef] PMC free article] [ Google Scholar]

36. Forshee RA, Anderson PA, Storey ML. Sugar-sweetened beverages and body mass index in children and adolescents: A meta-analysis. Erratum. [ Am J Clin Nutr 2009;89:441-442 [ PubMed] Google Scholar]

44. Willett W. Nutritional Epidemiology, vol. 30, 2nd ed. Oxford University Press: Oxford, UK, 1998 [ Google Scholar]

Articles from Childhood Obesity are provided here courtesy of Mary Ann Liebert, Inc.

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Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews

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Background: The prevalence of overweight and obesity among children and adolescents has increased worldwide and has reached alarming proportions. Currently, sugar-sweetened beverages (SSBs) are the primary source of added sugar in the diet of children ...

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This is credible information about childhood obesity because it is the United States National Public Health Agency that is under the U.S. Department of Health and Human Services.

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Childhood obesity is a serious health problem in the United States where 1 in 5 children and adolescents are affected. Some groups of children are more affected than others, but all children are at risk of gaining weight that is higher than what is considered healthy.

Obesity is complex. Many factors can contribute to excess weight gain including behavior, genetics and taking certain medications. But societal and community factors also matter: child care and school environments, neighborhood design, access to healthy, affordable foods and beverages, and access to safe and convenient places for physical activity affect our ability to make healthy choices.

Connect with Nutrition, Physical Activity, and Obesity

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Obesity now affects 1 in 5 children and adolescents in the United States. Learn more...

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Childhood Obesity: Issues of Weight Bias

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Childhood Obesity: Issues of Weight Bias

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This is credible information because this is known as the nations medical research agency that is apart of the U.S. Department of Health and Human Services, which is overseen by the government. This information about childhood obesity and issues of weight bias are credible.

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Peer Reviewed

Abstract

Although the effects of obesity on children's physical health are well documented, the social consequences of obesity are less well described and may not be addressed in intervention programs. Weight bias may take several forms. It may result in teasing and discrimination and may affect employment and educational opportunities. Health care providers may limit care of overweight or obese children. The media promote weight bias in multiple ways. Some parents are biased against their obese children. In an effort to avoid weight bias, new efforts to reduce obesity must be evaluated to determine whether these efforts do, in fact, add to the problem. It is important to understand that the weight bias that obese youth face is just as serious as the physical consequences of excessive weight on the welfare of the child.

Introduction

The obesity epidemic continues in the United States. Although the effects of obesity on the physical health of children are well documented, the emotional and social consequences of obesity are less detailed and not as well understood, and therefore are often ignored. The emotional consequences of obesity include low self-esteem, negative body image, and clinical depression ( 1). Any action or policy that exacerbates these consequences is considered a serious ethical problem. Obesity affects social health as well. These social effects often take the form of weight bias or stigma. This article summarizes what is known about weight bias based on selected reports. It is not intended to be a review of the literature. I hope that the opinions offered will increase interest in weight bias and its effects on children and generate further discussion.

Weight Bias

Weight bias can be defined as the inclination to form unreasonable judgments based on a person's weight. Stigma is the social sign that is carried by a person who is a victim of prejudice and weight bias. Obese children are at an increased risk for bias as a result of their weight.

Weight bias is caused by a general belief that stigma and shame will motivate people to lose weight or the belief that people fail to lose weight as a result of inadequate self-discipline or insufficient willpower. Our culture may not punish people who practice weight bias because our culture values thinness ( 1). Society frequently blames the victim rather than addressing environmental conditions that contribute to obesity.

Weight bias affects the child in multiple ways. Obese children are often the brunt of teasing or discrimination. Bias exists in the adult workplace and may affect children as they enter the workforce. Weight bias also influences educational success and may affect how health care is delivered. Weight bias is promoted in the media and even by parents of obese children. Curbing the obesity epidemic will require new strategies that do not result in bias or prejudice.

Weight Bias and Teasing

Teasing, a potential problem for all youth, is especially a problem for overweight and obese youth regardless of racial or ethnic group. In a study by van den Berg et al, one-quarter to one-half of children teased by family or peers were bothered by it, and more white females were disturbed than were people in other groups ( 2). Asian American adolescents may experience somewhat less weight-biased teasing from peers and more weight-biased teasing from family members. Efforts to eradicate weight bias can provide benefits to a sizeable number of adolescents across different racial/ethnic groups ( 2).

Weight Bias and Discrimination

Perceived weight and height discrimination have increased from 1995-1996 to 2004-2006, from 7% to 12% ( 3). During this same period, perceived racial/ethnic discrimination has remained stable, and the prevalence of weight and height discrimination has increased to levels that are now comparable with those reported for race and age discrimination ( 3).

Three hypotheses may explain the increase in weight discrimination. First, rates of obesity have escalated during the same period. Second, perceived weight discrimination may reflect experiences that have resulted from worsening societal attitudes and the acceptance of weight bias. Third, the media contribute and encourage weight bias and discrimination.

Information that emphasizes personal responsibility as the principal cause of obesity worsens negative stereotypes and increases bias toward obese people ( 4). Obese people are more likely to be blamed and negatively stereotyped when they are perceived by others to be personally responsible for their weight gain; however, they receive more favorable evaluations and less blame when obesity can be attributed to a physical cause outside of their personal control, especially among children ( 5).

Weight Bias and Employment

Weight bias against obese adults in the workplace has been widely reported ( 6, 7). Although studies involving children in the workplace do not exist, obese children are at great risk of becoming obese adults and, therefore, are at risk for bias in the workplace. Compared with job applicants who have similar qualifications, obese applicants are rated more negatively and are less likely to be hired. Obese applicants are also perceived to be unfit for jobs involving face-to-face interactions. Overweight and obese applicants are viewed as having inadequate self-discipline, low supervisory potential, unacceptable personal hygiene, and less ambition and productivity ( 6). As a consequence, overweight and obese employees earn 1% to 6% less than normal-weight people in comparable positions, and this salary difference is greater for obese women than obese men ( 7).

Obese people are promoted less often and are sometimes viewed by their employers and coworkers as lazy, less competent than their peers, and lacking self-discipline ( 8). Obese people believe they can be fired or suspended because of their weight, despite demonstrating satisfactory job performance, even when weight is unrelated to their job responsibilities ( 9).

Weight Bias and Education

Teachers perceive overweight students to be untidy, overly emotional, less likely to succeed at work, and more likely to have family problems compared with their normal-weight peers ( 10). Forty-three percent of principalsagree that most people are uncomfortable when they associate with obese people ( 11). In addition, teachers have lower expectations for overweight students compared with thinner students across a range of ability areas ( 12). Obese students are less likely to be accepted for admission into college, despite having comparable academic performance ( 13). These facts may explain why obese students feel a bias during their educational experiences.

Approximately 1 in 3 overweight females and 1 in 4 overweight males report being teased by peers at school; among the heaviest group of youth, that figure increases to 3 in 5 ( 1). Peers regard obese children as undesirable playmates who are lazy, stupid, ugly, mean, and unhappy ( 1). Negative attitudes begin in preschool and can worsen as children age ( 14). As a consequence, obese elementary school children miss more days of school than do their nonobese peers ( 15). Obese adolescent females are less likely to attend college than are nonobese females ( 16). Students who were obese at age 16 years had fewer years of education compared with nonobese peers, and youth who are victimized because of their weight are more vulnerable to depression, low self-esteem, inferior body image, and suicidal thoughts ( 17). Weight-biased teasing makes the youngster more likely to engage in unhealthful eating habits and to avoid physical activity in school ( 1).

Weight Bias and Health Care Discrimination

In a study of 400 doctors, 1 in 3 listed obesity as a condition to which they responded negatively. Doctors ranked obesity right behind drug addiction, alcoholism, and mental illness. They also associated obesity with noncompliance, hostility, dishonesty, and inadequate hygiene ( 18). Consequently, overweight patients may be reluctant to seek medical care, may cancel or delay medical appointments, or may postpone seeking important preventive services ( 19). Doctors examining overweight patients spend less time with them, engage in less discussion, are reluctant to perform preventive health screenings, and do fewer interventions ( 20). Self-monitoring - teaching the patient in a positive way to learn to monitor diet and activity to achieve weight maintenance or gradual weight loss - should be distinguished from making overweight and obese children feel guilty about personal habits related to weight gain. Educational efforts should be directed to health care providers to make them aware of the potential negative role they may play by giving negative messages.

Weight Bias and the Media

Children's media have a prevailing tendency to represent positive messages about being thin and negative messages about being overweight. In children's entertainment, thin characters are ascribed desirable attributes and dominate central roles ( 21), whereas overweight characters are onscreen rarely or in minor stereotypical roles. Compared with thin characters appearing on television, heavier characters rarely are portrayed in romantic relationships (and never with thin characters), are more likely to be objects of humor and ridicule, and often engage in stereotypical eating behaviors ( 22).

Weight Bias and Parents

In a study of 5-year-old girls, parents who were overweight (60% of mothers and 82% of fathers) or obese (28% of mothers and 31% of fathers) were just as likely to endorse negative stereotypes as were thinner parents ( 23). Girls were more likely than boys to display negative stereotypes if their parents emphasize the importance of thin body shape and weight loss. Fathers with higher education and income were more likely to endorse stereotypes than were fathers with less education and income, as were parents who reported a strong investment in their own appearance compared with parents who did not ( 23).

In 1 study, weight-biased teasing by family members was reported by 47% of substantially overweight females and 34% of substantially overweight males ( 1). Bias from parents may have unexpected consequences. Studies among high school seniors have demonstrated that overweight females receive less financial support from their parents for college than do average-weight females, even after controlling for parental income, race/ethnicity, family size, and education ( 24).

Weight Bias, Prevention, and Eating Disorders

As increased attention is paid to the obesity epidemic it would be unethical to, at the same time, increase weight bias. Efforts to promote environmental and policy changes to decrease overeating and inactivity (including banning competitive foods from schools, mandating menu labeling, reporting students' body mass index to parents, and requiring daily physical education) are met with concern that these activities may lead to an increase in societal preoccupation with dietary restraint and worsening body image, thereby increasing weight bias and the incidence of eating disorders ( 25). Data demonstrate, however, that recent societal focus on obesity prevention has not led to a discernible increase in eating and eating disorder behavior, and no evidence exists that increased media or professional discussions regarding childhood obesity have been associated with a concomitant increase in eating pathologies ( 25).

Conclusion

The obesity epidemic continues to spread at an alarming rate. Preventing childhood obesity has become a priority in an effort to improve the nation's health. The reduction of weight bias is just as important as the reduction of body mass index is. Children need adults to advocate for them and to fight against weight bias, especially as new interventions are developed. Although the effects of weight bias are not as well known, the consequences are just as serious as excessive weight is on the welfare of the child. Future studies are needed to better understand bias, especially the effect it has on the education and employment of children. Additional research is needed to determine how best to educate teachers and health care providers so that they do not add bias as they interact with obese children.

Acknowledgments

This article highlights ideas generated and conclusions reached at the Symposium on Ethical Issues in Interventions for Childhood Obesity, sponsored by the Robert Wood Johnson Foundation and Data for Solutions, Inc.

Footnotes

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Suggested citation for this article: Washington RL. Childhood obesity: issues of weight bias. Prev Chronic Dis 2011;8(5):A94. http://www.cdc.gov/pcd/issues/2011/sep/10_0281.htm. Accessed [ date].

Contributor Information

Reginald L. Washington, Rocky Mountain Hospital for Children. Dr Washington is also affiliated with the University of Colorado School of Medicine. 1719 E 19th Ave, Denver, CO 80218, Phone: 303-839-6100, Email: moc.seracENOhtlaeH@notgnihsaW.dlanigeR.

References

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Peer Reviewed: Childhood Obesity: Issues of Weight Bias

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Although the effects of obesity on children's physical health are well documented, the social consequences of obesity are less well described and may not be addressed in intervention programs. Weight bias may take several forms. It may result in teasing ...

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Childhood Obesity: A Review of Increased Risk for Physical and Psychological Comorbidities

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Childhood Obesity: A Review of Increased Risk for Physical and Psychological Comorbidities

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This is credible information that is from a scientific book that has been reviewed by doctors and other scientists. This would be considered credible information!

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Childhood Obesity: A Review of Increased Risk for Physical and Psychological Comorbidities

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Worldwide estimates of childhood overweight and obesity are as high as 43 million, and rates continue to increase each year. Researchers have taken in...

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Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities

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Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities

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This is a credible information source because it is an official peer-reviewed journal of the American Academy of Pediatrics (AAP). This would be considered credible and has great information on treatments of childhood obesity.

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Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities

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The objective of this technical report is to provide clinicians with actionable evidence-based information upon which to make treatment decisions. In addition, this report will provide an evidence base on which to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents.To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) “What are effective clinically based treatments for obesity?” and (KQ2) “What is the risk of comorbidities among children with obesity?” See Appendix 1 for the conceptual framework and a priori Key Questions.