Special Attention to Diet and Physical Activity in Children and Adolescents With Obesity During the Coronavirus Disease-2019 Pandemic
Valeria Calcaterra
Matteo Vandoni
Vittoria Carnevale Pellino3,4 
Hellas Cena- 1Pediatric and Adolescent Unit, Department of Internal Medicine, University of Pavia, Pavia, Italy
- 2Pediatric Unit, Children's Hospital V. Buzzi, Milan, Italy
- 3Laboratory of Adapted Motor Activity (LAMA), Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- 4Department of Industrial Engineering, University of Tor Vergata, Rome, Italy
- 5Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
- 6Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, Pavia, Italy
Coronavirus disease 2019 (COVID-19) is an acute infectious respiratory disease that has posed critical challenges for the global healthcare community. Following the outbreak of COVID-19 (1), the Italian government imposed a national quarantine, restricting the movement of the population as a fundamental safety step to limit exposure to the virus and contain contagion. All schools were closed, requiring childcare and education to be provided at home; public spaces were also closed, and mobility was restricted to health or work situations. Unfortunately, the mandatory directives locking down outdoor activities inevitably disrupted the daily routine of children, including regular physical activity and excercise. This increased the risk of major weight gain for children already prone to gaining weight. Therefore, eating healthy foods and being physically active is recommended.
COVID-19 involves all age groups, although children are less likely to develop severe illness than adults (2). In adults, conditions such as chronic lung diseases, hypertension, cardiovascular disease, and diabetes, seem to increase the risk for an adverse COVID-19 outcome. The effect of obesity on the outcome remains controversial. Initially, such implications were not seriously considered; however, recent papers showed an association between obesity and severe outcome (3).
So far no reports on severity of disease in children with obesity compared to normal-weight subjects have been reported, that we know of. However, several studies show that obesity is associated with inflammation and severe airway obstruction in patients with respiratory tract infections (4). As reported by Okubo (5), pediatric obesity is an independent risk factor for severity and morbidity among children with lower respiratory tract infections by means of potential factors including subclinical inflammation, obesity-related immune system dysregulation, decreased cell-mediated immune responses, and obesity-related respiratory dysfunction (6). Adipose tissue expresses components of the renin-angiotensin system (RAS) (7), including the expression of angiotensin-converting enzyme 2 (ACE2–the functional receptor for SARS-CoV), which is up-regulated in the adipocytes of subjects with obesity, turning adipose tissue into a potential target and viral reservoir. Additionally, in high-fat-fed animal experimental models, researchers described dysregulated ACE2 expression as increasing the risk of COVID-19 infection (7).
Lockdowns may worsen not only the weight but also the eating habits of children, since homes are likely stocked with ultra-processed and calorie-dense comfort foods (8). Good nutrition is very important before, during, and after an infection. Although COVID-19 infection cannot be prevented by any food or dietary supplements, maintaining a healthy diet is an important part of supporting a strong immune system (4, 8).
Diet and nutrition play an important role in inflammation and immunity. Specific foods (8), including simple sugars, trans fats, refined carbohydrates, and processed meat, may promote inflammation and also counteract the anti-inflammatory effects of omega-3 fatty acids (9). Therefore, consumption of junk food may increase systemic inflammation in subjects with overweight or obesity, promoting IL-6 production (4).
Although inflammation is one of the body's first responses to infection, overactive immune responses in a persistent stress and inflammation condition may increase risk of severe infections.
Keeping children on a healthy diet in a safe home environment is an important strategy for maintaining weight control for children with obesity during this emergency coronavirus social lockdown, as is promoting physical activity (Table 1).
Table 1. Crucial advice for diet and physical activity in children and adolescents with obesity during the COVID-19 pandemic.
Children need to play and keep physically active to protect their physical and emotional health during growth (10). In particular, physical activity (PA) contributes to daily energy expenditure, thus increasing lean body mass, improving energy intake and metabolic and psychological profiles (10). A previous study by McManus et al. (11) on PA evaluation in normal weight and obese children showed no difference between children regarding moderate to vigorous PA, but further analysis showed that lack of light-intensity tasks in obese children explained the difference in total daily energy expenditure. Thus, in obese children, acquiring correct PA targets by means of frequent, short-duration day-to-day tasks, rather than sustained organized sport or exercise, is crucial. In fact, since obese children do not usually spend their leisure time in light-intensity activities, we believe that proper suggestions of games and active lifestyle habits will be crucial in confinement to small spaces. During the COVID-19 pandemic, PA or exercise restriction at school or in outdoor settings leads to a vicious cycle of sedentary behavior and decreased daily energy expenditure ending in weight gain. In light of this, the implementation of recreation and games as well as programmed PA at home becomes of primary importance.
In order to promote adherence to PA, we suggest different games (Table 1) that should be chosen according to the characteristics and personal preferences of the child. For each activity and game, recommendations are made for the duration and intensity necessary to gain muscular strength and flexibility, to improve fundamental motor skills and functions such as cardiorespiratory endurance, core stability, balance, and posture, and also to have fun.
Healthy diet and behaviors such as programmed physical activity, limited screen time, and adequate sleep may help children deal with these required social restriction rules, contributing to positive emotions, emotional stress responses, weight control, and health.
Author Contributions
VC, MV, VP, and HC made a substantial contribution to the concept or design of the work, drafted the article, or revised it critically for important intellectual content. All authors approved the version to be published.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
References
1. Palacios Cruz M, Santos E, Velázquez Cervantes MA, León Juárez M. COVID-19, a worldwide public health emergency. Rev Clin Esp. (2020). doi: 10.1016/j.rce.2020.03.001. [Epub ahead of print].
2. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatr. (2020) 109:1088–95. doi: 10.1111/apa.15270
3. Samuels JD. Obesity and severe COVID-19 disease: a strong association. Obesity. (2020). doi: 10.1002/oby.22866. [Epub ahead of print].
4. Lee H, Lee IS, Choue R. Obesity, inflammation and diet. Pediatr Gastroenterol Hepatol Nutr. (2013) 16:143–52. doi: 10.5223/pghn.2013.16.3.143
5. Okubo Y, Nochioka K, Testa MA. The impact of pediatric obesity on hospitalized children with lower respiratory tract infections in the United States. Clin Respir J. (2018) 12:1479–84. doi: 10.1111/crj.12694
6. Huttunen R. Obesity and the outcome of infection. Lancet Infect Dis. (2010) 10:442–3. doi: 10.1016/S1473-3099(10)70103-1
7. Gupte M, Boustany-Kari CM, Bharadwaj K, Police S, Thatcher S, Gong MC, et al. ACE2 is expressed in mouse adipocytes and regulated by a high-fat diet. Am J Physiol Regul Integr Comp Physiol. (2008) 295:R781–8. doi: 10.1152/ajpregu.00183.2008
8. Rundle AG, Park Y, Herbstman JB, Kinsey EW, Wang YC. COVID-19-related school closings and risk of weight gain among children. Obesity. (2020) 28:1008–9. doi: 10.1002/oby.22813
9. Ma T, Liaset B, Hao Q, Petersen RK, Fjære E, Ngo HT, et al. Sucrose counteracts the anti-inflammatory effect of fish oil in adipose tissue and increases obesity development in mice. PLoS ONE. (2011) 6:e21647. doi: 10.1371/journal.pone.0021647
10. Committee on Physical Activity and Physical Education in the School Environment, Food and Nutrition Board, Institute of Medicine. Educating the student body: taking physical activity and physical education to school. In: Kohl HW III, Cook HD, editors. Physical Activity and Physical Education: Relationship to Growth, Development, and Health. Washington, DC: National Academies Press (US) (2013). p. 3.
Keywords: obesity, COVID-19, children, diet, physical activity
Citation: Calcaterra V, Vandoni M, Pellino VC and Cena H (2020) Special Attention to Diet and Physical Activity in Children and Adolescents With Obesity During the Coronavirus Disease-2019 Pandemic. Front. Pediatr. 8:407. doi: 10.3389/fped.2020.00407
Received: 24 May 2020; Accepted: 12 June 2020;
Published: 26 June 2020.
Edited by:
Barbara Heude, Institut National de la Santé et de la Recherche Médicale (INSERM), FranceReviewed by:
Adilson Marques, University of Lisbon, PortugalCopyright © 2020 Calcaterra, Vandoni, Pellino and Cena. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Valeria Calcaterra, valeria.calcaterra@unipv.it