Changes in the Morphological Development of Youth aged 16-18 from Eastern Poland in the Years 2006 - 2016 – 2021

Estimation of secular trends in adult height, and childhood socioeconomic circumstances in three Eastern European populations

Background: Due to the secular trend in length and height, growth references need to be updated regularly. Reference charts that were until recently used in Belgium are based on samples collected more than 30 years ago, and references for body mass index (BMI) and pubertal development have not been established before.Aims: To establish contemporary cross-sectional reference charts for height, weight, BMI, head circumference, and pubertal development from birth to 21 years of age, based on a representative sample of children from Flanders, Belgium.Subjects and methods: 15 989 healthy subjects of Belgian origin, 0–25 years of age, were measured in 2002–2004. Growth curves were fitted with the LMS method, and percentiles for the pubertal development were estimated with generalized additive models on status quo data from 8690 subjects aged 6–22 years of age.Results: A positive secular trend in height and weight is observed in children above 5 years of age. Adult median height has increased by 1.2 cm/decade in boys and 0.8 cm/decade in girls; median weight by 0.9 kg/decade in boys, and 1.0 kg/decade in girls, and the weight distribution became more skewed. The BMI curve is comparable to that of other populations, except for higher percentiles. This reflects the increasing prevalence of overweight and obesity. Median age at menarche (13.0 years) has not advanced any more over the past 50 years. Median ages at menarche and B2 in girls and G2 or T4 in boys are comparable to other West European estimates, but approximately 10% enter G2/T4 before 9 years of age.Conclusions: The ongoing secular trend in height and weight makes growth charts previously used in Belgium obsolete. New representative charts for growth and pubertal development are introduced. For weight monitoring, it is advised that the now-available BMI growth charts are used.

The records of height of 22841 18-year-old Portuguese males were analysed as well as their parents educational level and localities of subject's residence (districts). The sample includes all the Portuguese 18-year-old males, born in 1978 and examined in 1996, in central and southern Portugal, representing all the social strata. Statistically significant differences (p 0.001) among the districts were found: males from Setubal (172.75 cm) and Lisboa (172.64 cm), the most developed districts, are the tallest, and those from C. Branco (170.79 cm) and Coimbra (171.19 cm) are the shortest. Comparing to published data from 1904, a positive secular trend in height was found. The average increase was 8.99 cm, which yields a rate of 0.99 cm per decade. This positive trend must be related to the general improvement in the population's standard living conditions, as the striking drop of post-neonatal mortality rate shows after the 1960s and 1970s. Despite this positive trend, great social difference still exists: the gap between the two extremes of parents' educational level is almost 4 cm for height. Analysis of variance (ANOVA) showed significant effects of father's and mother's educational level as well as subject's locality of residence, but the influence of parents' educational level was stronger than that of geographic residence. These results suggest that the secular trend in height will continue for the Portuguese population in the future decade.

To examine the orientation, magnitude, and pace of secular trends in body height, weight, and body mass index (BMI) among Chinese urban students aged 7-18 years from 2000 to 2019. Data were extracted from Chinese urban students aged 7-18 years from the Chinese National Surveillance on Students' Constitution and Health in 2000, 2005, 2010, 2014, and 2019. The height, weight, and BMI of 548 419, 548 408, and 548 365 urban students aged 7-18 years, respectively, were tested. The mean differences across survey years were tested by one-way analysis of variance (ANOVA). The pace of secular trends is expressed as the change every 5 years between every two adjacent survey years. Height increments between 1.9 and 6.2 cm, weight increments between 2.7 and 8.6 kg, and BMI increments between 0.9 and 1.9 kg/m2 were observed in boys. For girls, height increments between 1.5 and 4.9 cm, weight increments between 2.2 and 6.0 kg, and BMI increments between 0.7 and 1.7 kg/m2 were observed. The pace of secular trends in height decreased in the last 5 years, and the secular trends in weight and BMI have accelerated in the last 9 years compared with the previous 10 years. Although the secular trend in height among Chinese urban students has slowed, it has not yet reached its genetic potential and continues to increase. The rapid increase in weight and BMI was a cause for concern. Our findings provide a basis for the future formulation of public health interventions in China.

BackgroundSince its independence in 1945, Indonesia has undergone rapid socioeconomic development. The fastest changes occurred in Java, which is the main island where more than half of the Indonesian population lives.ObjectiveThis study aimed to analyze the secular trend in the height of adults living in Java born between 1953 and 1995 by comparing their residence (rural, small city, or large city) and considering factors that contribute to adult height.MethodsThe analysis used the following data: birth year, body height, weight, body mass index, sex, educational attainment, share of household food expenditures, and residence of 20- to 40-year-old men and women collected by the Indonesia Family Life Survey (IFLS) waves 1 to 5. Multiple linear regression was conducted to analyze several factors that influence adult height. Significance was set at p < 0.05 with a 95% confidence interval (CI).ResultsThe study included 30,656 measurements of individuals born between 1953 and 1995 (54.9% female). Positive secular trends (95% CI) were observed for men and women: 1.3 (1.1–1.4) cm and 0.9 (0.8–1.0) cm per decade, respectively. Multiple linear regression analyses showed that, in addition to the year of birth, the adult height of both males and females was independently associated with level of education and share of household food expenditure. Stratifying the data into residence in rural areas, small cities, and large cities showed that education levels influenced the adult height of men and women living in all regions, whereas the influence of birth year and share of household food expenditure differed between areas and genders.ConclusionsWe observed positive secular trends in the height of adults living in Java who were born between 1953 and 1995. The birth year, educational attainment, and share of household food expenditure significantly influenced adult height. A higher education level was consistently associated with taller adult height in both men and women living in rural areas, small cities, and large cities.

To assess secular trend and changes in social inequalities of children's height across nearly 50years, when vast socio-political changes took place in Poland. Data on schoolchildren aged 7-18years were collected in 1966, 1978, 1988 and 2012 in Poland. Height was standardised for age using the LMS method. Socio-economic status (SES) was based on 4 factors: urbanisation level, mother's and father's education, and family size (number of children). Statistics included 2-way ANOVA with post hoc Tukey's test and effect size calculations. Positive secular trend in height was observed across all years. All analysed SES factors had significant effect on height which differed depending on SES category and year of Survey. Differences in height between extreme categories of SES factors decreased gradually, starting from 1978. However, only general SES in girls and urbanisation level in both sexes became insignificant in 2012. Improvement of living conditions across nearly 50years was reflected in the secular trend in children's height. Despite this improvement, however, the biological effects of social inequalities, visible in differences in height, to some extent, are still present in Poland.

To explore if the secular trend in height is contributing to delay overweight rise among Brazilian adolescents. Changes in BMI mean over time were fitted using linear regression including as independent variables survey year, height, survey-specific income quintiles, age and an interaction term of height × survey year. Overweight was defined as BMI≥25·0 kg/m2. Changes in overweight prevalence over time were fitted using Poisson regression. Four national household surveys: 1974/5, 1989, 2002/3 and 2008/9. Brazilian adolescents. Mean values of height and BMI increased over the period, for both sexes and in all age ranges, except for girls aged 14-19 years from 1989 to 2002/3. The highest average increment and mean rate of height were between 1989 and 2002/3 and in 10-15-year-olds. The annual increment of height decreased from 2002/3 to 2008/9 in parallel with the increment in BMI rate. After fitting the regression model, the height × survey year interaction and per capita income were strong vectors to increase BMI mean. Changes in increment rate of height played a protective role against overweight in the last two periods for both sexes, mainly for girls. The period from 1989 to 2002/3 was the strongest vector associated with overweight in boys and the association decreased to the next period, from 2002/3 to 2008/9. BMI and height of adolescents have increased in a wavering and alternate way throughout four decades in Brazil. The rate of height increment has played a protective role against overweight in adolescents.

Background: Poland is considered an ethnically homogeneous country, with no significant national, linguistic, religious or racial minorities. Thus, social differences in rates of maturation, height and weight may be assumed to contain a negligible genetic component and serve as a reflection of environment, i.e. living conditions.Aim: This study seeks to determine whether changes in economic conditions in Poland, in particular the acute economic crisis of 1977–1989 and the transformation of the political system in 1989, had an effect on the biological status of girls from various categories of the rural population.Subjects and methods: Rural girls aged 9.5–18.5 years were studied in 1967 (n = 7889), 1977 (n = 7771), 1987 (n = 13 556) and in 2001 (n = 9599). The stratification of participants (farmers, farm-workers and non-farmers) was based on the source of their family income, parents' education, number of children per family and household appliances. Age at menarche (AM), body height, and weight were used as biological indicators of living conditions.Results: During the decade 1967–1977, while a relatively good economic situation prevailed in the country, AM decreased by 0.64 years and distinct secular trends in height and weight were noted. During the decade 1977–1987, years of economic crisis, secular trends were arrested and AM increased by 0.11 years. Landless rural families were more strongly affected by food shortages than were farmers who were the food producers. The study, repeated in 2001, showed positive secular trends in body height and a decrease in AM of 0.24 years for decade for daughters of farmers this decrease in AM was twice as high as in non-farmer families. The latter group experienced acute unemployment after the political and economic system transformation (1989). AM was earliest in daughters of non-farmers, and latest in those from farmer families. In 1967, the difference between the mean ages at AM for these groups amounted to 0.53 years, in 1977 to 0.44 years, in 1987 to 0.33 years and to only 0.15 years in 2001.Conclusion: The categories of the rural population, farmers, farm-workers and landless rural inhabitants were variously affected by the economic crisis, as well as by the process of economic transformation. This shows that living conditions of each of those categories changed in different ways and to a different degree during the years 1967–2001. Farmers' families achieved the highest social advancement, as the AM of girls from those families decreased by 0.98 years compared to those from farmer-worker and landless rural families, which decreased by 0.85 and 0.60 years, respectively.

Human physical growth, biological maturation, and intelligence have been documented as increasing for over 100 years. Comparing the timing of secular trends in these characteristics could provide insight into what underlies them. However, they have not been examined in parallel in the same cohort during different developmental phases. Thus, the aim of this study was to examine secular trends in body height, weight, and head circumference, biological maturation, and intelligence by assessing these traits concurrently at four points during development: the ages of 4, 9, 14, and 18 years. Data derived from growth measures, bone age as an indicator of biological maturation, and full-scale intelligence tests were drawn from 236 participants of the Zurich Longitudinal Studies born between 1978 and 1993. In addition, birth weight was analyzed as an indicator of prenatal conditions. Secular trends for height and weight at 4 years were positive (0.35 SD increase per decade for height and an insignificant 0.27 SD increase per decade for weight) and remained similar at 9 and 14 years (height: 0.46 SD and 0.38 SD increase per decade; weight: 0.51 SD and 0.51 SD increase per decade, respectively) as well as for weight at age 18 years (0.36 SD increase per decade). In contrast, the secular trend in height was no longer evident at age 18 years (0.09 SD increase per decade). Secular trends for biological maturation at 14 years were similar to those of height and weight (0.54 SD increase per decade). At 18 years, the trend was non-significant (0.38 SD increase per decade). For intelligence, a positive secular trend was found at 4 years (0.54 SD increase per decade). In contrast, negative secular trends were observed at 9 years (0.54 SD decrease per decade) and 14 years (0.60 SD decrease per decade). No secular trend was observed at any of the four ages for head circumference (0.01, 0.24, 0.17, and - 0.04 SD increase per decade, respectively) and birth weight (0.01 SD decrease per decade). The different patterns of changes in physical growth, biological maturation, and intelligence between 1978 and 1993 indicate that distinct mechanisms underlie these secular trends.

Currently, there is a growing incidence of diabetes mellitus and obesity.Objective. To determine the prevalence of overweight and obesity in children with type 1 diabetes mellitus.Materials and methods. The study included 313 patients (245 under 14 years old, 68 adolescents aged 15–17 years) with type 1 diabetes mellitus. At the first stage, a single-stage observational study was conducted to assess the prevalence of obesity and excess body weight in children with type 1 diabetes mellitus. The second stage was a retrospective study to evaluate body weight at the onset of 1 diabetes mellitus in patients with excess body weight and obesity after 5 years of the disease.Results. 68 (21.7%) patients with type 1 diabetes mellitus were overweight, and 32 (10.2%) had obesity of varying degrees. There was no difference in the incidence of obesity and excess body weight in children of different age groups: the incidence of obesity was 9.8% and 11.8%, and excess body weight was 22.9% and 17.6%, respectively. After 5 years of type 1 diabetes mellitus disease in all age groups, the prevalence of obesity increases 2.6 times, increasing from 5.4% to 14.3% (p=0.077), excess body weight — from 10.8% to 28.6%, respectively (p=0.030). Retrospective analysis found, that the most patients, with excess body weight prevalence of type 1 diabetes mellitus (58.3%), at the 1st year of the disease was determined normal body weight, which was increased to excess (p&lt;0.001). Additionally, in 50% of patients who developed obesity after five years of type 1 diabetes mellitus, overweight was already present in the first year of the disease (p=0.030) and later progressed to obesity.Conclusion. Given the increasing prevalence of obesity in children with type 1 diabetes mellitus, as well as the increased risk of cardiometabolic and other complications in such patients, special attention should be paid to the development of effective strategies for the management and prevention of obesity in children with type 1 diabetes mellitus.

Background/Objectives: Secular trends in children’s physical development are important indicators of population health, nutritional status, and socioeconomic conditions. This study aimed to assess long-term changes in the height, weight, Body Mass Index (BMI), and nutritional status of boys from Eastern Poland between 1986 and 2021. Methods: Anthropometric data were collected from 13,172 boys aged 8, 13, and 17 years at five time points (1986, 1996, 2006, 2016, and 2021). Standardized measurement protocols were used throughout the study. The BMI was calculated and categorized using international cut-off points for age and gender. Secular changes in the height, weight, and Body Mass Index (BMI) were analyzed using an analysis of variance (ANOVA) with post hoc tests, and differences in dietary categories were assessed using chi-square tests (p ≤ 0.05). Results: The height, weight, and BMI increased significantly across all ages. The largest height gain was seen in 13-year-olds, while the greatest BMI increase occurred between 2016 and 2021. The overweight and obesity prevalence rose sharply by an average of 21.70% across age groups, with the normal BMI prevalence decreasing by 18.41%. The underweight prevalence declined, especially among adolescents; however, this likely reflects a general upward shift in the BMI rather than a true nutritional improvement. Conclusions: Strong secular trends are evident, influenced by global and local socioeconomic factors, including Poland’s EU accession and the COVID-19 pandemic. While an increased height suggests better living standards, the rising overweight and obesity rates indicate emerging health risks. Due to the lack of direct lifestyle and socioeconomic data, further research incorporating these factors and the pubertal BMI variability is needed to clarify underlying causes. Targeted regional strategies promoting healthy diets, physical activity, and lifestyles are urgently required.

To assess long-term changes in body mass index (BMI) and weight status among girls from Eastern Poland between 1986 and 2021. Data were obtained from repeated cross-sectional, population-based surveys conducted in Eastern Poland in 1986, 1996, 2006, 2016, and 2021. The study included 14,825 girls aged 8, 13, and 17 years, recruited from the same schools across survey waves. Body height and body mass were measured by trained personnel using standardised procedures, and BMI was calculated. Weight status categories (underweight, normal weight, overweight and obesity) were defined using international BMI cut-off points. Statistical analyses included analysis of variance and post hoc comparisons. Between 1986 and 2021, the largest increase in BMI was observed among 13-year-old girls (+1.66 kg/m2), followed by 8-year-olds (+1.14 kg/m2), while a decrease occurred among 17-year-olds (-1.13 kg/m2). The prevalence of underweight declined among 8- and 13-year-olds by 2.70 and 3.15 percentage points, respectively, but increased among 17-year-olds by 1.85 percentage points. In parallel, the combined prevalence of overweight and obesity increased across all age groups: 19.89 percentage points among 8-year-olds, 10.66 among 13-year-olds, and 3.87 among 17-year-olds, with the greatest increases occurring in recent survey periods. Over the past 35 years, BMI distribution among girls in Eastern Poland has shifted towards higher values, accompanied by a rise in overweight and obesity. The increase in underweight among older adolescents may reflect psychosocial pressures. These findings highlight the need for age-specific public health strategies addressing both excessive and insufficient body mass.

Aim: We aimed to examine the distribution and secular changes of conscript body height in the geographic network of Norway since 1878 and to study its association with the degree of urbanization, and population density. Material and methods: Data on body height of Norwegian military conscripts were provided by the Statistics Norway Department (SSB). The sample comprised eight cohorts with the following measurement years: 1st 1877, 1878 and 1880, 2nd 1895-1897, 3rd 1915-1917, 4th 1935-1937, 5th 1955-1957, 6th 1975-1977, 7th 1995-1997, and 8th 2009-2011. For determining neighborhood correlations, a network was created consisting of neighboring counties, sharing a common border. Results: Average body height of Norwegian men increased by 10.9 cm between 1878 and 2010, but this trend was heterogeneous. Some counties increased by more than 1 cm per decade (Finmark) others by only 7 mm per decade (Sor-Trondelag). Urban counties and counties with higher population density showed stronger height trends than rural counties. The largest spread in body height between the various counties was observed in 1936 when for the first time people living in the more urban counties got taller than rural people. The height advantage of urban counties however, disappeared after 1996. At this time, also the secular trend in height had come to a halt. The secular trend in height had become obvious after the dissolution of the union between Norway and Sweden in 1905 and World War I, and was strongest between 1936 and 1956. During this period maximum between-county heterogeneity in height existed with body height differences of more than 6 cm between the tallest and the shortest county. The end of this period was characterized by social democratic reforms that flattened the income distribution, eliminated poverty, and ensured social services after World War II. Conclusion: The temporal coincidence between the trends in height, the degree of urbanization and the onset of the political transition of Norway from a Swedish province into an independent democratic wealthy modern European state after World War I and particularly after World War II, and the abatement of this trend after this period of transition had stabilized, suggest social and political components interfering with the regulation of physical growth in humans.

After completing this article, readers should be able to: Pediatric obesity has been viewed as a growing epidemic of the past few decades that requires intervention, similar to tobacco use and its accrued medical risks that has prompted multifaceted preventive efforts. Affecting as many as 34% of American children, (1) obesity can be viewed as a top public health threat due to its associated morbidity and mortality. (2) The medical consequences of obesity accounted for 40% of the health-care budget by 2006, with an expected $147 billion in health-care spending alone in 2008. (3) In 2006, obese adults had estimated medical costs $1,429 higher than those for persons of normal weight. (3) For children coming to a pediatric integrated health-care delivery system, expenses were $179 per year higher in obese children versus children who had normal body mass index (BMI). (4) Using the Medical Expenditure Panel Survey data from 2002 to 2005 for children ages 6 to 19 years, the total additional health expenditure in prescription drugs, outpatient appointments, and emergency department visits for children who had elevated BMIs was estimated to be $14.1 billion annually. (5)Pediatric obesity affects all organ systems, (6) with its medical sequelae paralleling the increasing prevalence in younger children. Type 2 diabetes is being diagnosed in morbidly obese 9-year-olds, and bariatric surgery has been performed in children as young as 12 years. Prevention is paramount, and pediatricians need easy tools that help with early recognition of developing obesity, preventive counseling, and treatment. Bariatric surgery remains an option, albeit a last resort, because the morbidly obese individuals who suffer medical complications remain at risk for a shortened lifespan if they do not achieve significant weight loss. This article discusses trends in epidemiology, recognition, and treatment of obesity in the primary care office as well as community interventions and prevention.Obesity occurs when energy intake exceeds energy expenditure. BMI (defined as weight in kilograms divided by height in meters squared) is an indirect measure of weight status and is plotted against age- and sex-specific percentiles. In the United States, children and adolescents are defined as obese if their BMI exceeds the 95th percentile for age and overweight if their BMI falls within the 85th to 95th percentile range for age.BMI is easily measured, has pediatric norms available on the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) websites, is easily calculated by available web programs, and can be used easily for tracking childhood obesity trends within a population. However, measuring overweight and obesity in children ages 5 to 14 years is challenging because, as noted by the WHO, there is no standard definition of childhood obesity applied worldwide (http://www.who.int/mediacenter/factsheets/fs311/en/index.html). Comparison of the CDC and WHO data and methodology reveals similar graphs, with small variations. (7)Pragmatically, the pediatrician can use the WHO's downloadable growth charts for children from birth through 23 months, and the CDC website's downloadable BMI graphs for tracking for children ages 2 years and up. The electronic medical record can make tracking of BMI even easier through programs that calculate BMI automatically and record both the vital signs and BMI into the health supervision visit record.However, BMI measurements do not reflect adiposity accurately because a muscular individual might have the same BMI as an oversized endomorph (for those in the United States, imagine Arnold Schwarzenegger in his competitive bodybuilding years compared with a life-size cartoon character such as Fred Flintstone). High lean body mass can elevate weight, leading to a higher BMI without corresponding high adiposity.The prevalence of pediatric obesity has grown in the past few decades, with increases occurring worldwide in developed more than in developing countries. Despite an increase in efforts to recognize and treat pediatric obesity, trends in obesity have not shown a decrease; at best, there is a plateau in rates. Ogden and associates (8) showed a prevalence of overweight of more than 33%, varying by ethnicity. The prevalence of obesity diagnosed in children ages 6 to 19 years tripled from 2003 to 2006; in children ages 2 to 5 years, the incidence of obesity rose from 5% to 12.4%. (9) A study of 11,653 children ages 5 to 17 years in a longitudinal set of eight cross-sectional surveys, with use of data from the Bogalusa Heart Study from 1973 to 1994 plus BMI data from routine school screening in 2008 to 2009, showed a threefold increase in the prevalence of overweight and obesity from 14.2% to 48.4%. (10)Prenatal influences include the food milieu provided by the placenta, with prenatal nutritional deprivation, gestational diabetes, and high birthweight all positively correlated with obesity. In the first year after birth, BMI increases substantially, and the infant has a large number of adipose cells. Between 4 and 6 years of age, adipose cells reach a nadir and subsequently increase sharply in number in a process termed adipose rebound. The younger and heavier the child is at the time of adipose rebound, the more likely he or she is to become an obese adult. As Ariza and associates state, "… the adipose cells accumulated during this period will forever call out to be fed." (11)Table 1 outlines the correlation between pediatric obesity and adult obesity by age, as adapted from various studies. (12)(13)(14)(15) In a retrospective cohort study of 854 children that included longitudinal data, Whitaker and colleagues (14) found that 1 to 2 year olds who had a nonobese parent had an 8% chance of becoming obese adults, whereas 10- to 14-year olds who had at least one obese parent had a 79% chance of becoming obese adults. Using the National Longitudinal Study of Youth 1979 health data on 1,309 children born in 1965 to 1966 and tracked from 1981 to 2002, Wang and associates (13) found that 80% of male and 92% of female adolescents whose BMIs were greater than the 95th percentile became obese adults. These results are similar to the longitudinal findings from the Bogalusa Heart Study, (12) a cohort of 2,610 adolescents ages 15 to 17 years from 1975 who were followed into their early 30s by 1993, at which time 86% of boys and 90% of girls whose BMIs were more than the 95th percentile in adolescence remained obese as adults.Protective factors for obesity include breastfeeding, being a part of families who have active lifestyles and minimal television usage, and having nonobese parents. (16)(17)(18)Genes play a role in pediatric obesity but do not account for the dramatic recent increase in prevalence. Exogenous influences such as the demise of the family dinner, with more families eating fast food on the run; prepackaged foods that have high ratios of saturated fat (and trans fats until recently) and high-fructose corn syrup; less accessible and lower intake of fruits and vegetables in the average urban family; lack of safe areas to play outside; sedentary lifestyles with more hours of television and video game use; and diminished school physical activity requirements are among many of the reasons for the recent trends. Sports for the elite child athlete are easily accessible, but affordable options for the recreational athlete, particularly the obese child, may be lacking.The media also has contributed to the increase in childhood obesity, with advertisements to children significantly affecting their food preferences. The average parent often succumbs to a child's request for the latest high-calorie, low-nutrient craze in the grocery store. Feeding trends also have an impact. For example, toddlers who are fed more than they require learn to select and eat more than they need. In a culture in which providing food represents providing love and providing more is better, conspicuous consumption has obvious consequences. (19)Underdiagnosis of pediatric overweight and obesity remains a concern. In a recent study using electronic medical records of 711 patients ages 2 to 18 years seen for well care between June 1999 and October 2007 in a large medical system in northeastern Ohio, (20) the prevalence of overweight and obesity was higher than typical, much more than the 10% seen in other countries. With overweight defined as BMI of at least the 85th percentile but less than the 95th percentile and obesity defined as BMI of at least the 95th percentile or at least 30, 19% of children were overweight, 23% were obese, and 33% of the obese group (8% of all children) were morbidly obese. Of note, when the assigned billing International Classification of Diseases (ICD)-9 code for obesity was used as the means to determine whether obesity was recognized and formally diagnosed, only 10% of overweight patients, 54% of the obese patients, and 76% of the morbidly obese patients were assessed accurately.Among undiagnosed patients whose electronic medical records were reviewed manually (n=195), 10.8% of overweight patients, 38.2% of obese patients, and 40% of severely obese patients were given a diagnosis other than overweight or obesity by ICD-9 code. This trend may reflect the current lack of reimbursement in Ohio and other states for treating only obesity; ICD-9 codes reflecting the medical complications of obesity have better reimbursement. In this cohort, girls were more likely to be diagnosed than boys, as were African American and Hispanic patients more than white children and adolescents. However, a statistically significant trend was documented toward an increasing rate of diagnosis during the study period until 2005, when the percentage of patients diagnosed per year reached a plateau; this trend parallels the heightened awareness of the obesity epidemic by the public, including parents and medical personnel. (20)Heightened awareness does not necessarily translate into vastly improved response, prevention, and treatment, as suggested by the plateau rather than decrease in prevalence of obesity in Ohio. Analogous to the challenges of opposing the tobacco industry with respect to smoking prevention and cessation, combating obesity begins with awareness of the problem followed by a steady progression of multilayered interventions leading to generational change. Benson and colleagues (20) found that use of automatic flagging of abnormal BMIs is insufficient to provide long-term increases in diagnostic rates; rather, more active strategies are necessary to encourage clinicians to diagnose pediatric obesity.Similar to recognizing domestic violence, many primary care clinicians do not know what to do once they diagnose obesity in a pediatric patient. Besides determining BMI, electronic medical record software can automatically produce a proactive response by suggesting handouts, action steps, and even recipes that are downloadable at the time of a patient encounter if a patient has a high BMI. However, pediatricians may lack access to such resources.Communities also can improve efforts to treat obesity. For example, the Ohio Business Roundtable declared pediatric obesity a priority issue and worked with legislators, vested business partners, health professionals, children's hospitals in the state, and the state chapter of the American Academy of Pediatrics to pass legislation for greater physical activity in schools, higher nutritional standards in school cafeterias, and limited choices in school vending machines.Unfortunately, the term obesity has been used for discrimination and teasing and not for recognizing a disease requiring treatment. This lack of disease nomenclature has been a barrier to insurance reimbursement, with tertiary prevention paradoxically paid better than primary prevention; it is relatively easy to have an insurance company pay for an adult coronary bypass in the United States as opposed to funding treatment for obese patients who do not have associated comorbidities. Until 2004, even Medicare payment regulations contained the phrase, "Obesity itself cannot be considered an illness." (21) Proponents of the view that obesity is not a disease argue that one can be overweight yet physically fit, but that belief should be challenged, as suggested by the evidence that obese children as young as 10 years of age develop atherosclerosis, at 9 years of age develop type 2 diabetes, and at earlier ages develop other comorbidities associated with obesity.Elevated BMI in childhood is associated with multiple comorbidities in the pediatric age group (Table 2). Blood pressure elevations can be seen in adolescence and rarely before that age. Table 3 outlines the simple positive changes associated with only a small drop in BMI. (22)(23)(24)(25)(26) Table 4 delineates recommended laboratory assessment for overweight and obese children. (27)(28) Overweight children tend to be taller, have advanced bone ages, and mature earlier compared with their nonobese peers. Early puberty correlates with higher adiposity in adulthood as well as an increase in truncal fat distribution in women. Adipose cells on the hips, once formed, last forever, and these cells increase in size more than number with age. Omental adipose cells, on the other hand, can increase in number with age. Central fat distribution, perhaps through an effect on insulin concentrations, appears to be an important mediating variable between lipid concentrations and obesity. Leptin, produced by adipocytes, is elevated in obese women, and a raised leptin value is associated with higher rates of infertility. (29) Early maturation can lead to lower self-esteem in girls, with a marked increase in unhealthy dieting behaviors.As noted earlier, the first step in the office setting is to recognize when overweight or obesity occurs; in simplest terms, pediatricians need to include in their practice the tracking of a patient's BMI with the same rigor applied to following other growth parameters. The second step is to react to an increasing BMI with an approach that promotes positive family change without decreasing the child's or the parent's self-esteem. For example, when confronted with a BMI at the 85th percentile and a weight percentile that is higher than the height percentile, the pediatrician can tell an 8-year-old child, "You are awesome, and together with your parents, we are going to keep you healthy and have your weight stay the same this year, while you keep getting taller!" Pairing this statement with small, steady changes that the parent can implement with close medical follow-up evaluations tends to work better than a remonstrative approach.Ideally, a child in the overweight category (BMI 85th to 95th percentile) should be seen at least quarterly, with dietitian visits for both child and family to help with portion sizes, healthier choices, and positive changes in family behaviors. Children in the obese category (BMI ≥95th percentile) should be seen monthly, with steady change promoted in positive terms. Reimbursement remains a challenge, but improvements may result from advocacy with groups such as the American Academy of Pediatrics and the Alliance for a Healthier Generation, community partnerships such as the Ohio Business Roundtable, and health-care organizations such as the Cleveland Clinic.Interventions in the office setting tend not to work until the child (and parent) is ready for change; premature interventions can lead to learned helplessness ("This diet will never work") and ongoing dieting attempts and disordered eating ("Maybe this diet will work"). The result can be long-term weight gain and physiologic changes supporting the disordered eating ("Skip the diet or either overeat or undereat accordingly"). In the very young child, the pediatrician requires parents (and other family members involved in food preparation and portioning) to modify diet and exercise willingly to ensure success.Motivational interviewing can be used to help manage change, such as asking open-ended questions about how the child feels about his or her weight: Has she ever been teased about her weight or bullied, and if so, how did she feel? What did she do at the time or after? Together, what do you think you (the child) could do the next time teasing or bullying happens? How and in which ways do you want your parents involved? Families can learn active listening strategies and ways to avoid weight-related teasing in the home and to advocate for the child at school.Family members should be encouraged to cut out their own weight-related talk and promotion of dieting with a "talk less, do more" philosophy, as promoted by Dr Diane Neumark-Sztainer (30)(31) and others. As she artfully notes, "… if the child is not a good reader, you don't want to make them feel stupid to help them read more" (presented in a talk to the Society for Pediatric and Adolescent Gynecology, Las Vegas, Nevada, April 16–18, 2010).Similarly, body dissatisfaction should not be used as a motivator for change in the obese child. Rather, obese children should be encouraged to feel great about themselves, and the pediatrician should play to their strengths, working to maintain an active and healthy lifestyle. Other simple solutions include removing television sets from the bedrooms and limiting television and video game use from infancy onward. Another simple intervention is encouraging families to discourage eating in front of the television or computer to stop the child (and parent) from eating more than anticipated.In the office setting, the pediatrician may be asked to prescribe medications to "treat" obesity, despite a paucity of data on drug effectiveness in the pediatric population. Metformin has been associated with modest weight loss of 5 to 10 lb in adolescents who have insulin resistance. Orlistat, which prevents absorption of fat, has been associated with some weight loss due to dietary fat malabsorption, but the associated gastrointestinal distress has limited its effective use. Sibutramine, which has been approved for use in adolescents 16 years of age and older, inhibits reuptake of norepinephrine and serotonin and has been associated with BMI of more than 5% when used in with and should not be because increases the risks of interventions often have in weight or a of loss followed by a company that various food and to help weight and maintain weight can value by with portion as by but adolescents need to be not to all their into one do not tend to and the a of a and a does not provide the fat necessary for a select few adolescents or young adults who require more than lb of weight the which a diet with energy to and fat is to and of fat for their for with to or elevations due to of fat cells. a patient who to be on this diet may require when concentrations increase 10 The fast diet has been associated with weight of to a patient is on the fast diet from to with a dietitian weight gain of no more than 5 or 10 lb during the the diet from to and a diet as he or she the to include and dietitian positive and high by the surgery is an treatment, a that is associated with a significant decrease in the comorbidities of obesity. rates in adolescents have tripled from to with better by those who in pediatric bariatric surgery and who more per being considered for bariatric surgery require and and assessment and to ensure healthy long-term have or the to have the to through with medical and be that they may need surgery for which may not be by health insurance in such as the United of the patient is for physical and programs for weight loss in the office setting are in of change, with a of the for the For example, the office pediatrician sets a of small, changes at the child and parent rather than following what the for weight loss obesity as part of routine child health supervision primary care in and treating overweight and obese children, including working with and care for the who bariatric surgery and after the and the to measure the of the readers a of a current that is we the of the Cleveland This a number of the of the obesity problem and a community from other the Cleveland developed for treating obesity. 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To assess the secular trend in height among adolescents in Florianópolis between 2007 and 2017/2018, and identify factors associated with height by sex. The sample included 664 adolescents from public schools in 2007 and 1,008 in 2017/2018. Height was the dependent variable, with age, economic status, sexual maturity, physical activity, body fat (skinfold thickness), and fat-free mass as independent variables. Analysis of covariance evaluated the secular trend, and multiple linear regression identified associated factors. There was a positive secular trend in height in both sexes when comparing the two surveys, with average increases of 3.5 cm in both sexes. Fat-free mass was a positive predictor and body fat was a negative predictor of height in both sexes. Additionally, physical activity emerged as a negative predictor of height specifically in boys. The research revealed a positive secular trend in the height of adolescents in Florianópolis. Fat-free mass contributes positively to gains in height, whereas body fat provides a negative contribution.