What played a role? In some cases, junk food and lack of exercise as the COVID-19 pandemic wears on.

Childhood obesity was already a concern in the United States. In 2018, the Centers for Disease Control (CDC) reported that 19.3% of the 2-19 age group were considered obese. That’s about 14.4 million children and adolescents with excessive weight that could lead to other medical problems like diabetes, heart disease, high blood pressure, and joint pain.

But doctors and dietitians fear obesity has gotten worse due to habits that changed during the COVID-19 lockdown and afterward, continuing today. A study cited by the National Institutes of Health (NIH) even uses the term “covibesity” to describe the phenomenon of rapid weight gain that resulted when people changed their eating and exercise routines during the pandemic.

If the early months of the pandemic set the stage for higher obesity rates, the toll on health is current and ongoing. Consider diabetes, for instance: Cook Children’s has seen 91 new cases of Type 2 diabetes diagnosed already this year.

Escalation in childhood obesity becomes an even more relevant and urgent concern given reports of higher risk of severe COVID-19 symptoms for those with obesity. The CDC points out that excessive weight can cause impaired immune function and decreased lung capacity, which may worsen the illness. The CDC cites one study that linked obesity in pediatric patients to higher rates of hospitalization, admission to intensive care, invasive mechanical ventilation and death from COVID-19. At Cook Children’s Medical Center, this rings true. Many of the patients admitted to the COVID-19 ICU are obese are require life-saving measures.

Alice Phillips, M.D., a pediatrician at Cook Children’s, described the accelerated rise in childhood obesity as an outcome of the dramatic lifestyle changes brought on by the COVID-19 lockdown beginning in 2020. Multiple times a day, Dr. Phillips encounters and counsels patients whose body mass index (BMI) has surged since their last checkup.

When the schools were closed, lots of homebound kids began to snack out of boredom. They watched more TV and did online learning in front of a computer – no walking required. Recess, PE classes and team sports were canceled.

“Parents have been trying to nurture their children during a very difficult time. Food remains a cultural norm of nurture for families, and we are seeing the unexpected consequences,” she said.

Dr. Phillips emphasized it’s appropriate to expect a child to pick up some weight during a growth spurt. Pediatricians track the curve using the BMI calculations, which take a patient’s age, height and gender into consideration. Obesity by definition occurs when BMI reaches the 95^th percentile or higher.

Dr. Phillips and her colleagues at Cook Children’s point out two trends: an increase in patients whose recent weight gain put their BMIs in the 95^th percentile for the first time, and previously obese patients who became even heavier.

“When you see an acute change in the BMI from the 75^th percentile to the 99^th percentile, that’s when it catches your eye and you say, ‘What was different this year that caused that change?’” she said. “All too often during the pandemic the families will say, ‘We haven’t been getting any exercise, and our eating habits are maybe a little worse.’”

She worries about the long-term consequences on their health. When she raises the subject of obesity with her patients, she speaks with sensitivity and tries to help the families feel empowered to set goals they can achieve.

“You have to be very careful that you handle that conversation in an empathetic way,” Dr. Phillips said. “I don’t want how I handle it to be part of the problem for this child.”

Here’s what’s important to know:

• Obesity commonly begins between the ages of 5 and 6, or during adolescence. The causes include overeating, genetic predisposition, stressful life events (such as divorce or a move), depression and low self-esteem.
• Obesity is a chronic disease that adversely affects both physical and mental health. It’s easy to diagnose but hard to treat – potentially setting up a lifetime of complications.
• Studies referenced by the NIH show that a child who is obese between the ages of 10 and 13 has an 80% chance of becoming an adult with obesity.

Susan Hsieh, M.D., a pediatric endocrinologist at Cook Children’s, is seeing more patients diagnosed with obesity-related spinoffs that used to be considered adult diseases: hypertension, high cholesterol and Type 2 diabetes. She also points to the COVID-19 lockdown as a tipping point for kids who gained 30-40 pounds since last year. “The body isn’t designed to take on that much weight in such a short period of time,” Dr. Hsieh said.

She explained that obesity causes insulin resistance, impeding the body’s ability to control the blood sugar. It used to be rare, she said, to see an 8- or 9-year-old diagnosed with Type 2 diabetes. Not anymore.

Data at Cook Children’s show that Type 2 diabetes has been on the rise, with 55 new diagnosed cases in 2018, 107 new cases in 2019, and 126 new cases in 2020. The count so far for 2021 is 91 new cases through early September.

Early onset diabetes, if hyperglycemia is mild, can be treated with oral medications. For those patients who require insulin injections, Dr. Hsieh encourages weight loss as a motivation to wean themselves off the injections. She urges families to address their child’s escalating obesity sooner rather than later.

“In general, it’s easy to gain weight and very hard to lose weight,” Dr. Hsieh said. “The more we educate, the better, because prevention goes a long way.”

The Endocrine Clinic at Cook Children’s offers a program called Risk Evaluation to Achieve Cardiovascular Health (REACH), targeting kids affected by cardiovascular diseases caused by obesity or other factors.

Since the start of the pandemic, registered dietitian Lauren Williams found that her REACH patients and their parents often report more junk food consumption and less physical activity. She counsels them to treat food as a source of nourishment.

Williams’ main message? “We need a healthy relationship with food. We don’t snack throughout the day when we’re not hungry. We move our bodies because our bodies were made to move. Exercise helps our mind; it helps our sleep. Get out and run and play even if it’s just with your siblings in your backyard, having fun.”

Cook Children’s also offers a one-time, free-of-charge class called Healthy Weight Healthy You, which promotes the MyPlate nutrition guide and other tools to eat right. The class is offered in both English and Spanish for children ages 5-18 and their parents. A physician’s referral is needed.

Another resource to fight obesity is the Cook Children’s Outpatient Nutrition Services, available only through referral from physicians in the network. Jean Mankin, a registered dietitian in the outpatient clinic, said the incidence of childhood obesity “exploded” during the COVID-19 pandemic.

“Almost every patient that I’ve seen will admit to boredom eating. And the parents will agree,” Mankin said. “The parents will say ‘I was trying to work… I was there for emergencies but the kids were left to their own devices and they were grazing all day on chips and cookies and crackers.’”

Now she works with families to undo the damage. Bad habits – constant snacking, inactivity -- can be corrected. But it starts with recognizing the problem.

The patients Mankin meets with often arrive with complications tied to the excess weight on their bodies. She lists orthopedic problems, respiratory issues, elevated lipids, elevated liver enzymes and sleep apnea among the ailments.

A one-hour consultation with Mankin encompasses a review of the family’s journal of food intake over several days; guidance on problems she identifies; a packet of information to take home; and lots of encouragement. No one is forced to get on the scale. Mankin says she frames the conversation around the proper nutrition necessary for growth and development -- avoiding the word “obesity” out of sensitivity.

“Some of these little ones and adolescents can easily get their feelings hurt. And when that happens, they shut down. I also encourage parents to be mindful of the language used at home,” she said. “I work really hard to focus on overall health and to keep a positive vibe in my office. Initially, many kids that come to me are somewhat fearful or trepidatious, but most leave with a smile on their face.”

She emphasized that parents must be committed to making changes in the family’s approach to meals and exercise. Improvements don’t usually happen right away. A follow-up visit with the dietitian might be needed after the initial consultation.

If you have a concern about your child’s weight, contact your pediatrician.

When I advise my 3 year old patients to wear helmets on their tricycles, then I end up with 10 year old patients who wear their helmets. It’s near impossible to convince my 10 year olds to START wearing a helmet.

Why do you think so many ED doctors end up advocating for car seat safety? They see the results of horrible car accidents that could have been prevented.

That’s how I feel about obesity prevention. Far and away, poor diet and a sedentary lifestyle wreak havoc on the mental and physical health of my patients – from young to old – those with poor lifestyle choices have a decreased quality of life. They come to see me with more illnesses, more headaches and most certainly more abdominal pain.

When I start talking to my families about diet, I try to give anticipatory guidance about offering fruits and vegetables and limiting processed foods. Toddlers and young children do two things really well – they don’t eat when they are not hungry and they stop eating when they are full.

We as parents, and grandparents, mess up their satiety cues by trying to get them to eat when they are not hungry and trying to get them to keep eating when they are full. Allowing children to control the amount of food they eat leads to a long term healthy relationship with food. Parents have control over what is offered but should not try to control how much is eaten.

Along those same lines, children are naturally conditioned to be outside and to be active. We as parents mess that up by keeping them inside in front of an iPad or video game. We have control over their media time.

I think focusing on healthy behaviors rather than BMI is a positive way to talk to parents. Most parents are doing 1 or more things right in the 5-2-1-0 recommendations. Kids are motivated to follow these recommendations, but they need their parents to create an environment at home that allows them to do so. This goes along with the thinking of the Blue Zones.

I do think there is value for using BMI as a tool. I usually show growth charts to families as an objective measurement of what is happening and then we turn to talking about healthy behaviors. But I do see a flattening of BMI with improved diet/activity choices. It is also not uncommon for me to see an increase in BMI and ask what has changed, and families are usually able to say – oh yeah, he quit playing soccer, or he doesn’t have PE this year….etc.

When you look at guidelines for treatment of obesity, the first thing you must have is motivation for change. If that is not there, you really can’t go forward. What if we don’t have to motivate people to change because they have been feeding their children correctly from the beginning?

But Aaron’s latest role is that of a young man whose weight has become such an issue, weighing in at 550 pounds, he was recently asked to leave a plane because he took up two seats.

“As I saw the seats, I’m literally hoping that no one had to sit next to me because I knew it wasn’t going to work if they did,” Aaron told NBC News.

The Centers for Disease Control and Prevention (CDC) report that Aaron’s struggles with his weight aren’t as unusual as you might expect. The CDC says that more than one third of kids and adolescents in the U.S. are overweight or obese. In addition to facing isolation and embarrassment, potentially continuing into adulthood, these children are at increased risk for numerous health ailments. Endowed Chair of Cardiovascular Health and Risk Prevention at Cook Children’s Don Wilson, M.D., warns, “most children with risk factors for cardiovascular disease will have them as an adult; being overweight or obese often results in weight related to health risks such as diabetes, high blood pressure, injury to bones and joints, disturbed sleep, fatty liver disease, abnormal blood fats and isolation and depression.”

To help children avoid problems caused by obesity in their adult life, parents have a responsibility to address concerns early. According to Wilson, “it is important to determine what, if any, cardiovascular risk factors your child may have, and begin working with your health care team in finding safe and effective long term solutions. Small changes at a young age can make a big difference in making sure your child has a healthy future.”

Becoming overweight or obese can happen to anyone; some factors can be controlled, while others are inevitable. One can’t control being predisposed to developing high blood pressure, having abnormal blood fats or family members with diabetes, for example, but there are always opportunities to improve one’s health, make lifestyle changes and develop a plan of action to reach a healthy weight.

Since children’s bodies are still growing, it can be difficult to identify when weight gain reaches a level of concern. Dr. Wilson suggests the following guidelines: “Is often difficult to simply look at a child and tell they are developing an unhealthy weight. That's why it's important that you calculate your child’s body mass index (BMI); there are several calculators available on-line. A BMI above the 85th percentile for age/sex is considered overweight, above the 95^th percentile is considered obese and over the 99^th percentile is regarded as morbidly obese.” The first step is to identify patterns that may indicate a problem; regardless of BMI, be sure your child is not gaining excessive amounts of weight each week or month and alert your doctor to any sudden changes. Bring up concerns during your child's health checkup and ask for guidance.

A common misconception is that poor diet and exercise is the only culprit for childhood obesity. These factors indeed have an impact in many cases, but an overweight child should never be blamed or labeled as “lazy,” as there are many other elements that can contribute to unhealthy weight gain. Be sure to rule out health-related causes while you are developing an appropriate weight-loss plan. Just as with adults, encouraging and motivating kids to lose weight can be a touchy issue. Parents often have the biggest influence to help their children become better informed about healthier food choices and the benefits of daily exercise. Wilson says, “As a concerned parent, you can help set realistic goals for weight, food and activities, talk about your child's food in terms of preference, preparation and portion size, increase physical activities for the entire family, discourage smoking and avoid smoking yourself and make healthy living a family affair.  Perhaps the most important thing you can do is to be a good role model for your child.

Aaron is using the uncomfortable experience of being kicked off his flight as motivation to speed up his weight loss plans. Remember, if you child’s BMI rises above the 85^th percentile or their weight gain is excessive (i.e. crossing percentiles on the CDC’s growth chart) be sure to discuss any underlying causes with your doctor and work with your family to develop healthy lifestyle patterns early on. Your child’s future depends on it.

For more information and to determine your child’s BMI, try using the American Academy of Pediatrics’ and Centers for Disease Control and Protection’s BMI calculators.