Implications of Obesity in Special Populations

#### **Chapter 1**

## Obesity in Children: Recent Insights and Therapeutic Options

*Mirjam Močnik and Nataša Marčun Varda*

#### **Abstract**

Obesity in children, including adolescents, is nowadays, in the light of the COVID-19 pandemic, an even more pressing problem than before it, leading to increased prevalence of obesity and its comorbidities at young age. A simple and correct approach to diagnosis is essential, and some new insights in epidemiology, pathophysiology, and diagnosis are currently under investigation. Obesity in preschool children and metabolically healthy obesity are new entities that are recently being defined and written about. Additionally, several new factors that might influence obesity development are being researched, such as pollutants, sleep duration, and gut microbiota. In this chapter, we briefly present them as possible therapeutic targets in the future along with current therapeutic options in the pediatric population, namely lifestyle change, pharmaceutical options, and surgery. A child is always significantly affected by his/her family lifestyle, home, and social environment, which has to be considered in childhood obesity management.

**Keywords:** obesity, children, adolescents, treatment, recent discoveries

#### **1. Introduction**

Obesity, defined by the World Health Organization, as an excess in fat mass great enough to increase the risk of morbidity, altered physical, psychological or social well-being, and/or mortality [1], has reached pandemic proportions in recent decades [2]. Simultaneously, several "adult diseases," such as type 2 diabetes mellitus, hypertension, and nonalcoholic fatty liver disease, are emerging also in the pediatric population, therefore increasing their cardiovascular risk at a young age. Rarely, children can have an underlying endocrine or monogenic cause of their weight gain. Therefore, obesity in childhood is mostly the result of energy intake and expenditure imbalance [2].

In this chapter, we will review some new insights into childhood obesity with possible therapeutic options.

#### **2. Epidemiology**

The increasing prevalence of childhood obesity with advancing age is a well-known fact in recent decades and varies by racial, ethnic, and socioeconomic factors [2].

Children of obese parents have an increased risk for obesity development, not only because of hereditary but also due to environmental factors [3]. Additionally, childhood, and especially adolescent obesity, are associated with obesity in adulthood [4, 5], creating a vicious cycle.

After a dramatic increase in obesity prevalence approximately 40 years ago, some studies after the year 2000 showed a steady state; however, these studies were not replicated and a true trend of stabilizing obesity incidence was not proven [2]. Some isolated studies still brought some hope in decreasing obesity in children, but then the COVID-19 pandemic happened and had a significant impact on childhood obesity.

#### **2.1 COVID-19 and obesity in children**

The pandemic of childhood obesity has collided with the pandemic of COVID-19 in the last few years [6]. Many countries from all over the world are reporting an increased prevalence of obesity in childhood [7]. Billions of people were subjected to home confinement leading them to change their lifestyles and eating behaviors, including buying and consuming large quantities of preserved and processed food. Simultaneously, sedentary behavior and increased screen time led to decreased physical activity. Isolation, restricted activity, and unhealthy food choices, associated also with financial reasons, are the most commonly identified culprits for increased obesity, along with other psychosocial, behavioral, and environmental factors [6, 7]. Additionally, preexisting disparities in obesity in terms of race, ethnicity, and socioeconomic status increased [8].

#### **3. Etiology and pathophysiology**

Obesity in children is usually the consequence of an imbalance between nutrient consumption and energy expenditure, rarely, other causes can be identified. Still, genetic etiology or at least predisposition might play an important role in the pathogenesis of obesity. Genetic predisposition to obesity has been widely accepted; however, there are only few articles associating specific gene pathways to obesity in children, namely Toll-like receptor 4 signaling pathway [9], leptin-melanocortin signaling pathway [10], c-Jun N-terminal kinase signaling pathway [11], and adenosine monophosphate-activated protein kinase signaling pathway [12]. Several genes, however, they were associated with overexpression in visceral fat and subcutaneous adipose tissues, including the phospholipid transfer gene, ras, adipsin, and calcyclin [13, 14] with gene variants associated with severe obesity in both childhood and adulthood [15, 16].

In addition, differentially expressed genes in children with obesity were identified recently in pathways associated with the immune system. Also, matrix metalloproteinase 9 and acetyl-CoA carboxylase ß were identified as hub genes in the proteinprotein interaction network and might be marker genes for childhood obesity [17].

Another important association, found recently, is between obesity and sleep deprivation, highlighted by growing evidence, described below. In these studies, autonomic dysfunction is presented as a new possible pathophysiological pathway to obesity development, which was supported by sympathovagal imbalance, particularly during the night in obese children compared to healthy controls [18]; however, the evidence is not conclusive.

#### **4. Diagnosis and risk factors**

Evaluation of children with obesity is aimed at determining the diagnosis and the cause of weight gain and assessing for comorbidities resulting from excess weight.

#### **4.1 Establishing the diagnosis**

Clinical diagnosis is based on anthropometric measurements, usually widely used as body mass index (BMI). BMI cut-off points in adults (25 and 30 kg/m2 for overweight and obesity, respectively) are used due to the observed increased health risks at these levels and are adjusted in the pediatric population according to age, sex, and height. BMI has some disadvantages; mainly it does not predict body fat percentage and it does not distinguish between lean and fat mass. Additional measurement of waist/hip circumference is a tool to identify central obesity, associated more strongly with complications, such as insulin resistance, dyslipidemia, and nonalcoholic fatty liver disease [19].

Measuring waist/hip circumference can also be challenging and time-consuming in terms of behavioral, cultural, and environmental issues. Additionally, waist circumference may be affected after eating by abdominal distension. Given these limitations, new strategies to find a better anthropometric obesity measure are evolving. One of them is neck circumference measurement, which has been associated with central obesity and abnormal metabolic status. It can be reliably used to screen overweight and obesity in children with identification of those with high BMI [20, 21].

Interestingly, dermatoglyphic differences have also been observed in children and adolescents with obesity. In participants with normal weight, a higher frequency of ulnar loops on the index and middle finger were noted along with presence of radial loops on the middle finger. In children with obesity, a greater frequency of whorls on the index and middle fingers were observed in males along with arches in the middle finger [22].

Body fat mass can further be estimated by several other methods, namely dualenergy X-ray absorptiometry, bioelectrical impedance assay, computed tomography and magnetic resonance imaging of abdomen, measurement of skinfold thickness at multiple sites, air displacement plethysmography, and stable isotope dilution techniques [19].

#### **4.2 Metabolically healthy obesity in children**

Metabolically healthy obesity in children is a new entity mainly regarded as obesity without cardiometabolic risk factors; however, definitions are variable. An international panel of 46 experts agreed that criteria for metabolically healthy obesity in children include high-density lipoprotein-cholesterol >1.03 mmol/l (or > 40 mg/ dl), triglycerides ≤1.7 mmol/l (or ≤ 150 mg/dl), systolic and diastolic blood pressure ≤ 90th percentile, and a measure of glycemia [23]. Due to the heterogeneous definition, the prevalence of metabolically healthy obesity varies from 3 to 80% [23]. Specific genetic predispositions and environmental factors or absence (family history, specific gene variants, and decreased physical activity) of them contribute significantly to metabolic health [24]; however, they were not widely researched and accepted yet. It is still unknown if these children have lower cardiovascular risk and can be managed less aggressively.

#### **4.3 Challenges of obesity in children under six years of age**

With increasing obesity, preschool years present a point of opportunity for children to be active, develop healthy habits, and maintain a healthy lifestyle, however, the prevalence of obesity in this age group is inconsistent in European countries and varies up to one-third of 5-year-old children. Measuring overweight and obesity in this group may be challenging [25]. The prevalence was lower among children born to parents with high education, and higher among children born to foreign parents and overweight mothers [26].

In younger children with obesity, there is also an increased risk for monogenic or underlying endocrine disease and should be excluded, especially when severe obesity is present. However, in this age group, establishing the diagnosis should be done with caution when obesity is not as severe. It was shown that young children with a high BMI percentile have lower fat mass than older children with the same BMI percentile and therefore obesity in this age group can be over diagnosed [27].

In order to plan appropriate management of obesity in younger children, we need a better understanding of potential modifiable factors. Specific risk factors for obesity in children under six years of age include maternal diabetes, maternal smoking, gestational weight gain, and rapid infant growth [28]. In preschool children, parents can have a significant influence on modifiable risk factors associated with severe obesity already in this age group and also in further growth. These risk factors include inappropriate nutrition (sugar-sweetened beverages and fast food and skipping breakfast), inactivity (low frequency of outdoor play and excessive screen time), behaviors (lower satiety responsiveness, sleeping with a bottle, lack of bedtime rules, and short sleep duration) and socio-environmental risk factors (informal childcare setting, maternal smoking, and maternal obesity) [27, 29].

#### **4.4 Risk factors for obesity development**

The development of obesity is very complex and includes many risk factors. Although we mostly define the etiology as an imbalance between calorie intake and consumption, the reality is not as simple. Genetic, biological, and socio-environmental factors, including family, school, community, and national policies, can play a crucial role. The complexity of risk factors among the pediatric population leads to difficulty in treatment and many interventional trials have been proven ineffective [30]. Therefore, early identification of possibly modifiable factors at an individual, local, and global level should be done to allow appropriate management and policies for obesity prevention and treatment.

Traditional risk factors in school children and adolescents include genetic predisposition, diet (fast food and sugar-sweetened food), eating patterns, lack of physical activity and increased sedentary time (viewing television, playing video games, and using computer), unresolved stress, environmental settings (home, school, and community), sociocultural factors [30].

Some new risk factors for obesity development are under investigation and could present a possible modifiable target in obesity management. Additionally, some new insights into already-known risk factors are presented.

#### *4.4.1 Screen time*

The relationship between screen time and increased risk of obesity is well documented. Screen media exposure leads to obesity in children and adolescents through

#### *Obesity in Children: Recent Insights and Therapeutic Options DOI: http://dx.doi.org/10.5772/intechopen.108987*

increased eating while viewing, increased sedentary time and reduced sleep duration. Randomized controlled trials of reducing screen time in community settings have reduced weight gain in children, demonstrating a cause-and-effect relationship. However, some evidence also suggests a promise for using interactive media to improve eating and physical activity behaviors to prevent or reduce obesity [31].

Studies, reporting associations between obesity and playing video games are almost half positive, and the rest reported no association. There was preliminary evidence on the effectiveness of exergame (physically active) play for weight reduction and to attenuate weight gain; however, there was little indication that interventions effectively reduced video game play or general screen time [32].

#### *4.4.2 Obesity and sleep duration*

The present studies indicate that short sleep duration increases the risk of childhood obesity, making appropriate sleep duration another priority in a child's life [33, 34]. Few studies examined other dimensions of sleep, namely quality, efficiency, and bed/wake time in association with weight status. Even when present, there were variations in defining and measuring these dimensions, making their comparison and potential discrepancies difficult to assess [35].

There are several mechanisms proposed to link sleep loss and the risk of weight gain, based on hormonal and neuroendocrine changes associated with sleep restriction. One of the potential may lie within the hypothalamus or within hypothalamic communication with the peripheral system, and through hormonal systems via leptin and ghrelin (with peripheral metabolic indicators, such as glucose and cholecystokinin). Two distinct neuropeptides, orexin A in B, are synthesized mainly by the neurons in some parts of the hypothalamus and are believed to play a key role in the interaction between sleep and feeding. Orexins induce and support arousal and promote feeding, and are involved in the regulation of many functions, such as sleepwakefulness, locomotor activity, feeding, thermoregulation, and neuroendocrine and cardiovascular control. Orexin neurons may be disinhibited by low levels of leptin and glucose and excited by ghrelin. Orexin activity is associated with an increased sympathetic tone, which in sleep deprivation may further inhibit leptin release and stimulate ghrelin release, consistent with the effects of short sleep on the peripheral levels of both hormones already observed in adult population [36]. Increased catecholamine levels in sleep deprivation also inhibit insulin secretion and promote glycogen breakdown, increasing the risk of hyperglycemia and insulin resistance seen in obesity [36]. Additionally, it has been suggested that C-reactive protein (CRP) is a leptin-binding protein, and increased CRP levels, seen in obesity, could present a possible mechanism for leptin resistance [36]. There may also be a role for the reward system in modulating food intake and energy storage following a state of sleep loss. Voluntary sleep restriction has been shown to increase snacking, the number of meals eaten per day, and the preference for energy-dense foods [37]. Decreased sleep may also have an adverse effect on energy expenditure. It is also possible that behavioral changes and poor parent-child dynamics may influence sleep deprivation in children, contributing further to weight gain, present already due to other socioeconomic factors [36].

#### *4.4.3 Obesity and gut microbiota*

Antibiotics are one of the most commonly prescribed drugs in childhood and their use can cause unwanted problems. Among these, antibiotic-induced gut

microbiota dysbiosis has been associated with obesity. This problem is even more relevant to children that are frequently treated with antibiotics. The microbiota composition and its disturbance in neonatal and in early childhood have a profound impact further in life. It can contribute to a decrease in the number and composition of microbiomes affecting glucose and lipid metabolism and immune system development [38]. Evidence suggests that short-chain fatty acids made by the gut microbiota directly or indirectly modulate physiological and pathological processes in relation to obesity. At first glance, excessive short-chain fatty acids represent an additional energy source and could cause an imbalance in energy regulation. Simultaneously, however, short-chain fatty acids participate in glucose-stimulated insulin secretion and release of peptide hormones, which control appetite [39]. However, the causal effect has not been defined and no definitive therapeutic approach has been elucidated. Probiotics and prebiotics could play a role in treating microbial dysbiosis. The addition of specific bacterial strains has been associated with normal weight gain [38]. Dietary modulation has been proven effective also in children with genetic obesity [40].

The exact microbiota status in obesity has not been elucidated yet; however, some studies have tackled this challenge. One study showed associations between *Firmicutes spp*. to obesity and *Bifidobacterium spp*. with a healthy weight in children [41]. Additionally, the addition of *Lactobacillus casei* strain was associated with weight loss while also improving lipid metabolism in obese children via significant increase in the fecal *Bifidobacterium* numbers [42].

#### *4.4.4 Obesity and pollutants*

Due to the increase in pollutants in our environment, their concentration has been associated with childhood obesity several times. Recent meta-analyses showed that air pollution is correlated with a substantially increased risk of childhood obesity [43, 44]. The biological and physiological mechanisms regarding the cause-and-effect between air pollution and obesity are still unclear [43]. Animal studies showed that ambient air pollution exaggerated adipose inflammation and insulin resistance [45]. This may further affect the basal metabolic rate and appetite control of exposed individuals [43]. Another animal experiment indicated that exposure to air pollution results in Toll-like receptor 2/4-dependent inflammatory activation in lipid oxidation could lead to metabolic dysfunction and weight gain [46]. Air pollution might also prevent people from going out, causing excess sedentary time, especially in some heavily polluted parts of the world [43].

Along with pollution, other chemicals may affect obesity development. They are called obesogens and are defined as exogenous chemicals belonging to the group of endocrine-disrupting chemicals and are believed to interfere with obesity development. The major mechanism through which obesogens can contribute to obesity is believed to be the activation of nuclear receptors involved in adipogenesis, lipid metabolism, inflammation, and maintenance of metabolic homeostasis. Several chemicals are under investigation as potential causal factors in obesity development; however, these associations remain controversial and it is difficult to find evidence for direct causality between environmental exposure and disease [47]. These chemicals include bisphenol A [47], phthalates [48], perfluoroalkyl substances [49], polycyclic aromatic hydrocarbons [50, 51], etc.

#### **5. Obesity prevention**

Disease prevention is even more important in obesity since there are numerous complications, presented in **Table 1**, associated with obesity and even more pronounced when obesity is present early in life [30].

Obesity prevention is therefore a major challenge that has yet to be tackled appropriately. So far, the success of our intervention showed that our understanding of effective prevention is still not achieved [52].

Preventive activity is divided into primordial, primary, secondary, and tertiary. It is primarily achieved by implementing measures to ensure a normal weight and health, and prevent the development of obesity. Public health and national policy strategies play an important role in primordial prevention. The approaches are costeffective and reduce the overall burden of obesity. With primary prevention, we want to eliminate or reduce exposure to all factors that cause obesity. Effective secondary prevention of obesity is based on early detection and population screening. Tertiary prevention strategies are focused on reducing or delaying the long-term complications that can be caused by obesity (**Table 1**) [53, 54].

Our understanding of childhood obesity, energy balance-related behaviors, determinants of behavior, and effective components of prevention programs is still deficient [52]. Mostly, interventions consist of diet combined with physical activity at individual or community level. Combined interventions had moderate success in children younger than 5 years; however, weaker evidence is present with only dietary or only physical activity interventions [55]. In contrast, in older children, interventions focused only on physical activity can reduce the risk of obesity, but there is no evidence that interventions focused only on diet are effective. Importantly, combined diet and exercise might prove more effective; however, behavioral prevention programs were associated with small improvements in weight outcomes [55, 56].


#### **Table 1.**

*Complications of childhood and adolescent obesity [30].*

#### **6. Therapeutic options**

Obesity management in childhood is based on lifestyle interventions with an emphasis on dietary and physical activity modifications, possibly involving the whole family. However, only a modest effect of lifestyle interventions is seen in severe obesity [57], requiring a consideration about which therapeutic approach to use according to the severity of obesity and the presence of obesity-related comorbidities. Pharmaceutical and surgical options are limited, as presented below.

#### **6.1 Lifestyle interventions**

Lifestyle interventions include behavioral measures to alter dietary habits and increase physical activity and are the preferred methods to treat overweight and obesity in children and adolescents. A variety of multicomponent lifestyle interventions may improve BMI in children and adolescents with varying degrees of overweight and obesity [57]. Commonly, they have produced losses from 5 to 20% of excess weight over 3 to 6 months in children [58]. Over 6 to 12 months, the change has ranged from 25% loss to 10% increase in excess weight [58]. In children up to the age of 6 years, a reduction in BMI Z-scores up to 2-year follow-up showed beneficial effects of diet, physical activity, and behavioral interventions. In older children, the beneficial effect of the same measures was found in at least of 6 months of interventions duration [59]. The durability of weight loss is often limited by physiologic systems that are evolutionarily designed to promote weight gain, making lifestyle interventions even more difficult. Continued treatment preventing relapse with face-to-face interventions with a multidisciplinary approach is recommended [60].

Physical activity of at least 60 minutes a day at a moderate-vigorous level is usually recommended [61]. Dietary approaches to weight loss focus on caloric restriction with limited guidelines recommending a very low-carbohydrate/ketogenic diet. Dietary approaches beyond simply caloric restriction with individual assessment and care are recommended for optimal patient outcomes [62]. Additionally, eating behavior has an important impact on obesity development. It was shown that skipping breakfast in the family had significantly increased the risk of childhood overweight and obesity [63]. The same applies to high-energy intake at dinner or late-night snacking [64].

Children that were breastfed for at least 12 months had a significantly lower risk of being overweight or obese than those breastfed for less than 17 weeks. The age of introduction of solid food was not associated with the risk of excess weight at 2 or 3 years of age [65]. Interestingly, dairy products consumption later in life has also been associated with decreased risk of obesity [66].

Not only the amount but also the composition of food intake is of crucial importance. Despite the increased intake, children with obesity often exhibit vitamin D deficiency, usually associated with decreased outdoor activities [67, 68], making appropriate dietary management even more demanding.

All lifestyle interventions should be supported by psychosocial support and treatment that are carried out simultaneously to achieve maximal success. Wellestablished psychological treatments include family-based behavioral treatment and parent-only behavioral treatment for children utilizing behavioral strategies. Appetite awareness training and regulation of cues treatments are considered experimental. Additional research is needed to test a stepped care model for treatment and to establish the ideal dosage (number and length of the sessions), duration, and intensity of treatments for long-term sustainability of healthy weight management [69].

Especially in severe obesity, lifestyle changes alone, although of fundamental importance, are frequently insufficient. Drug therapies for children are limited and surgical approaches associated with potential morbidity have less known long-term consequences. However, for children with severe obesity, a multifaceted behavioral, pharmacological and surgical approach may be implemented [70].

#### **6.2 Pharmaceutical options**

The current use of pharmacotherapy for the treatment of obesity in the pediatric population is limited. Several anti-obesity medications have been approved by the Food and Drug Administration for use among adult patients; however, they are used off-label in the pediatric population [71]. Most commonly prescribed drugs include metformin, topiramate, sibutramine, orlistat, and combinations with fluoxetine and exenatide [71, 72]. A systematic review showed that pharmacological interventions using metformin, sibutramin, orlistat, or fluoxetine may have small effects on BMI reduction. However, trials conducted were generally of low quality, with many having a short or no post-intervention follow-up period and high dropout rates. Adverse effects have also been reported but not in a standardized manner [72]. Therefore, the current endocrine society practice guidelines recommend that these drugs should be used only in clinical trials [73] and only orlistat for patients older than 12 years of age, and phentermine in those older than 16 years are currently approved by the Food and Drug Administration [71, 74].

#### **6.3 Surgical options**

The most commonly known surgical option is bariatric surgery, which has been shown to result in a significant and sustained decrease in BMI and improved comorbidities in adult patients. In the pediatric population, there has been an increase in bariatric surgery use, although it is still infrequently performed. Several types of bariatric surgery are being used, most commonly laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. The first one carries a lower risk of micronutrient deficiencies (the procedure does not result in malabsorption) and is less complex to do. The Roux-en-Y gastric bypass results in restriction of caloric intake (reduced capacity and neuroendocrine mechanisms) and malabsorption of food along with vitamins and minerals [2]. Adjustable gastric banding is also done in adolescents. Appropriate patient selection is of utmost importance, and the following criteria have been developed [modified according to references 2 and 75]:


Contraindications are rare but include a medically correctable cause of obesity, a medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens, current or planned pregnancy within 12 to 18 months of the procedure, an inability on the part of the patient or parent to comprehend the risks and benefits of the surgical procedure and an ongoing substance abuse problem [75]. Short-term complications include wound infections, leakage at anastomotic sites, pulmonary embolism, small bowel obstruction, gastrojejunal strictures, and gastrogastric fistula. Long-term complications include nutritional deficiencies of iron, vitamin B12, thiamine, and vitamin D. Lifelong vitamin and mineral supplementation is recommended to prevent the development of nutritional deficiencies as a result of decreased intake or malabsorption [2].

According to research, adolescents reached similar weight loss benefits as adults five years after gastric bypass surgery. Improvements in diabetes and hypertension were even greater than in adults [76].

Another possibility is endoscopic procedures, such as an intragastric balloon, for a limited period of time as an adjunct, which showed good efficacy in weight loss and comorbidities improvement with a good safety profile [76].

#### **7. Psychosocial and parental influence**

When managing behavioral changes in children, psychosocial and parental factors have to be considered as two elements necessary for effective management.

Childhood is regarded as the most important period of life affecting adulthood. Health problems or illnesses during this period would be brought to maturity or become a risk factor for the onset of diseases in adulthood [77]. The family and environment provide a great impact on social, cognitive, behavioral, and health aspects, including overweight and obesity. Interventions in this field should begin in childhood. Parents play a critical role in shaping child's healthy lifestyle from an early age. They should pay attention to children's weight, eating behavior, and food intake. They are also role models for their children. With their involvement, the long-term effects of lifestyle interventions are enhanced. The most effective way of preventing and controlling overweight and obesity is through family empowerment, including parental knowledge about nutrition, its influence on food choice, eating patterns, sedentary habits, and physical activity. The beliefs and parent's lifestyle and health promotion are also of vital importance due to learning by imitation [77]. Interestingly, parentonly interventions had a similar effect compared with parent-child interventions in children 5 to 11 years [78].

Several socioeconomic factors also influence obesity development in multifaceted ways from an early age on and should be accounted for in childhood obesity management [79, 80].

#### **8. Conclusions**

Obesity in children is a significant medical problem, leading to several comorbidities. Several new insights are being researched in diagnosis, management, and treatment options. Additionally, several new factors that might influence obesity development are being identified and researched, such as pollutants, sleep duration, and gut microbiota. In this chapter, we briefly presented them as a possible

therapeutic target in the future along with current therapeutic options in the pediatric population, namely lifestyle change, pharmaceutical, and surgical options. A child is always significantly affected by his/her family lifestyle, home, and social environment, which has to be considered in child obesity management.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Mirjam Močnik1 \* and Nataša Marčun Varda<sup>2</sup>

1 Department of Pediatrics, University Medical Center Maribor, Maribor, Slovenia

2 Department of Pediatrics, University Medical Center Maribor and Medical Faculty, University of Maribor, Maribor, Slovenia

\*Address all correspondence to: mirjammocnik91@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] WHO Technical Consultation. Obesity: Preventing and managing the global epidemic. In: Report of a WHO Consultation 2000. Report No.: 0512- 3054 (Print) 0512-3054, 2000. Geneva: WHO; 2000

[2] Kumar S, Kelly AS. Review of childhood obesity: From epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clinic Proceedings. 2017;**92**:251-265. DOI: 10.1016/j.mayocp.2016.09.017

[3] Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine. 1997;**337**:869-873. DOI: 10.1056/NEJM199709253371301

[4] Parsons TJ, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: A systematic review. International Journal of Obesity and Related Metabolic Disorders. 1999;**23**: S1-S107

[5] Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. Journal of the American Medical Association. 2002;**288**:1728-1732. DOI: 10.1001/ jama.288.14.1728

[6] Tsenoli M, Smith JEM, Khan MAB. A community perspective of COVID-19 and obesity in children: Causes and consequences. Obesity Medicine. 2021;**22**:100327. DOI: doi.org/10.1016/j. obmed.2021.100327

[7] Stavridou A, Kapsali E, Panagouli E, Thirios A, Polychronis K, Bacopoulou F, et al. Obesity in children and adolescents during COVID-19 pandemic. Children

(Basel). 2021;**8**:135. DOI: 10.3390/ children80220135

[8] Jenssen BP, Kelly MK, Powell M, Bouchelle Z, Mayne SL, Fiks AG. COVID-19 and changes in child obesity. Pediatrics. 2021;**147**:e2021050123. DOI: 10.1542/peds.2021-050123

[9] KIM KA, Gu W, Lee IA, Joh EH, Kim DH. High fat diet-induced gut microbiota exacerbates inflammation and obesity in mice via the TLR4 signalling pathway. PLoS One 2012;7:e47713. DOI: 10.1371/journal. pone.0047713

[10] Farooqi IS, O'Rahilly S. Mutations in ligands and receptors of the leptinmelanocortin pathway that lead to obesity. Nature Clinical Practice. Endocrinology & Metabolism. 2008;**4**:569-577. DOI: 10.1038/ncpendmet0966

[11] Vernia S, Cavanagh-Kyros J, Barrett T, Jung DY, Kim JK, Davis RJ. Diet-induced obesity mediated by the JNK/DIO2 signal transduction pathway. Genes & Development. 2013;**27**:2345- 2355. DOI: 10.1101/gad.223800.113

[12] Hwang JT, Kim SH, Lee MS, Kim SH, Yang HJ, Kim MJ, et al. Antiobesity effects of ginsenoside Rh2 are associated with the activation of AMPK signalling pathway in 3T3-L1 adipocyte. Biochemical and Biophysical Research Communications. 2007;**364**:1002-1008. DOI: 10.1016/j.bbrc.2007.10.125

[13] Vohl MC, Sladek R, Robitaille J, Gurd S, Marceau P, Richard D, et al. A survey of genes differentially expressed in subcutaneous and visceral adipose tissue in men. Obesity Research. 2004;**12**:1217-1222. DOI: 10.1038/ oby.2004.153

*Obesity in Children: Recent Insights and Therapeutic Options DOI: http://dx.doi.org/10.5772/intechopen.108987*

[14] Linder K, Arner P, Flores-Morales A, Tollet-Egnell P, Norstedt G. Differentially expressed genes in visceral or subcutaneous adipose tissue of obese men and women. Journal of Lipid Research. 2004;**45**:148-154. DOI: 10.1194/jlr.M300256-JLR200

[15] Frayling TM, Timpson NJ, Weedon MN, Zeggini E, Freathy RM, Lindgren CM, et al. A common variant in the FTO gene is associated with body mass index and predisposes to childhood and adult obesity. Science. 2007;**316**:889- 894. DOI: 10.1126/science.1141634

[16] Dina C, Meyre D, Gallina S, Durand E, Körner A, Jacobson P, et al. Variation in FTO contributes to childhood obesity and severe adult obesity. Nature Genetics. 2007;**39**: 724-726. DOI: 10.1038/ng2048

[17] Li L, Wang G, Li N, Yu H, Si J, Wang J. Identification of key genes and pathways associated with obesity in children. Experimental and Therapeutic Medicine. 2017;**14**:1065-1073. DOI: 10.3892/etm.2017.4597

[18] Jarrin DC, JJ MG, Poirier P, Quality Cohort Collaborative Group. Autonomic dysfunction: A possible pathophysiological pathway underlying the association between sleep and obesity in children at-risk for obesity. Journal of Youth and Adolescence. 2015;**44**:285-297. DOI: 10.1007/s10964-014-0235-3

[19] Aggarwal B, Jain V. Obesity in children: Definition, etiology and approach. Indian Journal of Pediatrics. 2018;**85**:463-471. DOI: 10.1007/ s12098-017-2531-x

[20] Taheri M, Kajbaf TZ, Taheri MR, Aminzadeh M. Neck circumference as a useful marker for screening overweight and obesity in children and adolescents. Oman Medical Journal. 2016;**31**:170-175. DOI: 10.5001/omj.2016.34

[21] Payab M, Qorbani M, Shahbal N, Motlagh ME, Hasani-Ranjbar S, Kelishadi R. Association of anthropometric indices with metabolic phenotypes of obesity in children and adolescents: The CASPIAN-V study. Frontiers in Endocrinology (Lausanne). 2019;**10**:786. DOI: 10.3389/ fendo.2019.00786

[22] Alberti A, Ruiz Reyes MA, De Jesus JA, Rossoni C, Grigollo L, Da Silva BB, et al. Identification of obesity in children and teenagers. Minerva Pediatrica. 2021. DOI: 10.23736/S0026- 4946.20.05731-X [Online ahead of print]

[23] Damanhoury S, Newton AS, Rashid M, Hartling L, Byrne JLS, Ball GDC. Defining metabolically healthy obesity in children: A scoping review. Obesity Reviews. 2018;**19**:1476-1491. DOI: 10.1111/obr.12721

[24] Li L, Yin J, Cheng H, Wang Y, Gao S, Li M, et al. Identification of genetic and environmental factors predicting metabolically healthy obesity in children: Data from the BCAMS study. The Journal of Clinical Endocrinology and Metabolism. 2016;**101**:1816-1825. DOI: 10.1210/jc.2015-3760

[25] Jones RE, Jewell J, Saksena R, Ramos Salas X, Breda J. Overweight and obesity in children under 5 years: Surveillance opportunities and challenges for the WHO European region. Frontiers in Public Health. 2017;**5**:58. DOI: 10.3389/ fpubh.2017.00058

[26] Paduano S, Borsari L, Salvia C, Arletti S, Tripodi A, Pinca J, et al. Risk factors for overweight and obesity in children attending the first year of primary schools in Modena, Italy. Journal of Community Health. 2020;**45**:301-309. DOI: 10.1007/s10900-019-00741-7

[27] Wright CM, Cole TJ, Fewtrell M, Williams JE, Eaton S, Wells JC. Body

composition data show that high BMI centiles overdiagnose obesity in children aged under 6 years. The American Journal of Clinical Nutrition. 2022;**116**:122-131. DOI: 10.1093/ajcn/nqub421

[28] US Preventive Services Task Force, Grossman DC, Bibbins-Domingo K, Curry SJ, Barry MJ, Davidson KW, et al. Screening for obesity in children and adolescents: US preventive services task force recommendation statement. Journal of the American Medical Association. 2017;**317**:2417-2426. DOI: 10.1001/jama.2017.6803

[29] Porter RM, Tindall A, Gaffka BJ, Kirk S, Santos M, Abraham-Pratt I, et al. A review of modifiable risk factors for severe obesity in children ages 5 and under. Childhood Obesity. 2018;**14**:468- 476. DOI: 10.1089/chi.2017.0344

[30] Lee EY, Yoon KH. Epidemic obesity in children and adolescents: Risk factors and prevention. Frontiers in Medicine. 2018;**12**:658-666. DOI: 10.1007/ s11684-018-0640-1

[31] Robinson TN, Banda JA, Hale L, Lu AS, Fleming-Milici F, Calvert SL, et al. Screen media exposure and obesity in children and adolescents. Pediatrics. 2017;**140**:S97-S101. DOI: 10.1542/ peds.2016-1758K

[32] Kracht CL, Joseph ED, Staiano AE. Video games, obesity and children. Current Obesity Reports. 2020;**9**:1-14. DOI: 10.1007/s13679-020-00368-z

[33] Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: A systematic review and meta-analysis of prospective cohort studies. Journal of Paediatrics and Child Health. 2017;**53**:378-385. DOI: 10.1111/jpc.13434

[34] Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on

overweight and obesity in children and adolescents: A systematic review and bias-adjusted meta-analysis. Obesity Reviews. 2015;**16**:137-149. DOI: 10.1111/ obr.12245

[35] Morrissey B, Taveras E, Allender S, Strugnell C. Sleep and obesity among children: A systematic review of multiple sleep dimensions. Pediatric Obesity. 2020;**15**:e12619. DOI: 10.1111/ijpo.12619

[36] Hanlon EC, Dumin M, Pannain S. Chapter 13 - sleep and obesity in children and adolescents. In: Bagchi D, editor. Global Perspectives on Childhood Obesity. 2nd ed. Cambridge, Massachusetts: Academic Press; 2019. pp. 147-178. DOI: 10.1016/ B978-0-12-812840-4.00013-X

[37] Chaput JP. Is sleep deprivation a contributor to obesity in children? Eating and Weight Disorders. 2016;**21**:5-11. DOI: 10.1007/s40519-015-0233-9

[38] Principi N, Esposito S. Antibiotic administration and the development of obesity in children. International Journal of Antimicrobial Agents. 2016;**47**:171-177. DOI: 10.1016/j. ijantimicag.2015.12.017

[39] Murugesan S, Nirmalkar K, Hoyo-Vadillo C, García-Espitia M, Ramírez-Sánchez D, García-Mena J. Gut microbiome production of short-chain fatty acids and obesity in children. European Journal of Clinical Microbiology & Infectious Diseases. 2018;**37**:621-625. DOI: 10.1007/ s10096-017-3143-0

[40] Zhang C, Yin A, Li H, Wang R, Wu G, Shen J, et al. Dietary modulation of gut microbiota contributes to alleviation of both genetic and simple obesity in children. eBioMedicine. 2015;**2**:968-984. DOI: 10.1016/j. ebiom.2015.07.007

*Obesity in Children: Recent Insights and Therapeutic Options DOI: http://dx.doi.org/10.5772/intechopen.108987*

[41] Da Silva CC, Monteil MA, Davis EM. Overweight and obesity in children are associated with an abundance of Firmicutes and reduction of Bifidobacterium in their gastrointestinal microbiota. Childhood Obesity. 2020;**16**:204-210. DOI: 10.1089/ chi.2019.0280

[42] Nagata S, Chiba Y, Wang C, Yamashiro Y. The effects of the lactobacillus casei strain on obesity in children: A pilot study. Beneficial Microbes. 2017;**8**:535-543. DOI: 10.3920/ BM2016.0170

[43] Guo Q, Xue T, Jia C, Wang B, Cao S, Zhao X, et al. Association between exposure to fine particulate matter and obesity in children: A national representative cross-sectional study in China. Environment International. 2020;**143**:105950. DOI: 10.1016/j. envint.2020.105950

[44] Parasin N, Amnuaylojaroen T, Saokaew S. Effect of air pollution on obesity in children: A systematic review and meta-analysis. Children (Basel). 2021;**8**:327. DOI: 10.3390/ children8050327

[45] Sun Q, Yue P, Deiuliis JA, Lumeng CN, Kampfrath T, Nikolaj MB, et al. Ambient air pollution exaggerates adipose inflammation and insulin resistance in a mouse model of diet-induced obesity. Circulation. 2009;**119**:538-546. DOI: 10.1161/ CIRCULATIONAHA.108.799015

[46] Wei Y, Zhang JJ, Li Z, Gow A, Chung KF, Hu M, et al. Chronic exposure to air pollution particles increases the risk of obesity and metabolic syndrome: Findings from a natural experiment in Beijing. The FASEB Journal. 2016;**30**:2115-2122. DOI: 10.1096/ fj.201500142

[47] Kim KY, Lee E, Kim Y. The association between bisphenol a exposure and obesity in children - a systematic review with meta-analysis. International Journal of Environmental Research and Public Health. 2019;**16**:2521. DOI: 10.3390/ijerph16142521

[48] Amin MM, Ebrahimpour K, Parastar S, Shoshtari-Yeganeh B, Hashemi M, Mansourian M, et al. Association of urinary concentrations of phthalate metabolites with cardiometabolic risk factors and obesity in children and adolescents. Chemosphere. 2018;**211**:547-556. DOI: 10.1016/j.chemosphere.2018.07.172

[49] Geiger SD, Yao P, Vaughn MG, Qian Z. PFAS exposure and overweight/ obesity among children in a nationally representative sample. Chemosphere. 2021;**268**:128852. DOI: 10.1016/j. chemosphere.202.128852

[50] Bushnik T, Wong SL, Holloway AC, Thomson EM. Association of urinary polycyclic aromatic hydrocarbons and obesity in children aged 3-18: Canadian health measures survey 2009-2015. Journal of Developmental Origins of Health and Disease. 2020;**11**:623-631. DOI: 10.1017/S2040174419000825

[51] Poursafa P, Dadvand P, Amin MM, Hajizadeh Y, Ebrahimpour K, Mansourian M, et al. Association of polycyclic aromatic hydrocarbons with cardiometabolic risk factors and obesity in children. Environment International. 2018;**118**:203-210. DOI: 10.1016/j. envint.2018.05.048

[52] Visscher TL, Kremers SP. How can we better prevent obesity in children? Current Obesity Reports. 2015;**4**:371-378. DOI: 10.1007/s13679-015-0167-6

[53] Patel SS, Daniels SR. Beginning with the end in mind: The case for primordial

and primary cardiovascular prevention in the youth. The Canadian Journal of Cardiology. 2020;**36**:1344-1351. DOI: 10.1016/j.cjca.2020.07.002

[54] Lancarotte I, Nobre MR. Primordial and primary prevention programs for cardiovascular diseases: From risk assessment through risk communication to risk reduction. A review of the literature. Clinics (Sao Paolo). 2016;**71**:667-678. DOI: 10.6061/ clinics/2016(11)09

[55] Brown T, Moore TH, Hooper L, Gao Y, Zayegh A, Ijaz S, et al. Interventions for preventing obesity in children. Cochrane Database of Systematic Reviews. 2019;**7**:CD001871. DOI: 10.1002/12651858.CD001871.pub4

[56] Peirson L, Fitzpatrick-Lewis D, Morrison K, Ciliska D, Kenny M, Usman Ali M, et al. Prevention of overweight and obesity in children and youth: A systematic review and metaanalysis. CMAJ Open. 2015;**3**:E23-E33. DOI: 10.9778/cmajo.20140053

[57] Elvsaas IKO, Giske L, Fure B, Juvet LK. Multicomponent lifestyle interventions for treating overweight and obesity in children and adolescents: A systematic review and meta-analyses. Journal of Obesity. 2017;**2017**:5021902. DOI: 10.1155/2017/5021902

[58] Dietz WH, Robinson TN. Clinical practice. Overweight children and adolescents. The New England Journal of Medicine. 2005;**352**:2100-2109. DOI: 10.1056/NEJMcp043052

[59] Colquitt JL, Loveman E, O'Malley C, Azevedo LB, Mead E, Al-Khudairy L, et al. Diet, physical activity, and behavioural interventions for the treatment of overweight or obesity in preschool children up to the age of 6 years. Cochrane Database of

Systematic Reviews. 2016;**3**:CD012105. DOI: 10.1002/14561858.CD012105

[60] van der Heijden LB, Feskens EJM, Janse AJ. Maintenance interventions for overweight or obesity in children: A systematic review and meta-analysis. Obesity Reviews. 2018;**19**:798-809. DOI: 10.1111/obr.12664

[61] An R. Diet quality and physical activity in relation to childhood obesity. International Journal of Adolescent Medicine and Health. 2017;**29**(2):20150045. DOI: 10.1515/ ijamh-2015-0045

[62] Alman KL, Lister NB, Garnett SPO, Gow ML, Aldwell K, Jebeile H. Dietetic management of obesity and severe obesity in children and adolescents: A scoping review of guidelines. Obesity Reviews. 2021;**22**:e13132. DOI: 10.1111/ obr.13132

[63] Okada C, Tabuchi T, Iso H. Association between skipping breakfast in parents and children and childhood overweight/obesity among children: A nationwide 10.5-year prospective study in Japan. International Journal of Obesity (Lond). 2018;**42**:1724-1732. DOI: 10.1038/s41366-018-0066-5

[64] Karatzi K, Moschonis G, Choupi E, Manios Y, Healthy Growth Study group. Late-night overeating is associated with smaller breakfast, breakfast skipping, and obesity in children: The healthy growth study. Nutrition. 2017;**33**:141- 144. DOI: 10.1016/j.nut.2016.05.010

[65] Bell S, Yew SSY, Devenish G, Ha D, Do L, Scott J. Duration of breastfeeding, but not timing of solid food, reduces the risk of overweight and obesity in children aged 24 to 36 months: Findings from an Australian cohort study. International Journal of Environmental Research and

*Obesity in Children: Recent Insights and Therapeutic Options DOI: http://dx.doi.org/10.5772/intechopen.108987*

Public Health. 2018;**15**:599. DOI: 10.3390/ ijerph15040599

[66] Wang W, Wu Y, Zhang D. Association of dairy products consumption with risk of obesity in children and adults: A meta-analysis of mainly cross-sectional studies. Annals of Epidemiology. 2016;**26**:870-882.e2. DOI: 10.1016/j.annepidem.2016.09.005

[67] Pérez-Bravo F, Duarte L, Arredondo-Olguín M, Iniguez G, Castillo-Valenzuela O. Vitamin D status and obesity in children from Chile. European Journal of Clinical Nutrition. 2022;**76**:899-901. DOI: 10.1038/ s41430-021-01043-9

[68] Cunha KA, Magalhaes EI, Loureiro LM, Sant'Ana LF, Ribeiro AQ, Novaes JF. Calcium intake, serum vitamin D and obesity in children: Is there an association? Revista Paulista de Pediatria. 2015;**33**:222-229. DOI: 10.1016/j.rpped.2015.03.001

[69] Altman M, Wilfley DE. Evidence update on the treatment of overweight and obesity in children and adolescents. Journal of Clinical Child and Adolescent Psychology. 2015;**44**:521-537. DOI: 10.1080/15374416.2014.963854

[70] Coles N, Birken C, Hamilton J. Emerging treatments for severe obesity in children and adolescents. BMJ. 2016;**354**:i4116. DOI: 10.1136/bmj.i4116

[71] Czepiel KS, Perez NP, Campoverde Reyes KJ, Sabharwal S, Stanford FC. Pharmacotherapy for the treatment of overweight and obesity in children, adolescents and young adults in a large health system in the US. Frontiers in Endocrinology (Lausanne). 2020;**11**:290. DOI: 10.3389/fendo.2020.00290

[72] Mead E, Atkinson G, Richter B, Metzendorf MI, Baur L, Finer N,

et al. Drug interventions for the treatment of obesity in children and adolescents. Cochrane Database of Systematic Reviews. 2016;**11**:CD012436. DOI: 10.1002/14651858.CD012436

[73] Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH, et al. Pediatric obesity-assessment, treatment and prevention: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism. 2017;**102**:709-757. DOI: 10.1210/js.2016-2573

[74] Sherafat-Kazemzadeh R, Yanovski SZ, Yanovski JA. Pharmacotherapy for childhood obesity: Present and future prospects. International Journal of Obesity. 2013;**37**:1-15. DOI: 10.1038/ijo.2012.144

[75] Pratt JSA, Browne A, Browne NT, Bruzoni M, Cohen M, Desai A, et al. ASMBS pediatric metabolic and bariatric surgery guidelines. Surgery for Obesity and Related Diseases. 2018;**14**:882-901. DOI: 10.1016/j.soard.2018.03.019

[76] Camilleri M, Staiano A. Insights on obesity in children and adults: Individualizing management. Trends in Endocrinology and Metabolism. 2019;**30**:724-734. DOI: 10.1016/j. tem.2019.07.016

[77] Mado FG, Sirajuddin S, Muis M, Maria IL, Darmawansyah D, Arifin MA. Intervention empowerment of families in preventing and controlling overweight and obesity in children: A systematic review. Journal of Public Health Research. 2021;**10**:2185. DOI: 10.4081/ jphr.2021.2185

[78] Loveman E, Al-Khudairy L, Johnson RE, Robertson W, Colquitt JL, Mead EL, et al. Parent-only interventions for childhood overweight or obesity in children aged 5 to 11 years.

Cochrane Database of Systematic Reviews. 2015;**2015**:CD012008. DOI: 10.1002/14651858.CD012008

[79] Kaur J, Lamb MM, Ogden CL. The association between food insecurity and obesity in children - the National Health and nutrition examination survey. Journal of the Academy of Nutrition and Dietetics. 2015;**115**:751-758. DOI: 10.1016/j.jand.2015.01.003

[80] Alberdi G, McNamara AE, Lindsay KL, Scully HA, Horan MH, Gibney ER, et al. The association between childcare and risk of childhood overweight and obesity in children aged 5 years and under a systematic review. European Journal of Pediatrics. 2016;**175**:1277-1294. DOI: 10.1007/ s00431-016-2768-9

#### **Chapter 2**

## Stigmatization of the Patients Who Live with Overweight or Obesity

*Daria Lahoda*

#### **Abstract**

Historically, obesity was defined by a body mass index (BMI) ≥ 30 kg/m2 . Although increased body fat can have important health and well-being implications, its presence alone does not necessarily mean or reliably predict poorer health. Overweight is defined in the case of BMI from 25 to 29.9 kg/m<sup>2</sup> . There is a need to address this condition, as it precedes the development of obesity and requires medical intervention. Patients living with overweight or obesity often experience prejudice or stigmatization by society and/or health professionals. Weight stigmatization is a prejudiced attitude and/or discrimination against people based on a person's body weight and size. According to research, from 20 to 40% of patients living with overweight or obesity experience this attitude during their lifetime. In this study, we aimed to assess the degree of obesity and the prevalence of stigmatization among overweight and obese Ukrainians, using a questionnaire-based method.

**Keywords:** obesity, patient, stigmatization, overweight, bodyweight management

#### **1. Introduction**

This is a hardship that obese people encounter in various spheres of life, namely during education, employment, and when visiting medical institutions [1–4]. Often, doctors have a stereotypical mindset about patients living with overweight or obesity, who are often get described as, lacking self-control and willpower, do not follow prescribed recommendations, do not have a low level of intelligence and, in the end, it is their own fault, that they have high blood pressure or obesity [5, 6].

According to the data given in the studies, patients who are overweight or obese receive shorter consultations with doctors and doctors have less respect for such patients [7, 8]. These factors affect the quality of medical care provided to such patients and their compliance with the doctor. Doctors and nurses tend to stigmatize such patients, which is manifested in excessive attribution of medical symptoms and problems solely because the patient has increase in body weight (BW), which in turn affects diagnostic and treatment measures for such a patient [9].

Preconceptions about BW in healthcare settings may reduce the quality of care for patients living with obesity. A key factor in reducing bias, stigmatization, and discrimination in healthcare facilities is staff awareness of their own attitudes and behaviors toward people living with obesity.

Primary care clinicians should promote a holistic approach to BW and health with an emphasis on behavioral characteristics in all patients, focusing on healthy lifestyles and the underlying causes of increased BW, but avoiding stigmatization and overly simplistic statements such as "eat less and move more" [1].

It is imperative to investigate the prevalence of weight stigma in different healthcare systems, to determine the extent, nature, and factors associated with this phenomenon, and to implement interventions to eradicate and prevent it.

According to the data of the STEPS international study, which included 7,700 adults aged 18 to 69, in 2019 a quarter of the population in Ukraine was obese (BMI ≥30 kg/m2 ), and more than 50% were overweight (BMI 25–29.9 kg/m2 ) [10].

Therefore, more than half of Ukrainians currently have one or another manifestation of excess BW and may be subject to stigma regarding BW.

#### **2. Research materials and methods**

The study included 251 patients with BMI ≤ 25 kg/m<sup>2</sup> aged 18 years and older who participated in the study. The study was questionnaire-based and conducted at the Department of Family Medicine and Polyclinic Therapy of Odesa National Medical University. Patients were included in the study after completing the informed consent process, which provided an explanation of the purpose and content of the survey, as well as the names of the investigators. Potential participants were informed that the survey was anonymous, took approximately 5–10 min to complete, and that completion of the survey was optional. In addition, the respondents were informed that the results of the questionnaire will be summarized and published in the form of a scientific article. Informed consent was ensured by instructing patients to complete the questionnaire only if they agreed to participate in the survey.

The questionnaire consisted of two parts. The first included data on the age, sex, body weight, and height of the patient for further calculation of the body mass index. The second part included six open-ended questions about the characteristics of communication of a patient living with overweight or obesity with medical professionals (**Table 1**).

For clearer processing of open questions, we categorized the answers, as 0—never, 1—very rarely, 2—occasionally, 3—sometimes, 4—often, 5—always.


**Table 1.** *Survey question.*

Answers to the survey were recorded automatically using Google forms. Surveys were conducted during 2021–2022. After the survey was completed, the data were downloaded and permanently deleted from Google Forms.

The study was performed taking into account all standards of good clinical practice and the requirements of the Declaration of Helsinki of the World Medical Association "Ethical principles of medical research with the participation of a person as a research object."

Statistical processing of the research results was carried out according to generally accepted methods of variational statistics. Reliability was assessed by student's t-test. Differences were considered significant at p ≤ 0.05. The correlation was assessed using Spearman's correlation test and Pearson's correlation-regression analysis.

#### **3. Research results**

According to the design, our study included 251 patients whose mean age was 35.26 ± 5.27 years. There are more women among them, namely 173 women (68.92%) and 78 men (31.08%). Based on the weight and height of the patient, the BMI was determined and we were able to divide the patients according to the degree of obesity and obtained the data shown in **Table 2**.

It can be seen from **Table 2** that most of the interviewed patients had obesity class 2 (28.48%), and the fewest patients had overweight (21.12%).

When passing the second block of the survey, we had the data presented in Figure. **Figure 1** shows that the majority of patients when answering the question chose the answers "3" and "4," which are "sometimes" and "often," respectively. Let us analyze this in more detail. Thus, we received the most "never" answers to the question "Have there been cases when medical devices did not fit you because of your body weight?," namely 94 patients (37.45%). The item "very rarely" was most marked by patients in response to the question "Did you feel that you received less optimal treatment because of your body weight?," namely 74 (29, 48%) respondents.

The answer to the question "occasionally" was provided by 23.37% of patients. Participants who most often felt stigmatization expressed it in response to the question "Did you feel judged by the medical staff because of your body weight?" and "Have you refused a visit to a medical institution because of a premonition that the medical staff would treat you with disdain or judgment, because of your body weight?,": namely 41.83% and 46.61%, respectively.


#### **Table 2.**

*Distribution of patients according to the severity of obesity.*

#### **Figure 1.**

*Results of the second part of the survey.*

At the same time, it was established that positive answers to the questions were correlated with BMI, so a direct close correlation between BMI and the feeling of stigmatization of patients was determined, namely r = 0.81, p < 0.05.

#### **4. Discussion**

The results of the survey show that the majority of patients who are overweight or obese often experience disrespect due to their overweight. In addition, the vast majority of respondents said that they avoided visits to the doctor because of the premonition that the medical staff would treat them with disdain or judgment because of their body weight. However, it must be remembered that one of the main limitations of a voluntary online survey is selection bias, that is, a greater need to answer questionnaire questions for respondents who have experienced disrespect in the past.

Thus, the rates of adverse experiences reported in our study may be higher than in the general population of people living with hyperlipidemia or obesity. Nevertheless, our results are consistent with previous studies examining the prevalence of patient stigmatization within the healthcare system [11–13]. In one study, which was also conducted on the basis of a questionnaire, 89% of patients reported that they felt inappropriate comments from doctors about their body weight [14]. In addition, in a survey of 329 health professionals who specialized in eating disorders, 56% of respondents reported that their colleagues stigmatized patients with obesity [15].

Stigma from BW can manifest itself in a variety of ways, including less patientcenteredness, a less respectful approach, less positive communication and information provision, and less time allocated to medical appointments [6]. According to studies [4, 16], a disrespectful approach is registered at various levels of medical care. The main medical professionals who were accused of negligent care were family doctors, gynecologists, traumatologists, and anesthesiologists (mainly during the

administration of epidural anesthesia). Thus, these healthcare providers should be aware of the adverse impact of stigma on BW management and take a particularly sensitive approach to patients living with overweight or obesity.

#### **5. Conclusions**

When managing patients living with obesity, it is necessary to be more empathetic and sensitive. Stigmatization of this category of patients negatively affects weight loss as well as BW control. In addition, the stigmatization of a patient based on body weight affects all areas of the patient's life and, most of all, the quality of the patient's medical care. The problem of stigmatization of patients who live with overweight or obesity is relevant in Ukraine. But currently, we do not have enough such data on Ukrainians. The medical community should be aware of the existence of the problem of stigmatization of the patient according to body weight and also introduce mechanisms to overcome this problem.

### **Author details**

Daria Lahoda Philosophy in Medicine, Department of Family Medicine and Polyclinic Therapy, Odesa National Medical University, Odesa, Ukraine

\*Address all correspondence to: dlagoda19@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] CMAJ. Canada Obesity in Adults: A Clinical Practice Guideline. Available from: https://www.cmaj.ca/content/192/31/E875

[2] Mulherin K, Miller YD, Barlow FK, Diedrichs PC, Thompson R. Weight stigma in maternity care: Women's experiences and care providers' attitudes. BMC Pregnancy and Childbirth. 2013;**13**:19

[3] Spahlholz J, Baer N, Konig HH, Riedel-Heller SG, Luck-Sikorski C. Obesity and discrimination—A systematic review and meta-analysis of observational studies. Obesity Reviews. 2016;**17**(1):43-55

[4] Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity (Silver Spring). 2009;**17**(5):941-964

[5] Rubino F, Puhl RM, Cummings DE, Eckel RH, Ryan DH, Mechanick JI, et al. Joint international consensus statement for ending stigma of obesity. Nature Medicine. 2020;**26**(4):485-497

[6] Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews. 2015;**16**(4):319-326

[7] Huizinga MM, Cooper LA, Bleich SN, Clark JM, Beach MC. Physician respect for patients with obesity. Journal of General Internal Medicine. 2009;**24**(11):1236-1239

[8] Hebl MR, Xu J. Weighing the care: Physicians' reactions to the size of a patient. International Journal of Obesity and Related Metabolic Disorders. 2001;**25**(8):1246-1252

[9] Persky S, Eccleston CP. Medical student bias and care recommendations for an obese versus non-obese virtual patient. International Journal of Obesity. 2011;**35**(5):728-735

[10] World Health Organization. Available from: https://apps.who.int/ iris/bitstream/handle/10665/336643/ WHO-EURO-2020-1468-41218-56059 ukr.pdf?sequence=1&isAllowed=y [Accessed: May 15, 2023]

[11] Remmert JE, Convertino AD, Roberts SR, Godfrey KM, Butryn ML. Stigmatizing weight experiences in health care: Associations with BMI and eating behaviours. Obesity Science and Practice. 2019;**5**(6):555-563

[12] Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR, et al. How and why weight stigma drives the obesity "epidemic" and harms health. BMC Medicine. 2018;**16**(1):123

[13] Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obesity Research. 2003;**11**(9):1033-1039

[14] Friedman KE, Reichmann SK, Costanzo PR, Zelli A, Ashmore JA, Musante GJ. Weight stigmatization and ideological beliefs: Relation to psychological functioning in obese adults. Obesity Research. 2005;**13**(5):907-916

[15] Puhl RM, Latner JD, King KM, Luedicke J. Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes. The International Journal of Eating Disorders. 2014;**47**(1):65-75

[16] Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. American Journal of Public Health. 2010;**100**(6):1019-1028

### Section 2
