Musculoskeletal Problems in Overweight and Obese Children

The work by Krul et al. (1) demonstrates that overweight and obese youth experience musculoskeletal problems more often than do children of healthy weight, and are more likely to seek physicians’ care for their lower extremity problems, suggesting an increased severity of their problems. As the study is cross-sectional in nature, it is not possible to discern whether the musculoskeletal problems contribute to lower activity levels that in turn contribute to overweight and obesity, or whether excess body weight brings about the musculoskeletal problems for the study sample. However, existing studies show that obesity, particularly during the growth period, places high levels of stress on bones and joints that may result in joint damage and, ultimately, contribute to osteoarthritis in later years (2).

Regardless of whether excess body weight begets musculoskeletal problems or musculoskeletal problems beget excess body weight, an important clinical implication of the study is that musculoskeletal problems may present an additional barrier to initiating and sustaining recommended levels of physical activity for overweight youth – an important means of achieving and maintaining a healthy body weight. Those who provide health care to overweight youth should be cognizant of this and other important barriers to physical activity for these overweight youth, including the following:

1. Obesity appears to play a role in airway hyperresponsiveness and asthma severity. Both asthma prevalence and severity are increased in obese persons (3). In fact, obesity seems to play a role in irreversible airway remodeling. In children, the mechanical load of obesity results in smaller lungs and reduced pulmonary function. For youth, weight loss improves lung function but does not affect airway hyperresponsiveness (4). For adults, when morbidly obese asthma patients lose weight, there is a decrease in asthma symptoms and severity (5). Among inner-city children, there is a high concordance between asthma and obesity (6), and obesity is a strong predictor of the persistence of childhood asthma into adolescence (7). Studies also demonstrate that youth with asthma have lower levels of physical activity in comparison to youth without asthma, and that activity level of youth with asthma is related to disease severity as well as parental health beliefs (8,9). 2. Youth who are overweight or obese have lower participation in sports and less positive attitudes toward physical activity (10). In addition, there is a strong correlation between parents’ attitudes and participation in physical activity and children’s attitudes and participation in physical activity (11). 3. Peer victimization and childhood depression are negatively associated with physical activity among overweight youth (12). In particular, depressive symptoms and loneliness mediate the relationship between peer victimization and physical activity (13). 4. For overweight youth, particularly overweight girls, body-consciousness and concern about others seeing their bodies while being active are among the most frequently reported barrier to physical activity (14).

Clinicians should bear in mind these barriers to physical activity and effective strategies to increase physical activity when counseling and making recommendations for physical activity for overweight youth. For adolescents, multicomponent interventions (those with an educational component as well as an environmental or policy component) and interventions that include both school and family or community involvement have the potential to make important differences to levels of physical activity, and should be promoted. Notably, the environmental or policy element of the effective multicomponent interventions mostly consisted of alterations to the school-based physical education program or the availability of additional equipment. While it should be noted that research in this area is lacking, especially for children (15), counseling and behavioral strategies to promote physical activity for overweight youth might include the following:

1. Inclusion of the children’s parent(s) in role modeling physical activity, and counseling of the parents regarding the importance of their attitude regarding physical activity. 2. Assisting the child and his or her family to choose activities that they enjoy and in which they can take part in settings and attire comfortable to the child. 3. Consideration of body-related barriers, including musculoskeltal problems and self-consciousness, for a particular child and assistance in identifying activities and venues that might minimize bodily discomfort or harm and self-consciousness. There is limited research to suggest the particular type of physical activity that might be most effective for achieving a healthy body weight and most acceptable for the child. However, activities such as walking, stationary biking, or cycling may be a good starting point since they may be more comfortable for the child physically and psychologically. 4. Evaluation of exercise tolerance and airway hyperresponsiveness with institution of appropriate therapy and counseling regarding the benefits of exercise for those with elevated body weight. 5. Inclusion of a psychosocial component to address coping with peer victimization and depressive symptoms.

In addition to achieving a healthy body weight, there are other reasons for promoting physical activity among all youth, including those who are overweight or obese. The regular participation in physical activity is recognized as an essential component of a healthy lifestyle (16). Specifically, physical activity in childhood is associated with the prevention of the later development of chronic disease and improvement of psychological wellbeing (16,17). Among adolescents and teens, increased physical activity is followed by an improvement in self-esteem and a reduction in anxiety (18). Given the higher rates of depression and psychosocial stress among children who are overweight and obese, improvement of psychological wellbeing may be particularly important for overweight youth. Finally, recent research links increased physical activity and improved academic performance in the school setting. In recent years, many school systems have reduced or eliminated physical education under the assumption that more classroom instructional time will improve academic performance and increase standardized test scores. However, the available evidence today contradicts this view (19). Studies suggest that allocating more curricular time to physical activity does not negatively affect academic achievement, even when time for other subjects is reduced (20). In fact, some studies suggest a relative increase in academic performance, (20,21) and a positive influence on concentration and memory (22) and classroom behavior (20). Advocating for the inclusion of physical activity, particularly “lifestyle physical activity” in the daily experiences of our youth is a way in which physicians can address another important barrier to physical activity, i.e., the lack of opportunity to be active.

References:
1. Krul M, van der Wouden JC, Schellevis FG, van Suijlekom-Smit LW, Koes BW. Musculoskeletal problems in overweight and obese children. Annals of Family Medicine 2009;7:352-6.
2. Wills, M. Orthopedic Complications of Childhood Obesity. Pediatric Physical Therapy 2004; 16:230-235.
3. Shore SA, Fredberg JJ. Obesity, smooth muscle, and airway hyperresponsiveness. Journal of Allergy and Clinical Immunology 2005;115:925-927.
4. Guerra S, Wright AL, Morgan WJ, Sherrill DL, Holberg CJ, Martinez FD. Persistence of asthma symptoms during adolescence: role of obesity and age at onset of puberty. Am J Respir Crit Care Med 2004;170:78-85.s
5. Aaron SD, Fergusson D, Dent R, Chen Y, Vandemheen KL, Dales RE. Effect of weight reduction on respiratory function and airway reactivity in obese women. Chest 2004;125:2046-52.
6. Luder E, Melnik T, DiMaio M. Association of being overweight with greater asthma symptoms in inner city black and Hispanic children. Journal of Pediatrics 1998;132 :699 –703.
7. Saha C, Riner ME, Liu G. Individual and neighborhood-level factors in predicting asthma. Archives of Pediatric and Adolescent Medicine 2005;159-759-63.
8. Lang DM, Butz AM, Duggan AK, Serwint JR. Physical activity in urban school-aged children with asthma. Pediatrics 2004;113(4):e341-6.
9. Glazebrook C, McPherson AC, MacDonald IA, Swift JA, Ramsay C, Newbould R, Smyth A. Asthma as a barrier to children’s physical activity: implications for body mass index and mental health. Pediatrics 2006;118(6):2443-9.
10. Deforche BI, Bourdeauhuij IM, Tanghe AP. Attitude toward physical activity in normal-weight, overweight and obese adolescents. Journal of Adolescent Health 2006;38(5):560-8.
11. Burnet DL, Plaut AJ, Ossowski K, Ahmad A, Quinn MT, Radovick S, Gorawara-Bhat R, Chin MH. Community and family perspectives on addressing overweight in urban, African-American youth. Journal of General Internal Medicine 2007;23(2):175-9.
12. Storch EA, Milsom VA, Debraganza N, Lewin AB, Geffken GR, Silverstein JH. Peer victimization, psychosocial adjustment, and physical activity in overweight and at-risk-for-overweight youth. Journal of Pediatric Psychology 2007;32(1):80-9.
13. Gray WN, Janicke DM, Ingerski LM, Silverstin JH. The impact of peer victimization, parent distress and child depression on barrier formation and physical activity in overweight youth. Journal of Developmental and Behavioral Pediatrics 2008;29(1):26-33.
14. Zabinski MF, Saelens BE, Stein RI, Hayden-Wade HA, Wilfley DE. Overweight children's barriers to and support for physical activity. Obesity Research 2003;11:238-46.
15. Van Sluijs, E., McMinn, A., Griffin, S. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ 2007; 335:703
16. Sallis JF, Owen N. Physical Activity and Behavioral Medicine. Thousand Oaks, CA Sage Publications, 1999, pp. 110-134.
17. Sothern MS, Loftin M, Suskind RM, Udall JN, Blecker U. The health benefits of physical activity in children and adolescents: implications for chronic disease prevention. European Journal of Pediatrics 1999;158:271-4.
18. Paluska SA, Schenk TL. Physical activity and mental health: current concepts. Sports Medicine 2002; 29:167-80.
19. Strong W, Malina R, Blimkie C, et al. Evidence Based Physical Activity for School-age Youth. The Journal of Pediatrics 2005; 146(6):732 -37.
20. Shephard RJ. Curricular physical activity and academic performance. Pediatric Exercise Science 1997;9:113-25.
21. Sibley BA, Etnier J. The relationship between physical activity and cognition in children: a meta-analysis. Pediatric Exercise Science 2003;15:243-6.
22. Tomporowsi PD. Cognitive and behavioral responses to acute exercise in youths: a review. Pediatric Exercise Science 2003;15:348-59.

Competing interests:   None declared