Annals of Family Medicine
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Annals of Family Medicine 7:352-356 (2009)
© 2009 Annals of Family Medicine, Inc.
doi: 10.1370/afm.1005
This Article
Right arrow Abstract
Right arrow Full Text (PDF)
Right arrow Supplemental data: Appendix
Right arrow In Brief
Right arrow TRACK Discussion: Submit a Comment
Right arrow TRACK Discussion: View Comments
Right arrow Alert me when this article is cited
Right arrow Alert me when TRACK Comments are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Krul, M.
Right arrow Articles by Koes, B. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Krul, M.
Right arrow Articles by Koes, B. W.
Related Collections
Right arrow Disease pathophysiology / etiology
Right arrow Children's health
Right arrow Quantitative methods

Musculoskeletal Problems in Overweight and Obese Children

Marjolein Krul, MD1, Johannes C. van der Wouden, PhD1, François G. Schellevis, MD, PhD2, Lisette W. A. van Suijlekom-Smit, PhD3 and Bart W. Koes, PhD1

1 Department of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
2 Department of General Practice, EMGO Institute, VU University Medical Centre, Amsterdam, and NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
3 Department of Pediatrics, Erasmus MC, and Sophia Children’s Hospital Rotterdam, Rotterdam, The Netherlands

CORRESPONDING AUTHOR: Marjolein Krul, MD, Department of General Practice, Room Ff304, Erasmus MC University Medical Center, Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands, m.krul{at}erasmusmc.nl


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE The obesity epidemic in children is spreading at alarming rates. Because musculoskeletal problems can influence physical activity, we compared the frequency of musculoskeletal problems in overweight and obese children with that in normal-weight children.

METHODS We performed a cross-sectional database and face-to-face interview study that included 2,459 children aged 2 to 17 years from Dutch family practices. We collected data on self-reported height and weight (body mass index), self-reported musculoskeletal problems in the 2 weeks before the interview, number of family physician consultations for musculoskeletal problems in 1 year, and age (2 age-groups were analyzed: 2 to 11 years and 12 to 17 years, because of the proxy interview in the youngest age-group). We calculated the odds ratio (OR) and 95% confidence interval (CI) for musculoskeletal problems in overweight and obese children, compared with normal-weight children.

RESULTS Overweight and obese children in both age-groups (2 to 11 years and 12 to 17 years) reported significantly more musculoskeletal problems (OR = 1.86; 95% CI, 1.18–2.93; and OR = 1.69; 95% CI, 1.08–2.65, respectively) than normal-weight children. The total group of children who were overweight or obese reported more lower extremity problems than did the normal-weight children (OR = 1.62; 95% CI, 1.09–2.41); furthermore, they reported more ankle and foot problems than children who were of normal weight (OR = 1.92; 95% CI, 1.15–3.20). Overweight and obese children aged 12 to 17 years consulted their family physicians more often with lower extremity problems than did the normal-weight children (OR = 1.92; 95% CI, 1.05–3.51).

CONCLUSION This study shows that overweight and obese children more frequently experience musculoskeletal problems than do normal-weight children.

Key Words: Children • obesity • overweight • musculoskeletal


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Childhood obesity is a serious health problem, and an obesity epidemic is spreading in alarming rates among children.1 Currently about 16% of the children in Europe are overweight, and 8% are obese.2 Obesity-associated problems and diseases decrease the quality of life and life span. Many studies have shown that overweight children are more likely to become overweight adults than their normal-weight peers.3–7 Furthermore, children may also be more vulnerable to specific obesity-related health problems (such as hypertension, hepatic steatosis, hyperandrogenism, and pseudoacromegaly)8 because their bodies are growing and developing.

Adult obesity has been associated with a higher prevalence of musculoskeletal disorders, primarily affecting the lower limbs,9–13 but comparative data in children are scarce. Some musculoskeletal disorders that are unique to childhood, such as slipped capital femoral epiphysis14 and tibia vara (Blount’s disease),15 have retrospectively been associated with excess weight. Few studies have quantified the prevalence of musculoskeletal problems in overweight and obese children.16–19 Although these few studies imply that childhood obesity may predispose children to musculoskeletal problems, convincing empirical verification is currently lacking.

In our present research we use the results of a large survey in Dutch family practices performed in 2001 and aim to answer the following questions: (1) do overweight and obese children report more (lower extremity) musculoskeletal problems in daily life than their normal-weight peers; and (2) do overweight and obese children seek help for (lower extremity) musculoskeletal problems more often than their normal-weight peers?


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
We analyzed data from the second Dutch national survey of family practice (NS2), which was carried out by the Netherlands Institute for Health Services Research (NIVEL) in 2001. The survey included a representative sample of the Dutch population; for further details see the article by Westert et al.20 This national survey consisted of morbidity registration by family physicians and face-to-face health interviews conducted in the Dutch language with a randomly selected sample of the listed patient population. Interview and morbidity data were linked and used for the present study.

Interview
An all-age, computer-generated sample of 150 registered patients per participating full-time family physician was invited to participate in an elaborate, face-to-face, multiple-choice health interview until the target number of 80 patients per physician had been reached. For nonresponders, attempts to contact (when possible), reason not to participate, sex, age, and zip code were documented. Trained interviewers performed the interviews, and the interviews were evenly distributed among 4 consecutive 3-month periods to adjust for seasonal fluctuations. Items used for this study included age, self-reported height and weight, and self-reported musculoskeletal symptoms during the previous 2 weeks. If children were younger than 12 years, a proxy interview was carried out with a parent. To increase readability, the information provided by the parents is reported as if it were information provided by the children themselves.

Morbidity Registration
Morbidity data on the interviewed children were derived from the electronic medical records. The physicians registered all health problems reported during a consultation and coded the diagnosis using the International Classification of Primary Care (ICPC). The ICPC codes used to identify musculoskeletal problems are displayed in the Supplemental Appendix, which is available online at http://www.annfammed.org/cgi/content/full/7/4/352/DC1). This survey was episode orientated, meaning that different consultations concerning the same health problem were clustered into 1 disease episode. Baseline characteristics (such as age and sex) were derived from patient records.

Overweight and Obesity
The body mass index (BMI) was used as a measure of overweight and obesity in the children21 and was based on self-reported weight and height. A standard developed for age-specific overweight and obesity BMI cutoff points in Dutch children was used to determine the presence of overweight and obesity in the study population.22 These cutoff points are almost identical to the recommended worldwide standard definition of overweight and obesity.23

Study Population
We analyzed interview data and corresponding physicians’ morbidity registration data of the 2- to 17-year-old children. Only Dutch natives were included to reduce selection bias related to language and to enhance compatibility with BMI cutoff values that had been developed for native Dutch children. Children under the age of 2 years were excluded because obesity is not defined for this group. Among 2,719 eligible children, we analyzed data for 2,459 (90%) for which we had height and weight information. A weighting factor was applied to compensate for differences between registration periods per practice. Children of normal weight and children with overweight and obesity contributed equal amounts of follow-up time.

Analysis
Using age- and sex-specific BMI cutoff value curves for Dutch native children,22 the children were divided into 3 groups: normal weight, overweight, and obese children. Because numbers were too small in the overweight and obese group to assess dose-effect relationships accurately, we chose to analyze overweight and obese children as 1 group. We have calculated odds ratios (ORs) and 95% confidence intervals (CIs) comparing the overweight and obese children with the normal weight children. Odds ratios and confidence intervals not including 1 were considered significant. t tests and {chi}2 analyses, as appropriate, were used to examine differences between these 2 groups. Significance was set at P <.05. We distinguished 2 age-groups, namely, children younger and older than 12 years of age, because of the proxy interview for children younger than 12 years. We calculated Mantel-Haenszel odds ratios to assess possible clustering of patients within physician practices. Analyses were conducted using Statistical Package for the Social Sciences, version 15.0 (SPSS Inc, Chicago, Illinois).

Ethical Approval
The study was carried out according to Dutch legislation on privacy. The Dutch Data Protection Authority approved the privacy regulation of the study. According to Dutch legislation, obtaining informed consent is not obligatory for observational studies.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Participant Characteristics
In total, 2,459 children were included in the analysis; 319 (13.0%) were overweight or obese, 219 (8.9%) and 100 (4.1%), respectively. There was no significant difference between the children of normal weight and overweight and obese children in mean age or in the distribution of boys and girls within the age subgroups. Clustering within physician practices did not affect our outcome, as Mantel-Haenszel odds ratios were comparable to crude odds ratios.

Self-Reported Musculoskeletal problems
Self-reported musculoskeletal problems are shown in Table 1Go. Overweight and obese children in both age-groups (2 to 11 years and 12 to 17 years) reported significantly more musculoskeletal problems in daily life than did normal-weight children (OR = 1.86; 95% CI, 1.18–2.93; and OR = 1.69 95% CI, 1.08–2.65, respectively). Children aged 2 to 11 years who were overweight or obese reported neck and back pain more often than did the normal-weight children in that age category (OR = 2.60; 95% CI, 1.30–5.19). The total group of children who were overweight and obese reported more lower extremity problems than did the total normal-weight group of children (OR = 1.62; 95% CI, 1.09–2.41). We were able to split these lower extremity problems in a subgroup of hip and knee problems and a subgroup of ankle and foot problems. Ankle and foot problems were significantly more common in the total group and in the youngest age-group of overweight and obese children compared with these groups of normal-weight children (OR = 1.92; 95% CI, 1.15–3.20; and OR = 2.27; 95% CI, 1.15–4.47, respectively). Rates of self-reported upper extremity problems did not differ between overweight and obese children and normal-weight children for either age subgroup.


View this table:
[in this window]
[in a new window]

  		Table 1. Self-Reported Musculoskeletal Problems in Normal-Weight and Overweight and Obese Children
 
Musculoskeletal Problems Reported in Family Practice
Episodes of health problems derived from the electronic medical record are displayed in Table 2Go. Among children aged 12 to 17 years, overweight and obese children consulted their family physicians more frequently with lower extremity problems (OR = 1.92; 95% CI, 1.05–3.51). Regarding upper extremity problems and neck and back problems, there was no difference in consultation rate between children who were not overweight and the overweight and obese children.


View this table:
[in this window]
[in a new window]

  		Table 2. Musculoskeletal Problems Reported to Family Physicians in Normal-Weight and Overweight and Obese Children
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this large study of children aged 2 to 17 years seen in Dutch general practice, we found overweight and obese children reported musculoskeletal problems and lower extremity problems more frequently in daily life than did their normal-weight peers. Overweight and obese children aged 12 to 17 years were also more frequently seen by their family physician for lower extremity problems than were their peers of normal weight.

Ankle and foot problems are significantly more common in overweight and obese children compared with normal weight children in our study. A number of studies have focused on the foot structure of overweight and obese children24–27 showing that these children have increased foot length and width and decreased navicular height,24 lower medial arch height,25,26 and higher plantar pressure27 compared with normal-weight children. It therefore seems reasonable to assume that these structural problems in the feet of the overweight and obese children are correlated with the reported ankle and foot problems. This assumption has been postulated before,27,28 but unfortunately none of the foregoing studies was designed in a way that such a theory could be verified. Although our study adds credibility, further investigation is necessary to confirm whether there is a causal relationship.

Although the absolute difference may not be large, de Sa Pinto et al19 have also reported more back pain among their obese children aged 7 to 14 years. In accordance with the same report, we found no differences in the occurrence of upper extremity problems between overweight and obese and normal-weight children.

Overweight and obese children experience musculoskeletal problems more often. The association between a low fitness level and excess body weight has been described.29,30 Normal-weight children with musculoskeletal problems are possibly less active and can therefore become overweight, and musculoskeletal problems can prevent overweight and obese patients from successfully using exercise to reduce body weight. We hypothesize that a vicious circle results wherein being overweight, musculoskeletal problems, and a low fitness level reinforce each other. It is therefore important to be aware of the higher occurrence of musculoskeletal problems in these children, to provide adequate management of their problems, and to give healthy life style advice proactively.

Limitations
We used self-reported weight and height to determine the BMI, which may have introduced misclassification. We believe, however, that possible misclassification is limited, because we used face-to-face interviews, which promote validity of answers.31 Furthermore, people will tend to underestimate weight and overestimate height, resulting in an underestimation of the number of overweight and obese children. It is, therefore, not likely that the possible misclassification will have affected the positive relation found in this study. Our findings are supported by those of Strauss,32 who compared self-reported with actual weight and height. The study showed small differences in weight, but it did not have an impact in the assessment of obesity-related morbidity.

Although there was a 35% nonresponse for the interview, we argue that selection bias was limited. Our participants were sampled independently of general practice consultation, and the children in our sample, compared with data from Statistics Netherlands, were representative (by sex, age, and region) of the Dutch childhood population. Although approximately 10% of data on height and/or weight was missing, we believe the missing data were random, because the health interview was elaborate and covered many more topics than obesity and musculoskeletal problems.

Our study shows that overweight and obese children more frequently report musculoskeletal problems in daily life than do normal-weight children. In addition to more self-reported musculoskeletal problems in overweight and obese children, we also found that overweight and obese children older than 12 years sought medical help more frequently for their lower extremity problems than did their normal-weight peers.


   ACKNOWLEDGMENTS
 
The authors thank all the family physicians and family practices involved in this study.


   FOOTNOTES
 
Funding support: The Dutch ministry of Health, Welfare and Sports mainly funded the surveys directly or indirectly. In addition, the ‘Stichting Centraal Fonds RVVZ’ contributed financially to the second survey. The analysis reported in this paper was made possible through internal funding of the department of General Practice, Erasmus MC-University Medical Center Rotterdam

Conflicts of interest: none reported

Received for publication August 19, 2008. Revision received January 1, 2009. Accepted for publication January 30, 2009.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Ten things you need to know about obesity. Presented at WHO European Ministerial Conference on Counteracting Obesity; November 15–17, 2006; Istanbul, Turkey. http://www.euro.who.int/document/nut/obesityconf_10things_eng.pdf.
  2. Internation Association for the Study of Obesity. International Obesity Taskforce. May 24, 2004. EU "childhood obesity out of control". http://www.iaso.org/popout.asp?linkto=http%3A//www.iotf.org/media/IOTFmay28.pdf.
  3. Guo SS, Wu W, Chumlea WC, Roche AF. Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. Am J Clin Nutr. 2002;76(3):653–658.[Abstract/Free Full Text]
  4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869–873.[Abstract/Free Full Text]
  5. Eriksson J, Forsén T, Osmond C, Barker D. Obesity from cradle to grave. Int J Obes. 2003;27(6):722–727.[CrossRef][Medline]
  6. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22(2):167–177.[CrossRef][Medline]
  7. Power C, Lake JK, Cole TJ. Measurement and long-term health risks of child and adolescent fatness. Int J Obes. 1997;21(7):507–526.[CrossRef][Medline]
  8. Gunturu SD, Ten S. Complications of obesity in childhood. Pediatr Ann. 2007;36(2):96–101.[Medline]
  9. Tsuritani I, Honda R, Noborisaka Y, Ishida M, Ishizaki M, Yamada Y. Impact of obesity on musculoskeletal pain and difficulty of daily movements in Japanese middle-aged women. Maturitas. 2002;42(1):23–30.[CrossRef][Medline]
  10. Kortt M, Baldry J. The association between musculoskeletal disorders and obesity. Aust Health Rev. 2002;25(6):207–214.[Medline]
  11. He XZ, Baker DW. Body mass index, physical activity, and the risk of decline in overall health and physical functioning in late middle age. Am J Public Health. 2004;94(9):1567–1573.[Abstract/Free Full Text]
  12. Fabris de Souza SA, Faintuch J, Valezi AC, et al. Postural changes in morbidly obese patients. Obes Surg. 2005;15(7):1013–1016.[CrossRef][Medline]
  13. Aro S, Leino P. Overweight and musculoskeletal morbidity: a ten-year follow-up. Int J Obes. 1985;9(4):267–275.[Medline]
  14. Loder RT, Aronson DD, Greenfield ML. The epidemiology of bilateral slipped capital femoral epiphysis. A study of children in Michigan. J Bone Joint Surg Am. 1993;75(8):1141–1147.[Abstract/Free Full Text]
  15. Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (Tibia vara): another skeletal disorder associated with childhood obesity. J Pediatr. 1992;101(5)735–737.
  16. Henderson RC. Tibia vara: a complication of adolescent obesity. J Pediatr. 1992;121(3):482–486.[CrossRef][Medline]
  17. Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics. 2006;117(6): 2167–2174.[Abstract/Free Full Text]
  18. Bazelmans C, Coppieters Y, Godin I, et al. Is obesity associated with injuries among young people? Eur J Epidemiol. 2004;19(11): 1037–1042.[CrossRef][Medline]
  19. de Sá Pinto AL, de Barros Holanda PM, Radu AS, Villares SMF, Lima FR. Musculoskeletal findings in obese children. J Paediatr Child Health. 2006;42(6):341–344.[CrossRef][Medline]
  20. Westert GP, Schellevis FG, de Bakker DH, Groenewegen PP, Bensing JM, van der Zee J. Monitoring health inequalities through general practice: the Second Dutch National Survey of General Practice. Eur J Public Health. 2005;15(1):59–65.[Free Full Text]
  21. Pietrobelli A, Faith MS, Allison DB, Gallagher D, Chiumello G, Heymsfield SB. Body mass index as a measure of adiposity among children and adolescents: a validation study. J Pediatr. 1998;132(2):204–210.[CrossRef][Medline]
  22. Hirasing RA, Fredriks AM, van Buuren S, Verloove-Vanhorick SP, Wit JM. [Increased prevalence of overweight and obesity in Dutch children, and the detection of overweight and obesity using international criteria and new reference diagrams]. Ned Tijdschr Geneeskd. 2001;145(27):1303–1308.[Medline]
  23. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000;320(7244):1240–1243.[Abstract/Free Full Text]
  24. Morrison SC, Durward BR, Watt GF, Donaldson MDC. Anthropometric foot structure of peripubescent children with excessive versus normal body mass: a cross-sectional study. J Am Podiatr Med Assoc. 2007;97(5):366–370.[Abstract/Free Full Text]
  25. Villaroya MA, Esquivel JM, Tomás C, Buenafé A, Moreno L. Foot structure in overweight and obese children. Int J Pediatr Obes. 2007;2(1):1–7.
  26. Mickle KJ, Steele JR, Munro BJ. The feet of overweight and obese young children: are they flat or fat? Obesity (Silver Spring). 2006;14(11):1949–1953.[CrossRef][Medline]
  27. Dowling AM, Steele JR, Baur LA. What are the effects of obesity in children on plantar pressure distributions? Int J Obes. 2004;28(11):1514–1519.[CrossRef][Medline]
  28. Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP. Musculoskeletal disorders associated with obesity: a biomechanical perspective. Obes Rev. 2006;7(3):239–250.[CrossRef][Medline]
  29. Kim J, Must A, Fitzmaurice GM, et al. Relationship of physical fitness to prevalence and incidence of overweight among schoolchildren. Obes Res. 2005;13(7):1246–1254.[CrossRef][Medline]
  30. Minck MR, Ruiter LM, Van Mechelen W, Kemper HC, Twisk JW. Physical fitness, body fatness, and physical activity: The Amsterdam Growth and Health Study. Am J Hum Biol. 2000;12(5):593–599.[CrossRef][Medline]
  31. de Leeuw ED, van der Zouwen J. Data quality in telephone and face-to-face surveys; a comparative meta-analysis. In: Telephone Survey Methodology. New York, NY: Wiley; 1988:283–300.
  32. Strauss RS. Comparison of measured and self-reported weight and height in a cross-sectional sample of young adolescents. Int J Obes Relat Metab Disord. 1999;23(8):904–908.[CrossRef][Medline]



This article has been cited by other articles:


Home page
 Ann Fam MedHome page
K. C. Stange
Organizing Health Care for Value
Ann. Fam. Med, September 1, 2009; 7(5): 465 - 466.
[Full Text] [PDF]

Home page
 Ann Fam MedHome page
E. A. Bayliss
In This Issue: Systematic Strategies and Individualized Approaches to Care
Ann. Fam. Med, July 1, 2009; 7(4): 290 - 291.
[Full Text] [PDF]

TRACK Comments:

Read all TRACK Comments

Comment on article
Stewart C Morrison
Annals of Family Medicine, 15 Jul 2009 [Full text]
The locomotor system exam in the young obese population
Ana Lucia S Pinto
Annals of Family Medicine, 23 Jul 2009 [Full text]
A new insight
Remy A Hirasing, et al.
Annals of Family Medicine, 26 Jul 2009 [Full text]
Barriers to physical activity are afoot for overweight youth
Anne L. Dunlop, et al.
Annals of Family Medicine, 28 Aug 2009 [Full text]
This Article
Right arrow Abstract
Right arrow Full Text (PDF)
Right arrow Supplemental data: Appendix
Right arrow In Brief
Right arrow TRACK Discussion: Submit a Comment
Right arrow TRACK Discussion: View Comments
Right arrow Alert me when this article is cited
Right arrow Alert me when TRACK Comments are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Krul, M.
Right arrow Articles by Koes, B. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Krul, M.
Right arrow Articles by Koes, B. W.
Related Collections
Right arrow Disease pathophysiology / etiology
Right arrow Children's health
Right arrow Quantitative methods

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS