When Pandemics Collide: The Impact of COVID-19 on Childhood Obesity
2020; Elsevier BV; Volume: 56; Linguagem: Inglês
10.1016/j.pedn.2020.11.004
ISSN1532-8449
AutoresNancy T. Browne, Julia Snethen, Cindy Smith Greenberg, Marilyn Frenn, Jill F. Kilanowski, Bonnie Gance‐Cleveland, Pamela J. Burke, Linda Lewandowski,
Tópico(s)Birth, Development, and Health
Resumo•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. Obesity and COVID-19 are pandemics that negatively affect the health and well-being of children. The disease of childhood obesity has risen to pandemic levels in United States (U.S.) youth with the fastest rise seen in severe obesity (Skinner et al., 2018Skinner A.C. Ravanbakht S.N. Skelton J.A. Perrin E.M. Armstrong S.C. Prevalence of obesity and severe obesity in US children, 1999-2016.Pediatrics. 2018; 142e20181916https://doi.org/10.1542/peds.2018-1916Crossref PubMed Scopus (17) Google Scholar). COVID-19 is a highly contagious disease in humans causing significant rates of illness, hospitalization, and death. The World Health Organization (World Health Organization, 2020World Health Organization Novel Coronavirus(2019-nCoV) situation report – 51.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10Date: 2020, JulyGoogle Scholar) declared COVID-19 a pandemic on March 11, 2020. Obesity is identified as an independent risk factor for COVID-19 disease severity (Lighter et al., 2020Lighter J. Phillips M. Hochman S. Sterling S. Johnson D. Francois F. Stachel A. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission.Clinical Infectious Diseases. 2020; (Advance online publication)https://doi.org/10.1093/cid/ciaa415Crossref Scopus (857) Google Scholar). Children with obesity may experience a more severe COVID-19 trajectory, including the need for respiratory support (Zachariah et al., 2020Zachariah P. Johnson C.L. Halabi K.C. Ahn D. Sen A.I. Fischer A. Columbia Pediatric COVID-19 Management Group Epidemiology, clinical features, and disease severity in patients with Coronavirus Disease 2019 (COVID-19) in a children's hospital in New York City, New York.JAMA Pediatrics. 2020; (Advance online publication): e202430https://doi.org/10.1001/jamapediatrics.2020.2430Crossref PubMed Scopus (349) Google Scholar). Responses to the COVID-19 pandemic evoked major lifestyle changes including stay-at-home orders and physical distancing. Schools closed and children lost the safety net of access to nutritious food, a safe place to be, and mandatory physical activity as well as their social networks and familiar routines. Potential consequences of being restricted to home, as addressed in this clinical report, threaten the health and well-being of children with obesity. This report will address the impact of COVID-19 on children with obesity, describe how stress exacerbates both conditions, and identify interventions to reduce the negative impact. Childhood obesity is a complex disease, with multiple influences and varied outcomes. Urie Bronfenbrenner's Social Ecological Model (SEM) has been a useful framework for describing the multi-factorial interactions associated with childhood obesity (Davison and Birch, 2001Davison K.K. Birch L.L. Childhood overweight: A contextual model and recommendations for future research.Obesity Reviews. 2001; 2: 159-171https://doi.org/10.1046/j.1467789x.2001.00036.xCrossref PubMed Google Scholar; Feeg et al., 2014Feeg V.D. Candelaria L.M. Krenitsky-Korn S. Vessey J.A. The relationship of obesity and weight gain to childhood teasing.Journal of Pediatric Nursing. 2014; 29: 511-520https://doi.org/10.1016/j.pedn.2014.08.011Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar; Golden and Earp, 2012Golden S.D. Earp J.A. Social ecological approaches to individuals and their contexts: Twenty years of health education & behavior health promotion interventions.Health Education & Behavior. 2012; 39: 364-372https://doi.org/10.1177/1090198111418634Crossref PubMed Scopus (761) Google Scholar; Lemus et al., 2016Lemus B. Mercado F. Bryars T. Mouttapa M. Conkey T. Robertson T. Reflections regarding the social ecological model to address obesity in Southern California youth.California Journal of Health Promotion. 2016; 14: 64-69Crossref Google Scholar; Ohri-Vachaspati et al., 2015Ohri-Vachaspati P. DeLia D. DeWeese R.S. Crespo N.C. Todd M. Yedidia M.J. The relative contribution of layers of the social ecological model to childhood obesity.Public Health Nutrition. 2015; 18: 2055-2066https://doi.org/10.1017/S1368980014002365Crossref PubMed Scopus (92) Google Scholar). Bronfenbrenner's early work on the SEM emphasized the environment context. However, over time, the model has evolved to address developmental experiences of continuity and change through four dynamic, interrelated components: proximal processes (interaction between organisms and their environment), person characteristics, context and time (Bronfenbrenner and Ceci, 1994Bronfenbrenner U. Ceci S.J. Nature-nurture reconceptualized in developmental perspective: A bioecological model.Psychological Review. 1994; 101: 568-586https://doi.org/10.1037/0033-295x.101.4.568Crossref PubMed Google Scholar; Bronfenbrenner and Morris, 2006Bronfenbrenner U. Morris P.A. The bioecological model of human development.in: Lerner R.M. Damon W. Handbook of child psychology: Theoretical models of human development. John Wiley & Sons Inc., 2006: 793-828Google Scholar; Rosa and Tudge, 2013Rosa E.M. Tudge J. Urie Bronfenbrenner's theory of human development: Its evolution from ecology to bioecology.Journal of Family Theory & Review. 2013; 5: 243-258Crossref Google Scholar). Bronfenbrenner's model is a constructive framework for exploring the impact of COVID-19 on childhood obesity. Fig. 1 depicts five nested or multi-layered systems and their subsystems. The Chronosystem connotes lifespan development (ontogeny) and the time during which an individual lives (history). The Macrosystem entails healthcare policy and societal impacts, along with influences of culture, traditions, values, and beliefs. The Exosystem reflects the multiple institutions that affect the context of a person's existence, including government, the legal system, mass media, the school system, industry or the workforce. The Mesosystem captures the bidirectional relationships and linkages between Microsystems which are vital parts of a person's immediate or most proximal environment, such as family, neighborhood, school, and peers. Examination of the impact of COVID-19 on childhood obesity from an ecological perspective and framed by Bronfenbrenner's Bioecological model reveals a plethora of biopsychosocial antecedents, risks and potential consequences. The current COVID-19 pandemic along with overlapping economic and social crises have triggered a cascade of demands on children and their parents. With schools and daycare centers closed or using hybrid models, workers furloughed or laid off, and peer group activities cancelled, families are coping with a 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 (Centers for Disease Control and Prevention, 2020Centers for Disease Control and Prevention Defining childhood obesity.https://www.cdc.gov/obesity/childhood/defining.htmlDate: 2020Google Scholar) standardized growth charts define excess adiposity in youth as overweight (85th–94th percentiles), obesity (95-98th percentiles), and severe obesity (≥99th percentile). Obesity affects over 337 million children globally with 213 million youth classified as overweight and 124 million with obesity and severe obesity (NCD Risk Factor Collaboration (NCD-RisC), 2017NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.Lancet. 2017; 390: 2627-2642https://doi.org/10.1016/S0140-6736(17)32129-3Abstract Full Text Full Text PDF PubMed Scopus (4848) Google Scholar). Pediatric obesity rates vary by age, ethnicity, location, and social determinate factors (Ogden et al., 2018Ogden C.L. Fryar C.D. Hales C.M. Carroll M.D. Aoki Y. Freedman D.S. Differences in obesity prevalence by demographics and urbanization in US children and adolescents, 2013-2016.JAMA. 2018; 319: 2410-2418https://doi.org/10.1001/jama.2018.5158Crossref PubMed Scopus (314) Google Scholar; Yusuf et al., 2020Yusuf Z.I. Dongarwar D. Yusuf R.A. Bell M. Harris T. Salihu H.M. Social determinants of overweight and obesity among children in the United States.International Journal of MCH and AIDS. 2020; 9: 22-33https://doi.org/10.21106/ijma.337Crossref PubMed Google Scholar). 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 and the Children's Hospital Association, 2020American Academy of Pediatrics & the Children''s Hospital Association Children & COVID-19: State data report.https://downloads.aap.org/AAP/PDF/AAP%20and%20CHA%20-%20Children%20and%20COVID-19%20State%20Data%20Report%207.30.20%20FINAL.pdfDate: 2020, October 16Google Scholar). 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., 2020Feldstein L.R. Rose E.B. Horwitz S.M. Collins J.P. Newhams M.M. Son M. Randolph A.G. Multisystem inflammatory syndrome in U.S. children and adolescents.The New England Journal of Medicine. 2020; (NEJMoa2021680. Advance online publication)https://doi.org/10.1056/NEJMoa2021680Crossref Scopus (1716) Google Scholar). As of October 2020, the CDC reports 1097 confirmed MIS-C cases with 20 deaths (Centers for Disease Control and Prevention, 2020dCenters for Disease Control and Prevention Coronavirus Disease 2019 (COVID-19).https://www.cdc.gov/mis-c/cases/index.htmlDate: 2020, October 22Google Scholar). 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 environment (Roh et al., 2016Roh E. Song D.K. Kim M.S. Emerging role of the brain in the homeostatic regulation of energy and glucose metabolism.Experimental & Molecular Medicine. 2016; 48e216https://doi.org/10.1038/emm.2016.4Crossref PubMed Scopus (224) Google Scholar; Timper and Brüning, 2017Timper K. Brüning J.C. Hypothalamic circuits regulating appetite and energy homeostasis: Pathways to obesity.Disease Models & Mechanisms. 2017; 10: 679-689https://doi.org/10.1242/dmm.026609Crossref PubMed Scopus (455) Google Scholar). 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., 2017Berthoud H.R. Münzberg H. Morrison C.D. Blaming the brain for obesity: Integration of hedonic and homeostatic mechanisms.Gastroenterology. 2017; 152: 1728-1738https://doi.org/10.1053/j.gastro.2016.12.050Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar). 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 and Saltiel, 2017Reilly S.M. Saltiel A.R. Adapting to obesity with adipose tissue inflammation. Nature Reviews.Endocrinology. 2017; 13: 633-643https://doi.org/10.1038/nrendo.2017.90Crossref PubMed Scopus (782) Google Scholar). 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., 2017Ellulu M.S. Patimah I. Khaza'ai H. Rahmat A. Abed Y. Obesity and inflammation: The linking mechanism and the complications.Archives of Medical Science. 2017; 13: 851-863https://doi.org/10.5114/aoms.2016.58928Crossref PubMed Scopus (1030) Google Scholar). 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 et al., 2020Yuki K. Fujiogi M. Koutsogiannaki S. COVID-19 pathophysiology: A review.Clinical Immunology. 2020; 215: 108427https://doi.org/10.1016/j.clim.2020.108427Crossref PubMed Scopus (1256) Google Scholar). Inflammation from the disease of obesity combined with COVID-19 hyperinflammation and weakened immune response (Frydrych et al., 2018Frydrych L.M. Bian G. O'Lone D.E. Ward P.A. Delano M.J. Obesity and type 2 diabetes mellitus drive immune dysfunction, infection development, and sepsis mortality.Journal of Leukocyte Biology. 2018; 104: 525-534https://doi.org/10.1002/JLB.5VMR0118-021RRCrossref PubMed Scopus (177) Google Scholar; Korakas et al., 2020Korakas E. Ikonomidis I. Kousathana F. Balampanis K. Kountouri A. Raptis A. Lambadiari V. Obesity and COVID-19: Immune and metabolic derangement as a possible link to adverse clinical outcomes.American Journal of Physiology, Endocrinology and Metabolism. 2020; 319: E105-E109https://doi.org/10.1152/ajpendo.00198.2020Crossref PubMed Scopus (132) Google Scholar) increases the risk of individuals developing overwhelming sepsis and organ failure (Shekerdemian et al., 2020Shekerdemian L.S. Mahmood N.R. Wolfe K.K. Riggs B.J. Ross C.E. McKiernan C.A. International COVID-19 PICU CollaborativeCharacteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units.JAMA Pediatrics. 2020; https://doi.org/10.1001/jamapediatrics.2020.1948Crossref PubMed Scopus (712) Google Scholar). Fig. 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., 2020Fegert J.M. Vitiello B. Plener P.L. Clemens V. Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.Child and Adolescent Psychiatry and Mental Health. 2020; 14: 20https://doi.org/10.1186/s13034-020-00329-3Crossref PubMed Scopus (1077) Google Scholar; Human Rights Watch, 2020Human Rights Watch COVID-19's devastating impact on children.https://www.hrw.org/news/2020/04/09/covid-19s-devastating-impact-childrenDate: April 9, 2020Google Scholar). Stress triggers 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., 2018Condon E.M. Sadler L.S. Mayes L.C. Toxic stress and protective factors in multi-ethnic school age children: A research protocol.Research in Nursing & Health. 2018; 41: 97-106https://doi.org/10.1002/nur.21851Crossref PubMed Scopus (15) Google Scholar; Reichel, 2019Reichel C. Toxic stress in children has health effects that can last into adulthood. Harvard Kennedy School, Shorenstein Center on Media, Politics, and Public Policy, 2019https://journalistsresource.org/studies/society/public-health/aces-toxic-stress-health-research/Google Scholar; Shonkoff et al., 2012Shonkoff J.P. Garner A.S. Siegel B.S. Dobbins M.I. Earls M.F. Garner A.S. Wood D.L. The lifelong effects of early childhood adversity and toxic stress.Pediatrics. 2012; 129: e232-e246https://doi.org/10.1542/peds.2011-2663Crossref PubMed Scopus (3208) Google Scholar). 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., 2020Fegert J.M. Vitiello B. Plener P.L. Clemens V. Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.Child and Adolescent Psychiatry and Mental Health. 2020; 14: 20https://doi.org/10.1186/s13034-020-00329-3Crossref PubMed Scopus (1077) Google Scholar) 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., 2019Baskind M.J. Taveras E.M. Gerber M.W. Fiechtner L. Horan C. Sharifi M. Parent-perceived stress and its association with children's weight and obesity-related behaviors.Preventing Chronic Disease. 2019; 16E39https://doi.org/10.5888/pcd16.180368Crossref PubMed Scopus (39) Google Scholar). Disturbances in the social environment during infancy and early childhood appear to play a critical role in weight gain and obesity (Hemmingsson, 2018Hemmingsson E. Early childhood obesity risk factors: Socioeconomic adversity, family dysfunction, offspring distress, and junk food self-medication.Current Obesity Reports. 2018; 7: 204-209https://doi.org/10.1007/s13679-018-0310-2Crossref PubMed Scopus (147) Google Scholar). COVID-19 stressors disproportionally affect vulnerable populations already experiencing toxic stress from poverty, racism and structural inequality (Bailey et al., 2017Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: Evidence and interventions.Lancet. 2017; 389: 1453-1463https://doi.org/10.1016/S0140-6736(17)30569-XAbstract Full Text Full Text PDF PubMed Scopus (2755) Google Scholar; Bowleg, 2020Bowleg L. We're not all in this together: On COVID-19, intersectionality, and structural inequality.American Journal of Public Health. 2020; 110: 917https://doi.org/10.2105/AJPH.2020.305766Crossref PubMed Scopus (281) Google Scholar). Lack of, or decreased access, to treatments for chronic physical and/or mental illness conditions can exacerbate negative outcomes (Fegert et al., 2020Fegert J.M. Vitiello B. Plener P.L. Clemens V. Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.Child and Adolescent Psychiatry and Mental Health. 2020; 14: 20https://doi.org/10.1186/s13034-020-00329-3Crossref PubMed Scopus (1077) Google Scholar). Rates of domestic violence and child abuse have increased during the pandemic (Fegert et al., 2020Fegert J.M. Vitiello B. Plener P.L. Clemens V. Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality.Child and Adolescent Psychiatry and Mental Health. 2020; 14: 20https://doi.org/10.1186/s13034-020-00329-3Crossref PubMed Scopus (1077) Google Scholar; The Guardian, 2020The Guardian Lockdowns around the world bring rise in domestic violence.https://www.theguardian.com/society/2020/mar/28/lockdowns-world-rise-domestic-violenceDate: 2020Google Scholar) 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., 2014Bethell C.D. Newacheck P. Hawes E. Halfon N. Adverse childhood experiences: Assessing the impact on health and school engagement and the mitigating role of resilience.Health Affairs. 2014; 33: 2106-2115https://doi.org/10.1377/hlthaff.2014.0914Crossref PubMed Scopus (425) Google Scholar; Garasky et al., 2009Garasky S. Stewart S.D. Gundersen C. Lohman B.J. Eisenmann J.C. Family stressors and child obesity.Social Science Research. 2009; 38: 755-766https://doi.org/10.1016/j.ssresearch.2009.06.002Crossref PubMed Scopus (109) Google Scholar; Lohman et al., 2009Lohman B.J. Stewart S. Gundersen C. Garasky S. Eisenmann J.C. Adolescent overweight and obesity: Links to food insecurity and individual, maternal, and family stressors.The Journal of Adolescent Health. 2009; 45: 230-237https://doi.org/10.1016/j.jadohealth.2009.01.003Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar). Responding to an unpredictable threat like the COVID-19 pandemic evokes stress responses (Brooks et al., 2020Brooks S.K. Webster R.K. Smith L.E. Woodland L. Wessely S. Greenberg N. Rubin G.J. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence.Lancet (London, England). 2020; 395: 912-920https://doi.org/10.1016/S0140-6736(20)30460-8Abstract Full Text Full Text PDF PubMed Scopus (9573) Google Scholar; Vinkers et al., 2020Vinkers C.H. van Amelsvoort T. Bisson J.I. Branchi I. Cryan J.F. Domschke K. van der Wee N. Stress resilience during the coronavirus pandemic.European Neuropsychopharmacology. 2020; 35: 12-16https://doi.org/10.1016/j.euroneuro.2020.05.003Crossref PubMed Scopus (270) Google Scholar; 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 and Silman, 2013Sprang G. Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters.Disaster Medicine and Public Health Preparedness. 2013; 7: 105-110https://doi.org/10.1017/dmp.2013.22Crossref PubMed Scopus (729) Google Scholar). 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., 2020Patrick S.W. Henkhaus L.E. Zickafoose J.S. Lovell K. Halvorson A. Loch S. Davis M.M. Well-being of parents and children during the COVID-19 pandemic: A national survey.Pediatrics. 2020; https://doi.org/10.1542/peds.2020- 016824Crossref Google Scholar).Table 1Common sources and responses to stress from the COVID-19 pandemic.Sources of stressResponses to stressQuarantineDecreased concentrationSocial isolationIrritabilityLess interaction with peersSleep disturbancesThreat to food insecurityAnxietyChanges in routines and schedulesInterpersonal conflictThreat to stable family financesDepressionLimits to physical activityAngerAdaptation to online learningEmotional exhaustionParental stressWeight gainFear of COVID-19 disease Open table in a new tab The relationship between stress, mental health, and childhood obesity is complex (Small and Aplasca, 2016Small L. Aplasca A. Child obesity and mental health: A complex interaction.Child and Adolescent Psychiatric Clinics of North America. 2016; 25: 269-282https://doi.org/10.1016/j.chc.2015.11.008Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar). Children experiencing obesity have a higher risk for depression (Smith et al., 2020Smith J.D. Fu E. Kobayashi M.A. Prevention and management of childhood obesity and its psychological and health comorbidities.Annual Review of Clinical Psychology. 2020; 16: 351-378https://doi.org/10.1146/annurev-clinpsy-100219-060201Crossref PubMed Scopus (104) Google Scholar) because of stigma and isolation. Children with overweight or obesity report more stress (Thaker et al., 2020Thaker V.V. Osganian S.K. deFerranti S.D. Sonneville K.R. Cheng J.K. Feldman H.A. Richmond T.K. Psychosocial, behavioral and clinical correlates of children with overweight and obesity.BMC Pediatrics. 2020; 20: 291https://doi.org/10.1186/s12887-020-02145-2Crossref PubMed Scopus (8) Google Scholar) and eat in response to stress to a greater degree than normal weight peers (Miller et al., 2019Miller A.L. Riley H. Domoff S.E. Gearhardt A.N. Sturza J. Kaciroti N. Lumeng J.C. Weight status moderates stress-eating in the absence of hunger associations in children.Appetite. 2019; 136: 184-192https://doi.org/10.1016/j.appet.2019.02.005Crossref PubMed Scopus (18) Google Scholar). 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., 2020Vinkers C.H. van Amelsvoort T. Bisson J.I. Branchi I. Cryan J.F. Domschke K. van der Wee N. Stress resilience during the coronavirus pandemic.European Neuropsychopharmacology. 2020; 35: 12-16https://doi.org/10.1016/j.euroneuro.2020.05.003Crossref PubMed Scopus (270) Google Scholar). 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 and Parolin, 2020Van Lancker W. Parolin Z. COVID-19, school closures, and child poverty: A social crisis in the making.The Lancet Public Health. 2020; 5: e243-e244https://doi.org/10.1016/S2468-2667(20)30084-0Abstract Full Text Full Text PDF PubMed Scopus (834) Google Scholar). 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 (Rundle et al., 2020Rundle A.G. Park Y. Herbstman J.B. Kinsey E.W. Wang Y.C. COVID-19-related school closings and risk of weight gain among children.Obesity. 2020; 28: 1008-1009https://doi.org/10.1002/oby.22813Crossref PubMed Scopus (540) Google Scholar). School closure may affect children and their ability to maintain a healthy weight in the many ways (Table 2).Table 2Impact of school closure due to COVID-19 on children.Lack of family expertise with facilitating learning and accessing resourcesExacerbation of food insecurityChange in availability of healthy foodsChange in physical activityRegression in academic progress and decrease in exposure to art, music, library, and physical educationOnline learning challenges including inadequate computers and internetNegative impact on mental health and well beingLack of access to healthcare and immunizations through school-based health centers Open table in a new tab 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, 2020Hess A. Widespread school closures mean 30 million kids might go without meals. CNBC, 2020, March 14https://www.cnbc.com/2020/03/14/widespread-school-closures-mean-30-million-kids-might-go-without-meals.htmlGoogle Scholar). 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., 2020Patrick S.W. Henkhaus L.E. Zickafoose J.S. Lovell K. Halvorson A. Loch S. Davis M.M. Well-being of parents and children during the COVID-19 pandemic: A national survey.Pediatrics. 2020; https://doi.org/10.1542/peds.2020- 016824Crossref Google Scholar). Regression of academic progress is linked to time out of school and home schooling (Van Lancker and Parolin, 2020Van Lancker W. Parolin Z. COVID-19, school closures, and child poverty: A social crisis in the making.The Lancet Public Health. 2020; 5: e243-e244https://doi.org/10.1016/S2468-2667(20)30084-0Abstract Full Text Full Text PDF PubMed Scopus (834) Google Scholar). 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 2584 school-based health centers in 48 of the 50 states, the District of Columbia, and Puerto Rico (Love et al., 2019Love H.E. Schlitt J. Soleimanpour S. Panchal N. Behr C. Twenty years of school-based health care growth and expansion.Health Affairs. 2019; 38: 755-764https://doi.org/10.1377/hlthaff.2018.05472Crossref PubMed Scopus (98) Google Scholar). 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 t
Referência(s)