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Relative contribution of energy intake and energy expenditure to childhood obesity: a review of the literature and directions for future research

International Journal of Obesity volume 35, pages 1–15 (2011)Cite this article

Subjects

Abstract

Background:

Understanding the relative importance of overconsumption and physical inactivity to excess weight gain among children and adolescents can contribute to the development and evaluation of interventions and policies to reduce childhood obesity. However, whether energy intake or expenditure is the dominant contributor to childhood obesity is a subject of debate. To date, no study has systematically reviewed the literature on this subject.

Methods:

We searched PubMed and Ovid Medline (January 1970 to January 2010) for potentially relevant English-language abstracts and obtained full-text articles for the abstracts, which passed the initial inclusion–exclusion criteria. Reference lists of full-length articles were hand searched to identify additional studies potentially relevant for inclusion. Relevant studies were characterized into one of the following three categories: cross-sectional studies with a nationally representative sample, cross-sectional studies among population subgroups and longitudinal studies.

Results:

This review identified 26 studies examining factors related to energy intake, energy expenditure and obesity among children and adolescents. Cross-sectional and longitudinal studies suggest that the primary determinant of energy imbalance at both the population and the individual levels is not definitive. Our findings further suggest that there is wide variation in data quality between studies. Future research in this area should aim to improve the accuracy of measures of energy intake, expenditure and their net balance over time; capitalize on under-utilized, non-traditional data sources, which have not been widely used; use modeling techniques to synthesize studies of shorter follow-up period and different outcome measures; and examine the unique determinants of energy imbalance among demographic groups at higher risk for obesity.

Conclusions:

On the basis of the current evidence, there is no consensus on the main driver of secular trends on weight gain among US children and adolescents. More research and better methods are needed to identify the relative contribution of energy intake and energy expenditure to obesity in the pediatric population.

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Acknowledgements

We acknowledge support for this review from the Robert Wood Johnson Foundation and thank Dr Mary Story and Dr Tracy Orleans for helpful comments on earlier versions of this paper.

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Authors and Affiliations

  1. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    S N Bleich

  2. Department of Internal Medicine, Kaiser Permanente Medical Group, CA, San Francisco, USA

    R Ku

  3. Department of Health Policy and Management, Mailman School of Public Health, New York, NY, USA

    Y C Wang

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Correspondence to S N Bleich.

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Appendices

Appendix A

Table A1

Table a1 Summary of search terms for literature review
Full size table

Appendix B

Summary of common data sources used to estimate energy balance

The National Health and Nutrition Examination Survey (NHANES) combines both in-person interviews and physical exams (including measured height and weight) to determine the health and nutrition status of non-institutionalized adults and children in the United States. Data sets were collected from the following time periods: 1959–1962, 1971–1975, 1976–1980 and 1988–1994. In 1999, NHANES became a continuous program with an annual sample size of approximately 5000 persons.82

The Behavioral Risk Factor Surveillance System (BRFSS) is an on-going telephone survey that has been conducted annually since 1984 to track health conditions and risk behaviors in the United States. The program targets non-institutionalized adults aged 18 and older in all 50 states, Puerto Rico, United States, Virgin Islands and Guam. More than 350 000 adults are interviewed each year. Height and weight are self-reported.

Similar to the BRFSS is the Youth Risk Behavior Surveillance System (YRBSS), a nationally representative school-based survey conducted biennially since 1991 that targets young adults in grades 9–12 with annual sample sizes consistently above 10 000. The YRBSS monitors six main categories: behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behavior and physical inactivity. The surveys are administered by teachers in the classrooms, and height and weight are self-reported.

Food balance sheets (FBSs) from the Food and Agricultural Organization provide information on the per capita national supply and use of food. Although these offer the most comprehensive estimate of a nation's food consumption, they do not reflect actual consumption or household waste and spoilage. Thus, data from FBS tend to overestimate the energy intake.

The Continuing Survey of Food Intake by Individuals (CSFII) was a food recall study targeting non-institutionalized persons of all ages from all 50 states conducted in 1977–1978 and 1994–1996. Over 16 000 persons were interviewed in 1994–1996. Respondents provided 24-h dietary recall for two non-consecutive days during in-person interviews. Given that people may not recall everything that they eat, the CSFII tends to underestimate the energy intake.

Appendix C

Table C1

Table c1 Strengths and weaknesses of common methodologies used to measure the drivers of energy imbalance
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Bleich, S., Ku, R. & Wang, Y. Relative contribution of energy intake and energy expenditure to childhood obesity: a review of the literature and directions for future research. Int J Obes 35, 1–15 (2011). https://doi.org/10.1038/ijo.2010.252

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