Recommendations for prevention of childhood obesity

The majority of US youth are of healthy weight, but the majority of US adults are overweight or obese. Therefore, a major health challenge for most American children and adolescents is obesity prevention-today, and as they age into adulthood. In this report, we review the most recent evidence regarding many behavioral and practice interventions related to childhood obesity, and we present recommendations to health care providers. Because of the importance, we also suggest approaches that clinicians can use to encourage obesity prevention among children, including specific counseling strategies and practice-based, systems-level interventions. In addition, we suggest how clinicians may interact with and promote local and state policy initiatives designed to prevent obesity in their communities.     

Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report

To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child's obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient's age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.     

A pilot program to identify and reverse childhood obesity in a primary care clinic

This pilot study is an innovative approach to addressing the issue of childhood obesity that starts with the primary care physician and involves group education with peers. The primary care physician assesses the child's well-being at each interaction, whether for a scheduled well-child visit or for an acute illness. At each office visit the vital signs are taken, including the height, weight, and the calculated body mass index (BMI). The BMI is a tool that helps the provider identify children who are overweight or obese. Using the patient empowerment readiness model, the provider addresses obesity with the patient and the parent to determine if they are ready to implement behavioral changes. During a 10-month period, 68 patients were enrolled in the pilot program. The initial results after the 10 months showed that when the provider identified the issue of obesity and the child was assessed for readiness and integrated in the behavioral modification program the outcome was 63% of the group reduced their BMI. It was also noted that asthma was the most frequent comorbidity in the overweight/obese children. Whereas BMI increased in a matched control group, participants in the pilot program succeeded in reducing BMI.     

Definition of obesity in childhood: criteria and limits

A rigorous scientific definition of obesity in childhood is not yet available: in fact, there is not agreement among researchers on the adiposity index to use and on the best cut-off to define overweight and obesity. In this review, the reference methods for the diagnosis of childhood obesity in the clinical practice in Italy are reported. All the statements are based on evidences of the literature and obtained the consensus of the pediatricians of the Study Group on Obesity of the Italian Society of Pediatric Diabetology and Endocrinology. Obesity is caused by an excess of body fat. The methods more frequently used to measure body fat are the measure of subcutaneous skinfold thickness, bioimpedence assessment and DXA. The measure of skinfolds is preferable in the clinical setting because it is easy to use and cheap, although reproducibility is modest. Triceps skinfold is commonly used to define obesity: children with triceps higher than the 85(th) centile for age and gender, using Tanner's tables, are obese. An estimation of fat mass obtained, for instance, with skinfolds is always suggested in addition to the measure of weight and height. It is possible to define a child as obese calculating the ratio between weight (kg) and height squared (m). This ratio is an index, called body mass index (BMI), which is strictly associated to the level of adiposity in children, reproducible and valid. The BMI was recently proposed as the reference index for the diagnosis of childhood obesity at the international level. The use of the centiles of BMI may offer useful information on the changes of weight excess, simplifying the follow-up of the patient and the sensitivity to treatment. The cut-off limits of BMI to define overweight or obesity are still debated. However, in agreement with Cole et al., the choice to use the BMI cut-offs centiles passing through the adult BMI cut-off of 30, is reasonable. However, it is always preferable to use population specific BMI reference tables.     

Quality assessment of clinical practice guidelines for the prevention and treatment of childhood overweight and obesity

Background  The prevalence of childhood overweight and obesity is increasing at dramatic rates in children and adolescents worldwide. Clinical practice guidelines (CPGs) are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Their objective is to provide explicit recommendations for clinical practice based on current evidence for best practice in the management of diseases. Materials and methods  The aim of this study was to identify and assess the quality of CPGs for the prevention and treatment of obesity and overweight in childhood. We developed a search to identify CPGs published between January 1998 and August 2007. We considered for inclusion documents that provided recommendations for clinical practice referring to children and adolescents. Three independent appraisers assessed the quality of the1 CPGs using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument. We identified 376 references and selected 22 for further assessment. Results  The overall agreement among reviewers using the intraclass correlation coefficient was 0.856 (95% confidence interval [CI] 0.731–0.932). Six of the 22 initial guidelines were recommended and a further eight were recommended with conditions or provisos. We concluded that the number of documents with recommendations on the prevention and treatment of childhood obesity published during the 10-year study period was considerable, but only a few of them could be considered as high quality. CPGs were deficient in areas such as applicability, editorial independence and rigor in development. Conclusion  Due to the increasing burden of obesity among children and the potential for long-term comorbidities, clinicians need to be critical in assessing the rigor of how these are developed and their appropriateness for use in the clinician’s own practice. There is a need to improve the methodology and the quality of CPGs on childhood obesity to help clinicians and other decision-makers to tackle this disease. This project was funded with a grant (AE08_015) from CIBER de Epidemiología y Salud Pública (CIBERESP), Spain.     

Stratégies de prévention de l’obésité chez l’enfantPrevention strategies of childhood obesity

Considering the high prevalence and the increasing trends, obesity is now considered as a public health problem in numerous countries. The main aim of the National Program of Nutrition and Health is to stop the increasing prevalence of childhood obesity. In this frame work, a group of experts has established a new presentation of the corpulence curves, adapted for clinical practice, to define normal weight and obesity. Weight status is now currently assessed on the basis of weight and height measurements, after computing the Quetelet index or body mass index (BMI) corresponding to weight (m) divided by square of height (weight/height2). As body proportion varies during growth, age must be taken into account. Various curves were published. In 1982, based on the French sample of the international growth study, BMI curves were published. They were revised in 1991. The third and 97th centiles define the normal weight range. Overweight is defined by BMI values greater than the 97th centile. In the year 2000, a new international definition was established. Two centiles were constructed to define overweight and obesity. The new BMI charts adapted for clinical practice, proposed by the French National program of nutrition and health, include the French reference curves plus the centile defining obesity in the international definition. Thus, in the new French charts, the area above the 97th centile is split in two levels (degree 1 obesity and degree 2 obesity). Drawing the BMI curve for each child, like drawing weight and height curves, is a simple act which can be done routinely. The age at adiposity rebound (an indicator predicting the risk of adult obesity) can be read from the curve. It allows to identify an early phase of obesity development, even at the time when overweight is not yet clinically visible. When obesity appears clearly, the identification is easy. The use of BMI curves is particularly useful in two situations: (1) in very young overweight children, the curves allow to identify children who have a real risk of developing obesity. (2) By the age of 6 years, when due to normal physiological variations, clinical assessment can be misleading. The BMI curves allow to identify children at risk. When a child is identified as having a real risk of obesity, simple preventive measures, adapted for each subject, could avoid a development toward massive obesity, which may become difficult to reduce if managed too late.     

A primary care healthy choices intervention program for overweight and obese school-age children and their parents

IntroductionThe escalating crisis of childhood overweight and obesity creates an urgent demand for evidence-based interventions that can be used by primary care providers. Therefore, the purpose of this study was to test the feasibility, acceptability, and preliminary efficacy of a theory-based Healthy Choices Intervention (HCI) Program with fifteen 9-12 year old overweight and obese children and their parents in a primary care setting.MethodsA 1-group, 7-week pre-/posttest study design was used. Outcome measures included: body mass index (BMI) percentile, physical activity and nutrition knowledge, beliefs, choices and behaviors, anxiety, depression, self-concept, and social competence.ResultsChildren and parents found the HCI to be useful and informative. Positive effects of the HCI for the children included decreased BMI percentile, increased knowledge, beliefs, choices and behaviors, and self-control. Positive effects of the intervention for the parents included increased knowledge, beliefs, behaviors, and decreased anxiety.DiscussionThis study provides evidence to support the feasibility, acceptability, and preliminary effects of the HCI with overweight and obese school-age children and their parents within a primary care setting.     

Fitness levels of Greek primary schoolchildren in relationship to overweight and obesity

Objectives The aim of the present cross-sectional study was to provide estimates for overweight and obesity in a sample of Greek schoolchildren and to determine their possible relation with selected motor and health-related fitness parameters.Materials and methods The study sample consisted of 709 healthy children (328 girls, 381 boys, mean age = 8.9±1.6 years), living in the towns of Agios Stefanos (∼12 000 citizens) and Alexandroupolis (∼60 000 citizens), Greece. All pupils underwent anthropometric, motor and cardiovascular fitness assessments (Eurofit test battery). The body mass index (BMI) cut-off points adopted by the International Obesity Task Force were utilized for the assessment of overweight and obesity.Results 59.4% of the participants had a normal BMI, 25.8% were overweight and 14.8% were obese, without significant differences between genders.Discussions In general, the higher BMI categories were strongly associated with inferior performances in all fitness tests, except flexibility. This graded relationship was consistent for both boys and girls, although the statistical relationship between BMI categories and fitness performance varied by gender.Conclusions In conclusion, the findings of the current study offer some support to the reported high prevalence of childhood obesity in Greece and suggest that overweight and obesity are limiting factors for fitness performance in primary schoolchildren. The present data suggest that interventions promoting children’s health should, ideally, begin early in life and involve measures that simultaneously improve fitness and lower fatness.     

Body mass index measurements and prevalence of overweight and obesity in school-children living in the province of Belgian Limburg

In order to evaluate the distribution of body mass index (BMI) and the prevalence of overweight and obesity in school-children living in the province of Belgian Limburg, BMI percentiles for 9,487 children aged 3.2 to 16.0 years were calculated and compared with the Dutch 1980 values. Although the 5th and 50th percentile BMI values were comparable to or only slightly above the reference values, the 85th and 95th percentiles were much higher revealing an increased degree of obesity in the studied population. The prevalence of overweight and obesity, determined by calculating the proportion of children with a BMI value above the 85th or 95th percentile of the Dutch 1980 reference, ranged for overweight from 15% at the age of 3-4 years to 33% at the age of 12-13 years, and for obesity from 6% to 19%. CONCLUSION: this study shows a dramatic increase in upper body mass index percentiles and in the prevalence of overweight and obesity in children living in the province of Belgian Limburg. Strategies to prevent obesity in childhood should be a priority in child public health programmes.     

Genetic susceptibility and body mass in childhood cancer survivors

Childhood cancer survivors are at increased risk of many long-term treatment-related sequel such as second cancers, cardiovascular disease, and pulmonary complications. Certain treatments seem to influence the risk of becoming overweight, obese, or underweight, and abnormal body mass index (BMI) is associated with increased morbidity and mortality. Because BMI is modifiable, it is important to identify treatment and patient-related factors contributing to altered BMI. New research areas include exploring how genetic susceptibility through population polymorphism may contribute to BMI. Illuminating potential gene-environment interactions that influence obesity and underweight might be more readily accomplished in a study of high-risk individuals (i.e., childhood cancer survivors) with well-characterized exposures. The new Childhood Cancer Research Network in the Children's Oncology Group, when fully implemented, should make it less difficult in the future to recruit the large numbers of patients needed for such studies.     

儿童单纯性肥胖的诊断和治疗

关于肥胖的诊断国内外并尚无统一的判断标准，WHO认为10岁以下和10岁以上应有不同的评价标准，推荐10岁以下儿童使用身高别体质量，10～24岁采用体质量指数（BMI），国际肥胖问题工作组织（IOTF）认为BMI适宜用来判断儿童青少年超重和肥胖。WHO和IOTF提出的18岁BMI超重、肥胖标准完全一样，分别为25和30kg／m^2，而中国肥胖问题工作组（WGOC）制定的标准较比前二者低，18岁BMI超重和肥胖界值点分别为24和28kg／m^2。儿童肥胖的治疗不同于成人，成人期可使用的手术去脂、药物减肥、饥饿疗法、禁食等，在儿童时期均不宜使用。目前国内外公认儿童肥胖治疗方法包括行为矫正、饮食调整和运动等综合治疗方案。     

Overweight and obesity and their associated factors in adolescents in Tehran, Iran, 2004–2005

Overview Obesity is a significant health crisis around the world. Of great concern are the data pointing to the recent increase in the prevalence of obesity irregardless of age group and country. Overweight and obesity in adolescence are markers of overweight and obesity in adults, respectively. Very little data are currently available on the prevalence of childhood obesity in Iran, and more research on the risk factors is required before preventive public health programs can be formulated and put into practice.Objective The objective of this study was to quantify the prevalence of overweight and obesity and their associated factors in adolescent children living in Tehran.Materials and methods During a multistage stratified cluster sampling, 2900 students (1200 males and 1700 females) aged 11–17 years were selected from 20 secondary schools in the school year of 2004–2005. A questionnaire was filled, and weight and height were measured.Discussions and conclusions The body mass index (BMI) was calculated and adjusted for age and sex. Prevalences of overweight and obesity were 17.9 and 7.1%, respectively. BMI increased with age, and it was higher in those who had lower levels of physical activity. Age at menarche was negatively associated with BMI. There was no relationship between macro- and micronutrient intake and overweight and obesity. This study highlights the high prevalence of overweight and obesity in adolescent children in Tehran.     

Regulation of body mass and management of childhood overweight

Obesity has become an increasingly important public health problem. Recent evidence suggests that obesity has become a close second to tobacco use as a preventable cause of death in the United States. During the past decade an increase in the prevalence of type 2 diabetes in adolescents has been observed. The association of type 2 diabetes and obesity is well established and most adolescents with type 2 diabetes have body mass index (BMI) in a range that would already be considered obese in an adult. Childhood overweight is also associated with the atherosclerotic process. In the Bogalusa autopsy study, Berenson et al. found that the extent of fatty streaks and fibrous plaques in the aorta and coronary arteries was associated with BMI. There are three modalities currently available for the treatment of overweight in children and adolescents, including behavioral approaches, pharmacologic approaches, and surgical approaches. Surgical intervention may be considered if the BMI > or = 40 kg/m2 and a severe medical comorbidity including type 2 diabetes, obstructive sleep apnea or pseudotumor cerebri, or if the BMI is > or = 50 kg/m2 and comorbid conditions such as hypertension, dyslipidemia, or the metabolic syndrome are present. Behavioral intervention is usually made by a psychologist, behavioral therapist, dietician, or exercise physiologist. There is evidence that the effect of behavioral therapy for weight loss in childhood will be longer lasting than that seen in adults.     

The relationship of body mass index and blood pressure in primary care pediatric patients

OBJECTIVE: To determine whether an association of overweight, or risk of overweight, and blood pressure can be detected in children in the pediatric primary care practice setting. STUDY DESIGN: We examined electronic medical record (EMR) data from primary care practices on 18,618 children age 2 to 19 years. Each child was classified on the basis of age- and sex-specific body mass index (BMI) percentile as normal weight (BMI < 85th percentile), at risk for overweight (BMI > or = 85th and < 95th percentile), or overweight (BMI > or = 95th percentile). BMI Z-score and height Z-score were computed. Systolic and diastolic blood pressures were compared among age-sex-BMI groups. RESULTS: Among children in primary care pediatric practices, 16.7% were at risk of overweight and 20.2% were overweight. With increasing BMI status there was a significant increase in both systolic blood pressure (P < .001) and diastolic blood pressure (P < .001). The association of higher blood pressure with increasing BMI status was present in all age groups. CONCLUSIONS: Clinical data from pediatric primary care practices verify the high prevalence of childhood overweight. The effect of overweight on blood pressure is present in childhood and can be detected even in children as young as 2 to 5 years.     

Multicomponent school-initiated obesity intervention in a high-risk, Hispanic elementary school

The aim of the study was to determine the effectiveness of a school-initiated cognitive and behavioral program to reduce childhood obesity. Height, weight, body mass index (BMI), and BMI z scores were obtained at the beginning and end of the school year at an intervention school (n?=?1022) and at a control school (n?=?692). The prevalence of overweight and obesity was 18.9% and 30.4% versus 19% and 30.2%, respectively, in the intervention and control schools. The incidence of overweight increased in the control school, but the incidence of obesity, weight, and BMI z scores increased significantly in the intervention school, suggesting that implementation of any school-based obesity intervention programs requires careful planning to achieve goals.     

Obesity in childhood--diagnosis and therapy

Obesity during childhood represents one of the most common nutritional disorders in industrialized countries. The duration of obesity in childhood correlates well with the probability to become an obese adult. Diagnosis of obesity requires reference weight for height tables and the measurement of skinfolds with the caliper technique. Using this method a differentiation between overweight and overnutrition can easily be performed also in an outpatient clinic. For therapeutic purpose a longterm dietary regime with a hypocaloric nutrition has to be reached. Some other dietary regimes ("Protein-modified fast" and "very low calorie diets") are presented and their clinical practicability discussed. The earlier treatment starts for obese children and adolescents the higher is the likelihood for longterm-success. It is emphasized that even pediatricians should focus their interest on prevention of obesity by means of prudent diet education.     

Predicting obesity in early adulthood in Japanese women

Aim:   We analysed the body measurements of Japanese women to determine which factors may forecast adult obesity and also performed a comparative study of the utility of body mass index (BMI), which is used widely in Western Europe, and percentage of overweight, which is used in Japan.
Methods:   Subjects included 244 Japanese women who were born between 1983 and 1986. Using a questionnaire, we investigated anthropometric values from birth to present and parents' present anthropometric data, and analysed factors that correlate with current BMI data.
Results:   (i) BMI after 10 years of age and BMI increase between ages 7 and 8 years correlated with BMI in adulthood. The carrying over rate of overweight increased with age. Meanwhile, percentage of overweight after 13 years onwards correlated with BMI in adulthood. (ii) Adult BMI positively correlated to both parents' BMI.
Conclusions:   (i) For a Japanese woman, BMI in childhood is a good indicator of young adult BMI, and has the possibility of becoming an important parameter to monitor obesity progression. (ii) Therefore, attempts to control obesity in elementary school girls are necessary. (iii) Parents' weights may potentially influence obesity in adulthood; however, further examination of other confounding factors is necessary.