key: cord-0986327-qxshdkga
authors: Browne, Nancy T.; Snethen, Julia A.; Greenberg, Cindy Smith; Frenn, Marilyn; Kilanowski, Jill F.; Gance-Cleveland, Bonnie; Burke, Pamela J.; Lewandowski, Linda
title: When pandemics collide: The impact of COVID-19 on childhood obesity.
date: 2020-11-11
journal: J Pediatr Nurs
DOI: 10.1016/j.pedn.2020.11.004
sha: e603c8d24b19e7dd29d42fdff8a3813e9983d762
doc_id: 986327
cord_uid: qxshdkga

• Children with obesity face increased biopsychosocial risks during COVID-19. • Stress exacerbates inflammation and immune response in obesity and COVID-19. • The COVID-19 pandemic has significantly interrupted children's daily routines. • The health effects of the obesogenic environment are exacerbated by COVID-19. • Access to timely, comprehensive healthcare is critical during COVID-19.

myriad of stressors including uncertainty about the future. The Bioecological Model creates a context for effective assessment and intervention to assist children and families in their understanding and management of obesity in the current environment.

Obesity, a chronic disease resulting from breakdown of the body"s energy regulatory system (ERS), is impacted by genetic, environmental, and psychosocial factors. The Centers for Disease Control and Prevention (CDC, n.d.) standardized growth charts define excess adiposity in youth as overweight (85 th -94 th percentiles), obesity (95-98 th percentiles), and severe obesity (>99 th percentile). Obesity affects over 337 million children globally with 213 million youth classified as overweight and 124 million with obesity and severe obesity (NCD RisC, 2017) . Pediatric obesity rates vary by age, ethnicity, location, and social determinate factors (Ogden et al., 2018; Yusuf et al., 2020) .

The U.S. prevalence of COVID-19 in children and adolescents is 1053 cases per 100,000 (792,188 cases) which is 11% of all COVID-19 U.S. cases (American Academy of Pediatrics & Children"s Hospital Association, October 22, 2020). The number of cases not confirmed by testing is unknown. A severe form of COVID-19, classified as multisystemic inflammatory syndrome in children (MIS-C), was first reported in the U. S. in March, 2020. By July 2020, 53 U.S. hospitals had reported 186 MIS-C cases in all pediatric age groups (Feldstein et al., 2020) .

As of October 2020, the CDC reports 1097 confirmed MIS-C cases with 20 deaths (CDC, 2020d) .

Understanding of the human energy regulation system (ERS) has evolved from a simplistic "calories in = calories out" to recognition of a complex system modulated by genetics and J o u r n a l P r e -p r o o f environment (Roh et al., 2016; Timper & Brüning, 2017) . Ingested energy (calories) triggers multiple pathways designed to assess, process, store, and expend energy as the body perceives its acute and long-term needs. When working well, energy needs are accurately assessed, managed in a timely manner, and weight is stable (Berthoud et al., 2017) .

Individuals with an injured ERS are less capable of efficient energy management. Adipose tissue is an active endocrine organ that plays a critical role in maintaining energy balance (Reilly & Saltiel, 2017) . When excess nutrients enter the adipocyte (specialized cell for storage of fat), a cellular stress response initiates which results in a sustained increase in cortisol production and chronic inflammation. Chronic inflammation is marked by the over-expression of inflammatory mediators and decreased adiponectin (an anti-inflammatory adipokine) production (Ellulu et al., 2017) . Unchecked, chronic inflammation leads to ERS dysfunction manifesting as cardiovascular disease, metabolic abnormalities, depression, cancer, and other metabolic conditions.

Obesity is a risk factor for increased severity of COVID-19, as excess weight decreases an individual"s immune response. A decreased immune response results from chronic inflammation exacerbated by stress, causing associated metabolic complications (Yuki, 2020) . Inflammation from the disease of obesity combined with COVID-19 hyperinflammation and weakened immune response (Frydrych et al, 2018; Korakas et al., 2020) increases the risk of individuals developing overwhelming sepsis and organ failure (Shekerdemian et al., 2020) . Figure 2 depicts the relationship between the two pandemics.

The COVID-19 pandemic introduced potentially traumatic events into the lives of children and their families (Fegert et al, 2020; Human Rights Watch, 2020) . Stress triggers J o u r n a l P r e -p r o o f activation of our body"s stress response systems. "Toxic stress" ensues with prolonged activation of the stress response system with children experiencing stress that is strong, frequent, and protracted (Condon et al., 2018; Reichel, 2019; Shonkoff et al., 2012) .

Sustained activation of stress response systems can lead to chronic health issues, including obesity.

A supportive relationship with adults can help "buffer" a stressful experience and support the child"s adaptation. However, high levels of parental stress due to job loss, isolation, and unexpectedly working from home (Fegert et al., 2020) increases the difficulty for parents in providing a supportive buffering presence for their children.

Parental stress is associated with childhood obesity in some studies, most recently in non-Hispanic Black families (Baskind et al., 2019) . Disturbances in the social environment during infancy and early childhood appear to play a critical role in weight gain and obesity (Hemmingsson, 2018) .

COVID-19 stressors disproportionally affect vulnerable populations already experiencing toxic stress from poverty, racism and structural inequality (Bailey et al., 2017; Bowleg, 2020) . Lack of, or decreased access, to treatments for chronic physical and/or mental illness conditions can exacerbate negative outcomes (Fegert et al., 2020) .

Rates of domestic violence and child abuse have increased during the pandemic (Fegert et al., 2020; The Guardian, 2020) and children with pre-existing conditions may be particularly at risk. Studies demonstrate a relationship between exposure to toxic stress from adverse childhood events and the risk for childhood obesity (Bethell et al., 2014; Garasky et al., 2009; Lohman et al., 2009 ).

Responding to an unpredictable threat like the COVID-19 pandemic evokes stress responses (Brooks et al., 2020; Vinkers et al, 2020 ; Table 1 ). Post-traumatic stress disorder (PTSD) was reported in about one-third of children who were isolated or quarantined after the H1N1 and SARS epidemics in Central and North America (Sprang & Silman, 2013) .

The impact of the COVID-19 pandemic is having a similar impact with 27% of parents self-reporting worsening mental health and 14% reporting worsening behavioral health for their children (Patrick et al., 2020) .

The relationship between stress, mental health, and childhood obesity is complex (Small & Aplasca, 2016) . Children experiencing obesity have a higher risk for depression (Smith et al., 2020) because of stigma and isolation. Children with overweight or obesity report more stress (Thaker et al., 2020) and eat in response to stress to a greater degree than normal weight peers (Miller et al., 2019) . Promoting resilience is an important approach to successful stress management. However, this strategy is more difficult when experiencing poverty, isolation and mental health issues (Vinkers et al., 2020) .

As COVID-19 spread across the globe, many countries employed school closure as a part of their social distancing policies to slow the transmission and ease the burden on the healthcare systems. It is estimated that 138 countries have closed schools worldwide, affecting 80% of children across the world (Van Lancker & Parolin, 2020). It is anticipated that COVID-19 related school closures will have detrimental social and health consequences for children, especially for those living in poverty and underserved communities. Out of school time has been associated with weight gain especially for Hispanics, African Americans, and children with overweight J o u r n a l P r e -p r o o f Journal Pre-proof (Rundle et al., 2020) . School closure may affect children and their ability to maintain a healthy weight in the many ways (Table 2) .

For many children, school provides access to healthy food. Thirty million children in the U.S. receive lunch from the National School Lunch Program and over 14.7 million children participate in the School Breakfast Program (Hess, 2020) . Access to food for children in these programs during the COVID-19 pandemic varies depending on location and school district, as well as family and community support. A recent national study found that food insecurity increased from 32.6 to 36% from March-July 2020 (Patrick et al., 2020) .

Regression of academic progress is linked to time out of school and home schooling (Van Lancker & Parolin, 2020). Limited parental availability and discomfort with home schooling may influence this regression. Isolation from peers and disruption of normal routines may also impact children"s mental health and well-being.

Finally, the school closures resulting from stay-at-home orders and social distancing may impact access to health care provided in the schools. There are currently 6.3 million students who access health care through the 2,584 school-based health centers in 48 of the 50 states, the District of Columbia, and Puerto Rico (Love et al., 2019) . These health centers, (51% are Federally Qualified Health Centers) serve 10,629 schools and provide access to primary care for many poor and underserved populations. In addition to primary care and immunizations, health centers provide behavioral health, oral health care, vision screening, and health/nutrition education. Many centers are housed in the schools and have been impacted by school closure thus, preventing these vulnerable children from accessing healthcare.

During COVID-19, families have experienced the stress of increased job losses, furloughs, and layoffs, limiting financial resources. At the same time, many communities have seen significant increases in food costs (Fore, 2020) . Data suggest that families are stocking shelf-stable foods that are ultra-processed, calorie dense comfort foods (Almandoz et al., 2020; Rundle et al., 2020) . Higher caloric foods can negatively impact all children, placing them at risk for weight gain. In times of increased stress, meals can easily morph away from healthy nutrition.

Ensuring the health of children, especially those with the chronic condition of childhood obesity, requires ongoing monitoring by healthcare specialists (Almandoz et al., 2020; Kumar & Kelly, 2017; Spear et al., 2007) . However, as parental income was lost due to the COVID-19 pandemic (Board of Governors of the Federal Reserve System, 2020), health insurance for families also disappeared. Loss of health insurance has impacted especially vulnerable populations (Pifer, 2020) , where elevated childhood obesity rates are the highest (Yusuf et al., 2020) as well as access to well child care and immunizations. Many primary care providers transitioned to telemedicine during the COVID-19 pandemic, but immunizations require an inperson visit. Immunizations administered through the Vaccines for Children Program that is responsible for 50% of immunizations given to U.S. children were substantially reduced (decreased by 100,000 orders) after the COVID-19 emergency declaration (Santoli, 2020) .

The exacerbation of poverty by COVID-19 highlights ongoing health disparities, including childhood obesity, amongst vulnerable populations (Li et al., 2018) . Non-essential employees lost jobs and health insurance at high rates due to the pandemic (Kochhar, 2020) .

Essential employees, who did not have the option to work from home, were placed at greater risk J o u r n a l P r e -p r o o f of COVID-19 exposure (Dubey et al., 2020; Fegert et al., 2020) . A major risk factor for poor outcomes from COVID-19 disease includes having pre-existing chronic health conditions, including obesity (CDC, 2020c; Dubey et al., 2020) .

COVID-19 stay-at-home orders have placed children with obesity at risk for disease progression (Falbe et al., 2013) . Excess screen time and sedentary activities may increase during quarantine as normal rules and supervision adjust. School and daycare closures due to COVID-19 require families to organize children"s educational and social needs along with parental work responsibilities (Fegert et al., 2020) . Parents retain less control over regular routines and the ability to maintain healthy behaviors. Overwhelmed parents struggle to ensure healthy behaviors within the family, especially for children at risk for excess weight gain (Kakinami et al., 2015) .

An essential component to a healthy lifestyle is physical activity (Hagan et al., 2017) .

Physical activity fosters psychological well-being, increases self-esteem, capacity for learning, and helps children handle stress (U.S. Department of Health and Human Services, 2018).

COVID-19 increases risk factors for obesity through increased stress and decreased physical activity related to environmental, academic and social changes. Online education lacks physical education class, recess time, and normal levels of active movement for the school-aged child and adolescent. Hybrid education often schedules physical education as virtual sessions. With children at home and isolated, access to opportunities and environments that support physical activity are decreased (CDC, 2020a).

Depending on location of home residence, the availability of green space and safe walking areas may be limited during COVID-19 due to public health regulations. Children with J o u r n a l P r e -p r o o f Journal Pre-proof no place to go or no one to play with are less likely to engage in running, jumping, and performing large motor skills (Fegert et al., 2020) . A recent systematic review suggests that body mass index may be related to living in a lower-income community (Johnson et al., 2019) . Data from two international studies found that better macro-economic indicators were related to lower rates of childhood obesity (Olaya et al., 2015) , and distance to green space was the most significant factor contributing to obesity in urban children (Manandhar et al., 2019 ). Vrijheid"s study (2020) also found that children who live in densely populated areas or neighborhoods with fewer recreational facilities have increased childhood obesity rates. A recent study looking at the communities of Columbus, Ohio and Atlanta, Georgia demonstrated that larger disparities in access to green space in inner suburbs was associated with income in Columbus and race in Atlanta (Park & Gulmann, 2020) .

With children spending more time inside due to COVID-19 restrictions, indoor pollution especially from parental smoking, fine particulate matter, and nitrogen dioxide increase the likelihood of the child having overweight or obesity (Vrijheid et al., 2020 ). Children exposed to primary care giver"s smoking showed an increase in odds ratios for obesity at age three and five years, and it is hypothesized that tobacco smoke"s chemicals may lead to impaired metabolic and immune functions of the child increasing susceptibility to obesity (Sunday & Kabir, 2019) .

Due to COVID-19, childcare and social activity environments have changed significantly. Families returning to the office or those temporarily working at home need to make the decision regarding if, and when, their children return to childcare and social activities. The State University Extension, 2020; Today, 2020). With field trips cancelled and fewer children allowed to participate simultaneously in recreational activities, it is speculated that levels of physical activity are decreased. Children and adolescents, who grow and develop in the context of peer interactions, are missing these social opportunities (Erikson, 1950; Hagan et al., 2017; Piaget, 1974) . The risk for childhood obesity and the inability to follow prevention and treatment guidelines for healthy weight present a challenge for parents and children.

In a dynamic environment, the ongoing fear of COVID-19, as well as predicted resurgences are a source of chronic stress. Lack of comfort with returning full-time or in hybrid form to the office and daycare/school includes fear that public health regulations will not be followed. Not knowing if others will wear masks properly and how one should proceed with interactions outside of the family are worries for parents, children and adolescents. Earlier this year, anxieties prevailed as academic environments evaluated plans for the current school year including face-to-face or hybrid learning models with carefully constructed safe environments (AAP, 2020; CDC, 2020a; NAPNAP, 2020) . In school districts deciding to offer online education or hybrid models, parents may be forced to choose between employment or facilitating their child"s education or daycare. security and exacerbates pre-existing anxiety or depression. Timely access to medical and mental health services is crucial.

The deleterious effects from pediatric obesity & COVID-19 disease demand maximum efforts to support families and children. Internet resources can be used to support children with obesity to achieve a healthier lifestyle. Tailored interventions that include parents and the family unit show promise (Kaakinen et al., 2018; Knowlden & Conrad, 2018) . However, it is important that time on a computer not replace physical activity (Bozkurt et al., 2018) or interrupt sleep which is associated with obesity and trunk fat mass . Policy interventions are needed to provide appropriate oversight to limit internet advertising used to market food products high in salt, fat and sugar (Kent et al., 2013) . Please see Table 3 for helpful online resources.

Physical fitness is related to attention capacity in youth with obesity (García-Hermoso et al., 2020) . Thus, sustaining safe opportunities for activity during the COVID-19 pandemic is essential. Availability of parks, trails, and water activities, along with hydration and restroom access, is important for family outings. Establishing a social distance plan is key for all recreational activities. Working with neighbors for planned outdoor opportunities for youth activity promotes supervised small group socialization and interactions. Care needs to be taken to prevent the spread of COVID-19 at all levels of organized sporting events and competition including those with close friends and family.

Strategies for better nutrition may be possible while families spend more time at home.

Meal preparation can become a family activity, involving children in searching for recipes and preparing vegetables, fruit, and higher fiber meals. Families can engage children in identifying J o u r n a l P r e -p r o o f the healthiest snack from several choices. In contrast, less meal preparation time may lead to increased fast food or non-nutritious snack food (Lappan, 2020) . To address this, parents can help children choose the healthiest items on menus and work to reduce fast food consumption to no more than once a week.

The internalization of weight stigma may lead to disordered eating and unhealthy weight.

Strategies to address obesity and mental health include tailoring interventions to children"s developmental level and involving parents in multi-disciplinary team approaches (Cardel et al., 2020) . One important strategy by healthcare and clinical research professionals is using person first language which reduces the stigmatization of children with obesity and their families (Crocker et al., 2019) . Prior negative healthcare experiences may impact an open and trusting relationship with new providers. A sensitive office environment with appropriate chairs, blood pressure cuffs, gowns, and privacy (especially with obtaining weight measurements) reduces anxiety and stress for the child and family (Fruh et al., 2016) . Other evidence-based interventions to reduce stress include:

1. Mindfulness interventions incorporating parental engagement (Jastreboff et al., 2018) .

2. Structured physical activity, advance meal preparation, and watching television with children (Parks et al., 2016) .

3. Improving parenting skills through attachment and attunement to infant feeding cues (Ordway et al., 2018) .

Parenting styles may be a factor in the development of childhood obesity. Authoritative parenting is associated with smaller gains in BMI and lower likelihood of obesity while authoritarian or permissive parenting strategies are associated with higher child body mass percentile (Sokol et al., 2017) . Parents practicing authoritative parenting encourage choices (ex.

J o u r n a l P r e -p r o o f which vegetables for dinner) rather than telling the child to eat vegetables or allowing the choice of no vegetables. Involving children in selecting after-school and summer physical activity programs are authoritative effective parenting strategies. Alternate strategies include regular family meals together at the table (Bohnert et al., 2002) and collaborating with school nurses to address their child"s weight (Frenn et al., 2020) .

Policy changes that raise the nutrient standards of foods marketed to children show promise (Dunford et al., 2020) . Several countries have adopted regulations related to food advertising and foods offered free to children or provided in schools to address the obesity epidemic (Corvalán et al., 2019) . Obesity prevention policies for children that include parental partnership programs are needed. Parents may be rallied as supporters of school-based initiatives to combat childhood obesity (Wolfson et al., 2015) .

As policy options are considered for the colliding pandemics of COVID-19 and childhood obesity, ethical considerations of what is the best for the most people are essential.

COVID-19 restrictions, for the good of all, have reduced many healthy food and physical activity options for children. Clinicians, families and communities must create and prioritize alternate, safe options. The many effects of the COVID-19 pandemic on childhood obesity must be considered in creating effective health policy going forward.

The evidence is clear -childhood obesity and COVID-19 are international pandemics.

The clashing of the two diseases and the subsequent changes in the bioecological environment have placed children and adolescents at increased risk to develop obesity and exacerbate obesity disease severity. The once familiar environments of family, home, school, and community and

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