A Case Study of Obesity in a 3-Year-Old Nigerian Female: The Role of Culture and Additional Risk Factors in the Assessment and Treatment of Obesity

Abstract

Childhood obesity continues to be a public health concern in today's society. A variety of issues contribute to the development of childhood obesity, including culture and family lifestyle, maternal feeding habits, increased consumption of high-fat foods, and a decreased amount of physical activity. Early recognition of obesity in children is a key factor in the prevention of childhood obesity. Primary care providers play a vital role in the detection of childhood obesity. Using a multidisciplinary care approach and including families in the plan of care for these children will help to decrease the childhood obesity epidemic. Primary care providers can work together with families to ensure children become healthy and fit in order to prolong lives and decrease instances of co-morbidities.

Introduction

Childhood overweight and obesity continues to be a major public health concern in the United States. Since the 1970s, the prevalence of childhood overweight and obesity has nearly tripled.¹ In fact, one in five children aged 2–5 years are classified as at risk for overweight and 1 in 10 are overweight.² Body mass index (BMI) is a good indicator of overweight and obesity for most children and adolescents. BMI is gender specific and is calculated by using a child's height and weight according to their age. According to the National Health and Nutrition Examination Survey (NHANES),³ in 2007–2008 there were an estimated 16.9% of children and adolescents aged 2–19 years that were categorized as obese (BMI for age:>95th percentile). Almost 32% of youth aged 2–19 years are considered overweight or obese (BMI for age: 85th percentile or above).²

Primary prevention of childhood obesity, especially in early infancy and childhood, is an important strategy for reversing and combating the epidemic. The ultimate solution to defeating the epidemic is collaboration between families, schools, communities, and providers.⁴ Primary care providers (PCPs) are often the first providers that children and families see when there is a health concern or problem. PCPs play a vital role in confronting the increased prevalence of childhood overweight and obesity. PCPs have opportunities and the responsibility to provide education and promote healthy lifestyle choices and nutrition to children and their families. Detection (67%) and education (80%) are the PCPs' primary responsibilities in the battle of childhood obesity.⁵ Well-child visits are the ideal time to provide education to families regarding nutrition, physical activity, parenting, BMI, and other factors that may contribute to unhealthy lifestyle choices that cause childhood overweight and obesity. Early identification, prevention, and intervention at a young age are critical to the well-being of a child.

Key Factors

Studies have shown that there are multiple reasons for the increasing prevalence of childhood overweight and obesity, including genetic factors, lifestyle and environmental changes, decreased physical activity, increased sedentary lifestyle, and overnutrition.

Genetic contribution to childhood overweight and obesity

First, genetic inheritance factors have been shown to account for 16–85% of BMI and 40–62% of body fat percentage.⁶ The exact mechanism of the contribution of genes related to the frequency and severity of obesity is unknown. Gene regulation involved in thermogenesis, leptin, adipogenesis, insulin levels, or a combination of these issues are thought to be contributing factors to obesity.⁶ However, obesity is not inherited in families in a predictable pattern like other diseases, but rather demonstrates a more complex “polygenetic” pattern, meaning multiple genes are involved.⁷ There is a complex interaction between genetic, environmental, and behavioral predispositions that contribute to obesity.⁸

Environmental contributions to childhood overweight and obesity

The overall environment in which many Americans now live, learn, work, and play has potentially contributed to the obesity epidemic.⁹ Second, lifestyle and environmental changes have been shown to correlate with the increased prevalence of childhood obesity. Individuals choose the amount and type of food they eat and their level of physical activity. Choices are oftentimes limited by what is available in one's environment, including grocery stores, restaurants, and schools. Studies have shown that children who are being raised in an obesogenic environment (an environment that promotes increased food intake, increased consumption of nonhealthy foods, and physical inactivity) are more likely to become overweight and obese.¹

Within the environment, decreased activity or outdoor play and increasing numbers of sedentary play (television and video games) as part of a child's daily lifestyle are contributing factors to the increase in childhood overweight and obesity.⁹ Likewise, improper nutrition is another contributing factor. Increased food portions, or overnutrition, high-fat and high-salt foods, increased sweetened beverages, and decreased fruits and vegetables are becoming the norm for children.⁹ These poor choices in nutrition and eating habits can contribute to an overall unhealthy lifestyle. Multiple studies have shown that if a child is raised in a family where one or both parents are overweight and are of low income status, the child is much more likely to become overweight or obese.^10–13

Case Study

Betty is a 3-year-old African immigrant female who was recently seen by her PCP for her first well-child visit. Betty is accompanied by her mother, Mrs. J. The family has recently moved to the United States and has been living here for the past 9 months. Prior to this visit, Betty was seen in the office on two separate occasions for episodic visits at which time her height and weight were plotted at the 97th percentile for weight (18 kg) and 50th percentile for height (94 cm). Today, Betty weighs 20 kg (>97th percentile) and her height is 95 cm (between the 50–75th percentile). Her BMI is 22.1 (>97th percentile). Her blood pressure is normal at 88/40.

Mrs. J. states that Betty is a relatively healthy child and she has no issues or concerns at this time. Past health history is unremarkable. There is no significant history of illnesses, trauma, or hospitalizations. The family medical history is positive for maternal type 2 diabetes and both maternal and paternal hypertension. Betty has no known allergies and is currently not taking any medications. Betty is an only child and lives at home with her mother and her father. The patient's mother is obese and states that she is trying to work on her nutrition as well. The mother reports that Betty's immunizations are up to date.

Betty has met all developmental milestones. She kicks a ball, throws overhand, and runs well. She can copy a circle and a cross. She is imitating mom around the house and is starting to dress herself. She is feeding herself using a spoon. She knows her primary colors and shapes.

A diet history was elicited. According to Mrs. J., Betty is a good eater, and will “eat anything.” Betty eats three meals a day and has one or two snacks each day. Mrs. J. reports that Betty loves to drink milk. She drinks about 38–40 oz of whole milk a day. The patient also drinks two to three sodas a week and 10–12 oz of juice a day. Her nutrition consists mostly of high-calorie and high-fat foods including French fries, chicken nuggets, and macaroni and cheese. Mom states that she does not like vegetables, and will only eat bananas or apples for fruits. Her snacks are typically sweets, as this is her favorite thing to eat. Mrs. J. reports her normal snacks as being cookies, brownies, and cakes. The patient has at least two servings of sweets a day.

When questioned about physical activity, Mrs. J. reports that Betty is not very physically active. She enjoys watching television, playing video games, watching movies, and drawing. She spends about 3–4 hours a day in front of the TV watching her favorite shows. Betty is sleeping about 9–10 hours at night, and mom reports that she is still taking one short nap during the day. Betty is completely “potty trained” and has a bowel movement every other day.

A complete physical exam was completed. Except for the evident obesity, Betty's physical exam findings are normal for a 3-year-old child.

Assessment of Obesity

Culture and ethnicity

Parental influence, peers, the media, portion sizes, culture, biologic/genetic predisposition, and activity all play a major role in nutrition and obesity.¹⁴ Along with this, culture and ethnicity are known contributing factors in overweight and obesity. Additionally, it is well documented that substantial racial and ethnic disparities exist in the prevalence of obesity, as well as in prevention and treatment.² In a recent study examining BMI in relation to race and ethnicity, approximately 18–20% of non-Hispanic African-American females were at or above the 97th percentile for BMI compared with about 4–5% of non-Hispanic white females. According to the Center for Disease Control (CDC),¹ Hispanic boys and non-Hispanic African-American girls are disproportionately affected by obesity.

When seeing a patient like Betty who is of African descent, it is important for the PCP to recognize that obesity is now not just an issue in the United States. As an original citizen of an African nation, Betty's obesity is a reflection of a worldwide trend of rapidly rising obesity rates in rapidly developing and urbanizing environments.¹⁵ Overweight and obesity in men and women in 36 developing countries exceeded underweight in well over half of the countries: the median ratio of overweight to underweight was 5.8 in urban and 2.1 in rural areas.¹⁶ Even within countries on the African continent, the prevalence of childhood overweight and obesity in 2010 is 8.5%, which has increased from 5.7% in 2005.¹⁴ The prevalence of obesity in developing countries is estimated to be approximately 7–10%.¹⁷ Recent overviews of the childhood obesity problem have recognized that not only are its roots in overnutrition and decreased physical activity, but they are also socioculturally embedded, even in developing countries.¹⁵ It is important for healthcare providers to recognize that children from developing countries are just as much at risk for obesity onset as those from the United States.

Socioeconomic status is another contributing factor in the incidence and prevalence of overweight and obesity in developing countries and in the United States. Opportunities for physical activity and exercise are decreased in children and families with a poorer socioeconomic status.¹⁸ According to a study of school-aged children and adolescents in Nigeria, lower socioeconomic status children were at higher risk for being underweight and higher socioeconomic status children were at increased risk for being overweight.¹⁸ Contrary, in the United States the higher the socioeconomic status, the lower the risk for overweight and obesity.¹⁸

In order to have successful strategies for assessment to prevent and manage obesity, the PCP must also understand and engage the culture and ethnicity of the patients and families they care for. First, cultural patterns of shared understandings define what types of foods are healthy and what foods are unhealthy.¹⁹ Food is seen as an expression of cultural identity and a means of preserving family and community unity. The consumption of traditional family foods may lower or raise the risk of obesity in different cultures.¹⁹

Acculturation, defined as the process by which immigrants adopt the attitudes, values, customs, beliefs, and behaviors of a new culture, is also thought to be a risk factor for obesity. Acculturation has also been associated with lifestyle choices, including poorer nutrition, more tobacco use, and substance abuse.^20–22 Some studies have also shown that risk factors for poor physical and mental health were inversely associated with acculturation.^20,22 The United States Department of Agriculture (USDA) has reported that the Westernized diet, high in fat and sugars, has now become a staple in all childhood diets, regardless of culture.²³ Within the United States, African-Americans and Hispanics have reported cooking meals that are high in fat with increased quantities of sodium and sugars.²⁴

Second, interestingly, body image development occurs in a cultural context by which shared understandings are valued and disvalued by body image.¹⁹ Typically women (mothers) assume the responsibility of the feeding, care, and responsibilities, including the transmission of the shared cultural understandings to their children. Often times the mother's body image of herself, along with her beliefs regarding food and nutrition, have implications for their perception of and response to the body image of their children.¹⁹ Mrs. J., Betty's mom, is also obese. The PCP needs to take the time to assess the thoughts, cultural beliefs, and personal ideals of Mrs. J. and how she views herself in order to determine if her ideals about herself are being reflected onto Betty. Introducing and recommending counseling for Mrs. J. may very well be a good option if she has a poor body image of herself.

When working with families and their children, such as Betty and her mother, it is important therefore to have culturally sensitive communication strategies. Kittler and Sucher (1990)²⁵ state that to improve cross-cultured nutritional counseling, a thorough four-step process is important. First, the PCP must become familiar with his/her own cultural heritages. Second, the PCP must become acquainted with the cultural background of each client. Third, through an in-depth cross-cultural interview, the PCP must establish the client's cultural background, food habit adaptations made in the United States, and personal preferences. Fourth, the PCP can discuss with the patient how to modify Betty's and her family's diet based on unbiased analysis of the dietary data. The best chance for success to assist Betty to lose weight occurs when nutritional recommendations are modified with consideration for her and her family's cultural and personal preferences. Important questions therefore to ask in the assessment of any recently emigrated family may include: history of obesity, family medical history of any co-morbidities, and types of foods and food preparation that occurs within the home. Additionally, given that it is important to determine if a family has acculturated, it is important to quantify the amount of fast food a family and patient will eat in a given week.

With all this in mind, perceptions of healthy body image, healthy diet, food preparations, and eating habits differ among minority subgroups and across generations.²⁴ As in the case of Betty, the PCPs goal should be to acknowledge the cultural and ethnic connections to particular food groups while working with her and her parents to encourage healthy substitutions into the family's diet.²⁴ The environmental context in which many families live must be restructured to support the culturally determined behavioral changes necessary for maintain optimal weight in children.²⁴

Parental–child interaction

During the early years of growth and development, children's learning about food and eating plays an essential role in shaping of subsequent food choices, weight status, and dietary quality.²⁶ Parental feeding strategies continue to play a role in the development of childhood obesity. Excessive control of childhood nutrition with parents has been associated with poor eating regulation, which is related to increased body mass.²⁷ External cues such as portion size, rewards, and “cleaning the plate” may undermine internal cues of satiety.²⁷ This causes the child not to learn self-regulation, which then leads to overweight and obesity. Children's feeding practices have the potential to affect energy balance, therefore altering the patterns of intake. Experimental studies have shown that restricting the child's access to preferred foods increases the probability that children will eat the restricted foods when given free access to eat those foods.²⁷ For children, eating habits are learned. Parents are responsible for providing the best possible nutrition for their children. Success with this issue in Betty's case cannot be achieved without assessment of maternal/parental view of their daughter's obesity, willingness to evaluate food choices allowed for Betty, and family support in changing the household eating behaviors to support Betty.

Obesogenic environment

Environmental and lifestyle changes are thought to relate directly to the increasing numbers of childhood obesity in almost every part of the world, which results in children being raised in an obesogenic environment. An obesogenic environment promotes gaining weight and is not productive for losing weight. Access to higher fat and larger portion foods is much more readily available and cheaper than healthy and nutritious foods. Approximately 75% of all money spent on food consumed outside the home is spent on fast food.¹ When meals are not prepared at home and the meal of choice is fast food, there is a significantly greater risk of overweight and obesity.²⁸ Larger consumption of food portions with increased amounts of foods high in fat and saturated fat have unfortunately become the norm. According to the history elicited from Betty and her mother, her diet includes these higher fat, readily available foods. As the PCP in this case, it is important to gather information about portion sizes, 24-hour recall of food, and sweetened drinks. Portion size is important to review in this case (Fig. 1).

Fig. 1.

Quick portion size reference for families. Reprinted with permission of Prevention Nutrition.

Management and Plan

First and foremost, multiple studies have shown that PCPs are not very proficient in providing education and treatment to children who are overweight or obese. In fact, approximately 44% of pediatricians have reported that a lack of clinician knowledge about childhood obesity was a barrier to treatment.29 Because of this, it would be beneficial for PCPs to attend cultural competency training so that they are well versed and adequately prepared to address the questions and needs of their patients. Other reported barriers to treatment include a lack of patient motivation, lack of parent involvement, lack of clinician time, and lack of reimbursement for services. In the case of Betty, there is already concern regarding her nutrition, activity, and amount of sedentary behavior. Additionally, management for Betty may need to address the amount of acculturation that appears to have occurred in a very short period. With the limited amount of time in a well visit, this may be overwhelming for the PCP.

Reinforcing healthy eating practices for Betty

The USDA³⁰ provides recommendations and guidelines for structuring a healthy diet in preschool-aged children. A healthy diet encompasses fruits and vegetables, low-fat milk products, wholegrains, and lean meats. The USDA stresses limited amounts of high-fat foods, high cholesterol, added sugars, and sodium (see Table 1). In Betty's case, it is important to reinforce healthy eating habits with mom. The PCP should assess Betty's diet history and encourage healthier food choices and options with mom and Betty.

Table 1.

Dietary Guidelines Recommendations

		Nutrient recommendations by age (DRI) ^*
Nutrient	DV	2–3 year olds	4–8 year olds	9–13 year olds	14–18 year-old girls	14–18 year-old boys
Protein (g)	50	13	19	34	46	52
Iron (mg)	18	7	10	8	15	11
Calcium (mg)	1,000	500	800	1,300	1,300	1,300
Vitamin A (IU)	5,000	1,000	1,333	2,000	2,333	3,000
Vitamin C (mg)	60	15	25	45	65	75
Fiber (g)	23	14–19	19–23	Girls: 23–28; Boys: 25–31	23	31–34
Sodium (mg)	2,400	1,000–1,500	1,200-1,900	1,500–2,200	1,500–2,300	1,500–2,300
Cholesterol (mg)	300	<300 for over age 2	<300	<300	<300	<300
Total fat (g)^**	65	33–54 (30–35% of calories)	39–62 (25–35% of calories)	62–85 (25–35% of calories)	55–78 (25–35% of calories)	61–95 (25–35% of calories)
Saturated fat (g)^**	20	12–16 (>age 2) (<10% of calories)	16–18 (<10% of calories)	Girls: 18–22; Boys: 20–24 (<10% of calories)	22 (<10% of calories)	24–27 (<10% of calories)
Calories^***	2,000	1,000–1,400 (2–3 years)	1,400–1,600	Girls: 1,600–2,000; Boys: 1,800–2,200	2,000	2,200–2,400

Source: Dietary Reference Intakes Institutes of Medicine and 2005 and 2010 Dietary Guidelines.

Daily Reference Intake.

Fat in grams based on a 2,000 calorie Daily Value.

***

Based on a Daily Value of 2,000 calories.

DV, Daily Value; DRI, Daily Reference Intake.

Reinforcing limited TV time for Betty

Due to expanding technology and TV time, children have become increasingly inactive. Studies have shown a direct correlation with excessive TV viewing and obesity. A new report released in 2010 found that nearly two-thirds of children aged 6–18 say the TV is on during meals and nearly half report the TV is left on “most of the time” in their home.³¹ The hours children are spending in front of a TV are contributing to their sedentary lifestyle and increased risk for obesity.³² Additionally, over 10 billion dollars is spent on fast-food advertising yearly.³³ The exposure to food-related advertising was found to be 60% greater among lower socioeconomic minority children, with fast food as the most frequent category.³⁴ Most parents either do not set limitations on screen time or do not enforce the recommended 2 hours of viewing each day.³⁵ Therefore, it is important to review and recommend a plan with Betty's mother that includes establishing rules of limiting TV viewing to less than 2 hours, no TV at dinnertime, removing the TV from Betty's room, and consistently reinforcing these rules within the home.

Improving physical activity for Betty

According to the American Academy of Pediatrics, children are recommended to have at least 60 minutes or more of moderate to vigorous activity a day. For preschool children, this is usually interpreted as active play in which the child sweats when exerting energy. Increased physical activity has been shown to increase attention and improve mood.³⁶ Physical activity can help to control weight, reduce risk for many diseases, strengthen bones and muscles, improve mental health, and increase chances for a longer and healthier life.³ As the PCP for Betty, it is important to ask and evaluate the community environment in which they live to try to develop a plan for Betty and her family in regards to physical activity. A careful social history including home life, where the family lives, and whether or not they have a backyard or a local playground would be important to ask Betty's mother. Taking into account acculturation, the PCP should ask about specific cultural games and activities played by Betty, and incorporate these games or cultural influences in Betty's physical activity. Safety may be an issue for some families, and it is important that the family feels safe in going outside to be physically active.^37,43 Reinforcement that playground and social play is some of the best exercise for preschool children would be important for the PCP to review with Betty's mother.

Culture continues to be a contributing factor in the obesity epidemic. It is important as PCPs that we work with the families and within the culture to adopt culturally appropriate eating habits.³⁸ Obese children are part of a family unit, and success in the management and treatment of the child cannot be an individual effort. It is important to involve the entire family in the treatment plan by encouraging healthier meals, exercise, and limiting TV time. Success in the prevention and treatment of obesity and its co-morbidities involves both a tailored message to families and motivational interviewing. Motivational interviewing involves presenting information to families in a nonconfrontational way. It is directed at patient-centered care versus a more directive approach. Providing information on community resources and creating a plan of care with the families is helpful in the treatment of childhood obesity.³⁹

Assessing for Co-morbidities

New Task Force Guidelines recommend obtaining serum blood chemistries for a child 6 years and older, with a BMI>95th percentile, especially if there is a family history of hypertension, hyperlipidemia, or coronary heart disease. Even with the development of this new guideline, when to obtain serum blood chemistries is debated in the literature.^40,41 Serum chemistries to obtain from children who are obese or overweight with a significant history include a fasting lipid panel, cholesterol level, thyroid function levels, fasting glucose, and a hemoglobin A1C.⁴² If laboratory studies are abnormal, further evaluation and treatment are indicated. Betty is 3 years of age; according to guidelines, serum chemistries may not be warranted, but she needs to be monitored on a frequent basis to assess for any signs or symptoms of type 2 diabetes mellitus, obstructive sleep apnea, and increasing systolic or diastolic blood pressure. Tailoring the recommendations according to Betty's age and individual progression of weight gain is important for the PCP to consider.

Conclusion

The rise of childhood obesity has been dramatic over the last decade. Primary care clinicians have an important role in the prevention, recognition, and management of children who are overweight or obese. Early recognition and prevention in infancy are key factors in reducing this epidemic. Routine assessment including obtaining BMI for age, diet history, and family history should become standard clinical practice for PCPs. Family involvement in the treatment of childhood obesity is key to reversing the epidemic. Important to assessment and management is understanding the role of culture and acculturation in the development of obesity. Providers need to advocate for partnerships with families, communities, and multidisciplinary team approaches to fight this epidemic of childhood obesity in order to provide a healthier, fit nation.

Footnotes

Author Disclosure Statement

No competing financial interests exist

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