Investigating the Effects of the COVID-19 Pandemic on Pediatric Body Mass Index, and Health Status in an Inner-City, Low-Income Setting.

INTRODUCTION: The COVID-19 pandemic required unprecedented containment measures, including prolonged stay-at-home orders, to combat spread and prevent loss of life. One of the consequences of these mandates was the closure of schools. Children in resource-limited communities already experiencing disparities were placed at a significant disadvantage by the closure of schools. Many depended on the school systems as their primary source of nutrient-rich food. Additionally, for many, schools provide the only safe place for outdoor play and physical activity. The unintended consequences of the COVID-19 stay-at-home orders for these high-risk children are now being investigated.
METHOD: This article reports a retrospective chart review of children aged 9-11 years in a low-income, inner-city practice in a moderately sized Southeastern city. Baseline data were obtainef fro 2019 and compared to 2020 and/or 2021.
RESULTS: Findings indicate statistically significant increases in body mass index in this high-risk population of children. Additionally. chronic condistion associate with obesity were identified in many of the unhealthy weight children in the study. DISCUSSION: This study identifies unintended consequences form the pandemic containment measures that are consistent with other emerging research related to the pandemic's effects on body mass index in children.

In the last 50-years, an alarming trend has been documented among children across the United States and around the world. The rate of childhood overweight and obesity has become an epidemic. Tsoi et al. (2022) completed a 20-year analysis of NHANES data that included over 35,000 children that showed a steady increase in childhood obesity. In 2018, according to Tsoi et al., one in five adolescents was obese and ethnic minority children and those from low-income communities were the at most risk of being obese.

Most of the focus of 2020 through early 2022 was on the acute containment and prevention of COVID. Many of the interventions necessary to quell the spread of the virus and reduce the impact of illness on vulnerable populations carried with them unintended consequences, especially for vulnerable populations such as low-income and inner-city children and children of ethnic minorities (Mohanty et al., 2021). Many of these children depend upon the school system for safe play and for quality nutrition. With the school systems closed as a containment measure for much of 2020 and 2021, many of these children did not have access to a safe place or play area or high-quality food (Burkhart et al., 2021; Stewart et al., 2022; Sarni et al., 2021). Children replaced physical activity with increased screen time; fresh fruits and vegetables were replaced with calorie-dense processed foods (Sarni et al., 2021).

Low-income and ethnic minority children already experience childhood obesity at greater rates than other children (Mohanty et al., 2021), a condition that is likely to remain into adulthood (Simmonds et al., 2015). Low-income and minority children, already more likely to be affected by the social determinants of health (SDOH) before the pandemic, are more likely to impacted more from the pandemic's unintended consequences. One of those unintended consequences in a sharp rise in childhood obesity.

Childhood obesity is associated with adult-onset chronic conditions including type 2 diabetes mellitus (T2DM), hypertension (HTN), coronary artery disease, cardiomyopathy, heart failure, and certain cancers (Horesh et al., 2021).  Horesh et al. posit that the earlier these diseases present the life of an individual, the greater the risk of complications. They also point out that the attributable risk of developing T2DM for an overweight/obese adolescent male by adulthood is 57% and for a female is 61% (Horesh et al., 2021).

According to Horesh et al, hypertension is the most common obesity-associated comorbidity found in adolescents. Metabolic syndrome and T2DM are equally serious comorbidities found in childhood obesity and have great impact on adult health status (Horesh et al., 2021). However, they are not the only obesity-associated comorbidities noted in children. Other obesity-associated comorbidities include airway issues such as asthma, often poorly controlled (Fitzpatrick et al., 2021), tonsillar hypertrophy, sleep disordered breathing and other sleep issues (Daar et al., 2016), musculoskeletal disorders (Molina-Garcia et al., 2021), numerous skin conditions (Torres & Torres-Pradilla, 2014), and GI/GU problems, particularly, lower urinary tract disorders and bladder-bowel dysfunction (Arlen et al., 2017). All body systems are impacted in some way by obesity-associated comorbidities.

This article reports a retrospective chart review of the rate of overweight and obesity, obesity-related comorbidities, and the use of healthcare resources among 9–11-year, low-income, urban children in a moderately sized Southeastern city. Estimates of overweight and obesity within the clinic are determined and compared to State and National averages. Comparisons are made between BMIs pre-pandemic and post-pandemic. Estimates are made of the presence of obesity-associated comorbidities and comparisons are made between the use of medical resources for healthy weight children and unhealthy children.

Specifically, the retrospective chart review seeks to answer the following questions:

What is the rate of overweight and obesity in the clinic system compared to State and National averages?

What percentage of overweight/obese children have documentation of comorbid conditions and what types of conditions are seen?

Did the rates of overweight and obesity rise disproportionately during the pandemic confinements?

Did the pandemic result in children not receiving appropriate care for known health conditions?

Method

Research Design/Setting

A retrospective chart review was conducted on records of 9–11-year children receiving well-child care from May 1, 2020 through September 30, 2020 in an urban, inner-city, low-income pediatric practice in a moderately sized, Southeastern city to evaluate the effect the pandemic's stay-at-home orders had on BMI. A secondary analysis was conducted to determine if overweight and obese children had any documented obesity-related comorbid conditions and to determine if unhealthy weight children utilized more healthcare resources that healthy weight children.

Key terms for this review include:

Overweight- a BMI between 85th and 95th percentile for height, weight, and gender (CDC, 2021);

Obesity- a BMI greater than or equal to the 95th percentile for height, weight, and gender (CDC, 2021);

Obesity-associated comorbid condition- a condition that occurs more often in obese persons than in the general population, but for which there may not be a definitive cause/effect relationship. Sarni et al. give examples of obesity-associate comorbid conditions as adult obesity, mental health problems, diabetes, cardiovascular disease, and cancer.

Healthy weight- children whose BMI are categorized as either underweight or normal weight. Unhealthy weight- children whose BMIs are categorized as overweight or obese.

Sample

Charts eligible for the review included 9-11-year-old children who received any type of physical/well-child exam from January 1, 2019, through the end of the records collection period in September 2021. The health records from 2019 were used to establish baseline data for comparison standards. Health records from 2020 to 2021 determined the comparison data.

The State in which the review was conducted requires documentation of a school physical for students entering the sixth grade. Children 9-11-years of age between 2019-2021 were targeted for the chart review because they were in the sixth grade during one of those years. It was assumed that these patient records would provide the largest sample. There were 101 eligible records reviewed. Of the reviewed records, 66 had complete data and were use to establish the BMI trajectory over the course of the pandemic. The remaining records had only a single BMI recorded during the target period. These records helped to inform the prevalence of childhood obesity within the pediatric practice.

Instruments/Measures and Ethical Approval

Data were collected into an excel spreadsheet and included BMI, height, weight, blood pressure, obesity-related comorbid conditions, and the number of medical visits in the target years. Indiana Wesleyan University granted ethical approval with additional written permission received from the management of the pediatric practice in which the chart review was conducted. Data were stored in a password-protected excel file, in a password-protected laptop computer.

Results

Statistical Analysis

A paired samples t-test was conducted to evaluate the significance of the changes in BMI from the pre-pandemic baseline to post-pandemic status. Post-pandemic BMIs were significantly higher than pre-pandemic BMIs, df (65) t=7.45, p=,.001. These results suggest that post-pandemic BMIs (N=66) rose disproportionately (M=22.76, SD=6.53) compared to the pre-pandemic BMIs (M=20.4, SD=6.08). The Cohen's effect size was (d= 2.58) with a point estimate of .92 with a CI 95% (.63-1.2) showing a large effect size. These findings indicate a disproportional rise in BMIs over the course of the pandemic, a finding consistent with other current literature.

An independent samples t-test was conducted on the number of illness visits attended per years by healthy weight children compared to unhealthy weight for the 2019 data only as the remaining 2-years were impacted by the pandemic. There were 89 children for who illness visit data were available for 2019 of these 42 (M=.76, SD=1.17) were considered having healthy BMIs and 46 (M=1.28, SD=1.84) were considered having unhealthy BMIs. Data were approaching significance with df (87), t=1.56, p=.06, (p<.05). While these findings were not statistically significant, they do warrant further consideration.

Data Analysis

Initial data analysis began by evaluating the overall sample for the rates of overweight and obesity. Of the 101 charts sampled, 21.7% of the BMIs (N=22) were overweight, and 35.6% of the BMIs (N=36) were obese. According to the Robert Wood Johnson Foundation (2020), the State in which the clinic resided had a 23.8% obesity rate among similar aged children during the same timeframe, while the national obesity rate was 20.7% (CDC, 2022). The sample exhibited a significantly higher obesity rate than both State and National averages. Among the 66 records with complete data, the baseline overweight for 2019 rate was 18.2% (N=12) and the baseline obesity rate was 28.8% (N=19). Post-pandemic overweight rate was 19.7% (N=13) and post-pandemic obesity rate was 43.9% (N=29). Statistical analysis of the change in the BMIs post-pandemic documents this increase in overweight and obesity in this at-risk population as statistically significant.

The chart review sought to identify the presentce of obesity-associate comorbidities in all if the children with unhealthy weight. Among overweight children, 12 had documented obesity-associated comorbid conditions, while 21 of the obese children had obesity-associated comorbid conditions. The most common comorbid conditions in both groups involved airway-based conditions and included diagnoses such as asthma, sleep-disordered breathing, and tonsillar hypertrophy. Airway issues prevailed in 16.7% of overweight children with comorbid conditions and in 42.9% of obese children with comorbid conditions. Other obesity-associated comorbidities identified in the chart review included GI/GU disorders, skin conditions, and joint paint. While none of the identified comorbidities included metabolic syndrome or T2DM, one child did have pre-diabetes, another had pre-hypertension and a third had diagnosed hypertension. On figure 4, they are represented in the “other” category.

Figure 4

Incidence of Comorbid Conditions in 9-11 year children

When exploring the use of healthcare resources, the number of illness visits per group was broken down by quarter in an effort to mitigate the effect of the stay-at-home orders of the pandemic. In 2019, healthy weight children averaged eight visits per quarter for illness conditions while unhealthy children averaged 14.4 visits per quarter for similar problems. In 2020, illness visits per quarter dropped to seven for healthy weight children and to 11.5 for unhealthy weight children but these numbers included telehealth visits. In 2021, these numbers dropped further to six per quarter for healthy weight children and to nine per quarter for unhealthy children, again, including telehealth visits. While some speculation could be made that the stay-at-home orders contributed to these reduced number of patient visits by decreasing exposure to communicable illness, this warrants further exploration to determine the effect that decreased healthcare provider contact may have had on chronic condition management.

Discussion

When considering the findings of this retrospective chart review, one must examine them from the perspective of normal expectations for linear growth and weight gain in children in the same time frame. Healthy growth for prepubertal boys is expected to average two inches per year with an expected weight gain of six to seven pounds per year. For peak-pubertal boys, linear growth is typically four inches per year with a weight gain of 20 pounds per year (Sass & Kaplan, 2020). For prepubertal girls, healthy growth averages two inches per year, and weight gain averages six pounds per year. Peak-pubertal girls average three inches of linear growth per year and 17.5 pounds per year (Sass & Kaplan, 2020).

The mean age for peak height velocity for girls is 11.5 years and for boys is 13.5 years (Sass & Kaplan, 2020). The average child in this study is most likely in an early to middle stage of puberty. The boys averaged 2.2 inches of linear growth per year over the 2-year period and the girls averaged 3 inches of linear growth, very consistent with the expected averages for age and gender. However, average weight gain did not reflect this same consistency. Rather, weight increased disproportionally to linear growth. Of the children whose weight crossed into obese, 25% had BMIs between 30 and 40 while an additional 10% had BMIs greater than 40, categorizing them as morbidly obese. According to Simmonds et al., there is a moderate to significant correlation between BMI in childhood and adulthood. Particularly, children who are above the 90th percentile for BMI between the ages of 9 and 13-years are five times more likely to be obese at 30-years of age.

In a population of children already at great risk for long-term health complications related to SDOH, the additional burden of weight that has been added over the course of the pandemic creates lifelong health problems. Sarni et al. comment that the childhood obesity epidemic increases “the global burden of chronic disease” (p S44) because of the obesity-associated comorbid conditions. In the sample population of children in this review, 60% of the obese children and 58% of the overweight children already have documented obesity-associated comorbid conditions, some of them very serious.

It is beyond the scope of this review to make direct correlations between unhealthy weight and obesity-associated comorbidities in these children. This review can only document their presence. However, the abundance of published literature related to childhood obesity and obesity-associated comorbidities allows some inferences. A systematic review by Obita and Alkhatib (2022) placed obese boys and children from ethnic minority groups at greater risk for obesity-associated comorbidities. Both groups are strongly represented in the data from this review. Reinehr (2018) discusses the association of childhood obesity with multiple comorbidities, poor medical outcomes, impacts on the next generation through epigenetics and the creation of challenging treatment issues. He also points out the increased use of medical resources by this population and the subsequent cost to the healthcare system.

While the differences in using healthcare resources between the healthy weight and unhealthy weight children in this study only approached statistical significance, it has a clinical significance when the cost of healthcare is factored into the discussion.   Twelve additional illness visits per year at standard Medicaid rates amounts to more than $500.00 annually. The higher reimbursement rates associated with FQHCs, and rural health clinics produces a sum significantly higher than $500.00. If the sample selected for this review accurately represents the pediatric practice in which the study was conducted, over 40% of the children in the practice are using an extra 12 visits per year, in a usual year unaffected by a pandemic, for illness complaints. The financial implications of this are significant.

Implications

The COVID pandemic has had a significant impact on weight gain in children. This is a finding that is being reinforced in multiple studies (Vinker-Shuster et al., 2021; Chang et al., 202; Vogel et al., 2021). A meta-analysis of the association of adverse childhood events (ACES) with the development of obesity in childhood by Schroeder et al., (2021) showed that children with two or more adverse childhood events (ACEs) are more likely to develop childhood obesity. The events surrounding the pandemic have become a trauma exposure for most children (Pfefferbaum, 2022; Srivastav et al., 2021). In one study 43% of adolescent participants reported worsening depression symptoms and 34% reported worsening anxiety symptoms during the pandemic, 38% reported that their sense of well-being worsened (Stewart et al., 2022). Most of the participants in the study related their symptoms to school closures. Students reported that school was their safe place (Stewart et al., 2022). Children potentially experienced multiple trauma exposures during the pandemic. Considering that two or more ACES increased the likelihood of a child becoming obese, and that pandemic created multiple potential trauma exposures, and that children from low-income communities and ethnic minorities are at greater risk for developing obesity, providers need to be cognizant of the increased risks in these high-risk populations. The findings of this retrospective chart review are not unexpected and are consistent with the current literature. Finding like this are a call to action for healthcare providers caring for vulnerable pediatric populations and for researchers who are just beginning to uncover the long-term unintended consequences of the COVID pandemic.

Limitations

There are limitations to this study. First, of the 101 charts eligible for review, only 66 had complete data available. While a single BMI was available for the remaining records, it was impossible to tell how their BMI changed over the course of the pandemic. If those data were available, the findings may not have been as robust. Second, the clinic in which the retrospective chart review was conducted had paper records that had to be hand searched. There are unique challenges associated with paper records including missing and incomplete records, and the time it takes to collect data. Finally, the nature of a retrospective chart review does not allow direct correlations to be made, only inference can be drawn from the data. This study adds value to the growing body of literature by supporting findings of other researchers related to the pandemics effect on BMI in children. It also points to further areas of research that continue to need to be explored.

Conclusion

There is still much research to be done related to the pandemic's long-term effects on physical and mental health outcomes. Children stand to suffer the most long-term effects from the trauma of the pandemic experience because they will live with the experience for the longest amount of time. Children who were already experiencing health disparities pre-pandemic are the most vulnerable among us for experiencing negative health outcomes post-pandemic. Multiple studies have already documented an association with increased obesity and the pandemic (Vinker-Shuster et al., 2021; Chang et al., 202; Vogel et al., 2021). This retrospective chart review of weight status and physical health over the course of the pandemic in a low-income, inner-city, high-risk pediatric population, adds additional evidence to support the findings of these other researchers. Over the next two decades, pediatric clinicians will need to practice with an increased awareness of the potentially negative impact of the pandemic on the health of their most vulnerable patients.(Fig. 1 , 2 , 3 )

Figure 1

Pre-Pandemic BMIs

Figure 2

Post-Post Pandemic BMIs

Figure 3

Comparison of Severity of Obesity Pre and Post-Pandemig

I have no disclosures to make. There were no funding sources for this study.

Ethical Statement

I certify that the research reported in this article was conducted according to ethical research practices under the direction of an institutional review board and with the written permission of the practice administration in which the chart review was conducted. All patient data is anonymous. No financial incentives were received for conducting the study.

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