Treatment of Pediatric Overweight and Obesity: Position of the Academy of Nutrition and Dietetics Based on an Umbrella Review of Systematic Reviews

This Academy of Nutrition and Dietetics Position Paper describes current evidence on multi-component interventions with nutrition to treat pediatric overweight and obesity and discusses implications for RDNs. An umbrella review of eight systematic reviews provides evidence that multi-component interventions that include nutrition improve body mass index z-scores in all ages and in a variety of settings. More evidence is needed regarding appropriate body mass index measures to track weight and health status changes in children and adolescents with overweight and obesity. Current evidence indicates that multi-component interventions that include nutrition do not negatively impact psychosocial outcomes, but research on long-term outcomes is needed. Evolving technology and societal circumstances have created opportunities to provide innovative, collaborative, and engaging interventions through telehealth. RDNs specializing in pediatric overweight and obesity treatment play a crucial role in providing a wide range of evidence-based interventions in a variety of settings. These skills are important for tailoring treatment to each child or adolescent while accounting for community and societal factors, which can lead to improved health across the lifespan.     

Position of the Academy of Nutrition and Dietetics: Benchmarks for Nutrition in Child Care

It is the position of the Academy of Nutrition and Dietetics that early care and education (ECE) programs should achieve recommended benchmarks to meet children’s nutrition needs and promote children’s optimal growth in safe and healthy environments. Children’s dietary intake is influenced by a number of factors within ECE, including the nutritional quality of the foods and beverages served, the mealtime environments, and the interactions that take place between children and their care providers. Other important and related health behaviors that may influence the development of obesity include children’s physical activity, sleep, and stress within child care. Recent efforts to promote healthy eating and improve other health behaviors in ECE include national, state, and local policy changes. In addition, a number of interventions have been developed in recent years to encourage healthy eating and help prevent obesity in young children in ECE. Members of the dietetics profession, including registered dietitian nutritionists and nutrition and dietetics technicians, registered, can work in partnership with ECE providers and parents to help promote healthy eating, increase physical activity, and address other important health behaviors of children in care. Providers and parents can serve as role models to support these healthy behaviors. This Position Paper presents current evidence and recommendations for nutrition in ECE and provides guidance for registered dietitian nutritionists; nutrition and dietetics technicians, registered; and other food and nutrition practitioners working with parents and child-care providers. This Position Paper targets children ages 2 to 5 years attending ECE programs and highlights opportunities to improve and enhance children’s healthy eating while in care.     

Position of the Academy of Nutrition and Dietetics: Interventions for the Prevention and Treatment of Pediatric Overweight and Obesity

It is the position of the Academy of Nutrition and Dietetics that prevention and treatment of pediatric overweight and obesity require systems-level approaches that include the skills of registered dietitians, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change. This position paper provides guidance and recommendations for levels of intervention targeting overweight and obesity prevention and treatment from preschool age through adolescence. Methods included a review of the literature from 2009 to April 2012, including the Academy's 2009 evidence analysis school-based reviews. Multicomponent interventions show the greatest impact for primary prevention; thus, early childhood and school-based interventions should integrate behavioral and environmental approaches that focus on dietary intake and physical activity using a systems-level approach targeting the multilevel structure of the socioecological model as well as interactions and relationships between levels. Secondary prevention and tertiary prevention/treatment should emphasize sustained family-based, developmentally appropriate approaches that include nutrition education, dietary counseling, parenting skills, behavioral strategies, and physical-activity promotion. For obese youth with concomitant serious comorbidities, structured dietary approaches and pharmacologic agents should be considered, and weight-loss surgery can be considered for severely obese adolescents. Policy and environmental interventions are recommended as feasible and sustainable ways to support healthful lifestyles for children and families. The Academy supports commitment of resources for interventions, policies, and research that promote healthful eating and physical-activity behaviors to ensure that all youth have the opportunity to achieve and maintain a weight that is optimal for health.     

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.     

Position of the American Dietetic Association: individual-, family-, school-, and community-based interventions for pediatric overweight

The American Dietetic Association (ADA), recognizing that overweight is a significant problem for children and adolescents in the United States, takes the position that pediatric overweight intervention requires a combination of family-based and school-based multicomponent programs that include the promotion of physical activity, parent training/modeling, behavioral counseling, and nutrition education. Furthermore, although not yet evidence-based, community-based and environmental interventions are recommended as among the most feasible ways to support healthful lifestyles for the greatest numbers of children and their families. ADA supports the commitment of resources for programs, policy development, and research for the efficacious promotion of healthful eating habits and increased physical activity in all children and adolescents, regardless of weight status. This is the first position paper of ADA to be based on a rigorous systematic evidence-based analysis of the pediatric overweight literature on intervention programs. The research showed positive effects of two specific kinds of overweight interventions: a) multicomponent, family-based programs for children between the ages of 5 and 12 years, and b) multicomponent, school-based programs for adolescents. Multicomponent programs include behavioral counseling, promotion of physical activity, parent training/modeling, dietary counseling, and nutrition education. Analysis of the literature to date points to the need for further investigation of promising strategies not yet adequately evaluated. Furthermore, this review highlights the need for research to develop effective and innovative overweight prevention programs for various sectors of the population, including those of varying ethnicities, young children, and adolescents. To support and enhance the efficacy of family- and school-based weight interventions, community-wide interventions should be undertaken; few such interventions have been conducted and even fewer evaluated.     

The role of dental practitioners in addressing overweight and obesity among children: A scoping review of current interventions and strategies

IntroductionWith the growing prevalence of childhood obesity worldwide, there is a need for interventions to identify and address overweight and obesity in childhood. Although guidelines recommend general practitioners routinely screen for overweight and obesity among children, research suggests this is often not done. To address this, dental practitioners may be able to play a role in identifying and addressing overweight and obesity among children.MethodsThis review aimed to explore the evidence and efficacy of existing obesity and overweight interventions targeting children in the dental setting. A systematic search of nine electronic databases was conducted to identify relevant published and grey literature. This was expanded to also include strategies for promoting oral health in the dental setting.ResultsA total of 11 records were included in this review, which focussed on the current role and effectiveness of dental practitioners in addressing obesity among children, and the available strategies and resources. Although there was a paucity of research on the training of dental practitioners in this area and their efficacy in identifying and addressing obesity among children, evidence suggests that parents found it acceptable for dental practitioners to promote healthy practices to children who experience overweight or obesity. This review also identified screening tools and strategies for identifying and addressing overweight and obesity among children in dental practice.ConclusionThere is a clear role for dental practitioners in addressing overweight and obesity among children, however further research is required to identify the most effective interventions to implement in dental practice.     

Cognitive-behavioral approaches in the management of obesity

Many of the behavioral interventions designed to promote dietary change in individuals include medical assessment, initial assessment of diet history, assessing readiness, establishing dietary goals, self-monitoring, stimulus control training, training in problem solving, relapse prevention training, enlisting social support, nutrition education, dietary therapy, and ongoing contact to maintain progress. The comprehensive nature of a cognitive-behavioral weight management program is of value in modifying behaviors that are linked to adverse health effects and psychological distresses, without necessarily causing a drastic weight loss in obese individuals. The behavioral treatments for overweight and obesity directly modify behaviors that bear on health and illness, such as improving dietary choices, decreasing sedentary behaviors, and increasing habitual physical activity and exercises. Cognitive-behavioral treatment can be used to help overweight adolescents become more assertive in coping with the adverse social stigma of being overweight, enhance their self-esteem, and reduce their dissatisfaction with body image regardless of their weight loss. Cognitive-behavioral treatments seem to be more effective in children when delivered before puberty than they are for adults.     

Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Pediatric Nutrition

Pediatrics spans the first 2 decades of life and is a dynamic period with rapid changes in size and physical ability, cognitive development, behavior, and nutrient needs. Registered dietitian nutritionists (RDNs) who work with the pediatric population provide the nutrition knowledge and support needed to promote optimal health and nutrition during this time across a variety of settings. The Pediatric Nutrition Practice Group, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working with pediatric populations. The SOP and SOPP for RDNs in Pediatric Nutrition provide indicators that describe 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP illustrate how these standards apply to practice. The SOP and SOPP are intended to be used as a self-evaluation tool for assuring competent practice in pediatric nutrition and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.     

Peer Reviewed: Developmental Perspectives on Nutrition and Obesity From Gestation to Adolescence

Obesity results from a complex combination of factors that act at many stages throughout a person''s life. Therefore, examining childhood nutrition and obesity from a developmental perspective is warranted. A developmental perspective recognizes the cumulative effects of factors that contribute to eating behavior and obesity, including biological and socioenvironmental factors that are relevant at different stages of development. A developmental perspective considers family, school, and community context. During gestation, risk factors for obesity include maternal diet, overweight, and smoking. In early childhood, feeding practices, taste acquisition, and eating in the absence of hunger must be considered. As children become more independent during middle childhood and adolescence, school nutrition, food marketing, and social networks become focal points for obesity prevention or intervention. Combining a multilevel approach with a developmental perspective can inform more effective and sustainable strategies for obesity prevention.     

School-Based Nutrition Interventions in Children Aged 6 to 18 Years: An Umbrella Review of Systematic Reviews

Schools are identified as a key setting to influence children’s and adolescents’ healthy eating. This umbrella review synthesised evidence from systematic reviews of school-based nutrition interventions designed to improve dietary intake outcomes in children aged 6 to 18 years. We undertook a systematic search of six electronic databases and grey literature to identify relevant reviews of randomized controlled trials. The review findings were categorised for synthesis by intervention type according to the World Health Organisation Health Promoting Schools (HPS) framework domains: nutrition education; food environment; all three HPS framework domains; or other (not aligned to HPS framework domain). Thirteen systematic reviews were included. Overall, the findings suggest that school-based nutrition interventions, including nutrition education, food environment, those based on all three domains of the HPS framework, and eHealth interventions, can have a positive effect on some dietary outcomes, including fruit, fruit and vegetables combined, and fat intake. These results should be interpreted with caution, however, as the quality of the reviews was poor. Though these results support continued public health investment in school-based nutrition interventions to improve child dietary intake, the limitations of this umbrella review also highlight the need for a comprehensive and high quality systematic review of primary studies.     

Food Insecurity and Pediatric Malnutrition Related to Under- and Overweight in the United States: An Evidence Analysis Center Systematic Review

Both food insecurity and malnutrition are associated with adverse health outcomes in the pediatric population. However, the research on the relationship between these factors has been inconsistent, leading to uncertainty regarding whether or how evaluation of food insecurity should be incorporated into nutrition screening or the nutrition care process. The objective of this systematic review was to determine the association between food insecurity and malnutrition related to undernutrition or overnutrition (defined by anthropometrics) in the pediatric population in the United States. A literature search was conducted using Medline, Embase, and CINAHL databases for studies published from January 2002 through November 2017. A total of 23 studies (19 cross-sectional and 4 prospective cohort studies) met inclusion criteria and were included in qualitative analysis. In 6 studies, there was no overall relationship between food insecurity and underweight. All included studies examined the relationship between food insecurity status and overweight/obesity and results were mixed, with large cross-sectional studies demonstrating a positive relationship between food insecurity and overweight/obesity. There were no clear patterns according to subpopulation. Evidence quality was graded as fair due to heterogeneity in how food insecurity was measured and populations included as well as inconsistency in results. Use of a 2-item food insecurity screening tool may allow for efficient, effective screening of food insecurity in order to identify potential contributors overweight and obesity.     

School- and family-based interventions to prevent overweight in children

There have been only a few controlled studies on the prevention of overweight and obesity in children and adolescents. These studies differ in relation to strategy, setting, duration, focus, variables of outcome and statistical power, and therefore do not allow general conclusions to be made about the value of preventive measures. All school-based interventions aimed at the prevention of overweight and obesity show some improvement of health knowledge and health-related behaviours. Short-term effects on nutritional state seem to be more pronounced in girls than in boys. School-based interventions can reduce the incidence of overweight. There is evidence that families of intermediate and high socio-economic status as well as intact families benefit more from treatment than families sharing other characteristics. Selected prevention in obese children is most successful when children are treated together with their parents. However, there are social barriers limiting the success of family-based interventions. Although some positive effects have been reported, simple interventions in a single area (e.g. a school health education programme) are unlikely to work on their own. The development of effective preventive interventions probably requires strategies that affect multiple settings simultaneously. At present there is no concerted action, rather many strategies in health promotion that are followed in isolation. Faced with the epidemic of overweight there is a need for national campaigns and action plans on childhood overweight and obesity. It is tempting to speculate that this strategy will also increase the value of isolated approaches (e.g. in schools and families).     

Position of the Academy of Nutrition and Dietetics: Nutrition Guidance for Healthy Children Ages 2 to 11 Years

It is the position of the Academy of Nutrition and Dietetics that children ages 2 to 11 years should achieve optimal physical and cognitive development, maintain healthy weights, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. Rapid increases in the prevalence of childhood obesity during the 1980s and 1990s focused attention on young children’s overconsumption of energy-dense, nutrient-poor foods and beverages and lack of physical activity. While recent data suggest a stabilization of obesity rates, several public health concerns remain. These include the most effective ways to promote healthy weights, the number of children living in food insecurity, the under-consumption of key nutrients, and the early development of diet-related risks for chronic diseases, such as cardiovascular disease, type 2 diabetes, cancer, obesity, and osteoporosis. This Position Paper reviews what children 2 to 11 years old in the United States are reportedly eating, explores trends in food and nutrient intakes, and examines the impact of federal nutrition programs on child nutrition. Current dietary recommendations and guidelines for physical activity are also discussed. The roles of parents and caregivers in influencing the development of life-long healthy eating behaviors are highlighted. The Academy of Nutrition and Dietetics works with other allied health and food industry professionals to translate dietary recommendations and guidelines into positive, practical health messages. Specific recommendations and sources of science-based nutrition messages to improve the nutritional well-being of children are provided for food and nutrition practitioners.     

Practice Paper of the Academy of Nutrition and Dietetics Abstract: Oral Health and Nutrition

This paper supports the “Position of the Academy of Nutrition and Dietetics: Oral Health and Nutrition” published in the May 2013 Journal of the Academy of Nutrition and Dietetics. It is the position of the Academy of Nutrition and Dietetics that nutrition is an integral component of oral health. The Academy supports integration of oral health with nutrition services, education, and research. Collaboration between registered dietitian nutritionists (RDNs); dietetic technicians, registered (DTRs); and oral health care professionals is recommended for oral health promotion and disease prevention and intervention. There is a synergistic multidirectional association between diet, nutrition, and oral health. Given that the mouth is the portal of entry into the body, it is essential that RDNs and DTRs include the oral cavity in their assessment for nutritional risk factors and deficiencies. Nutrition assessment is vital to identifying dietary intake and nutritional factors impacting oral health. Conversely, decreased salivary flow, compromised oral integrity, tooth decay, or poor periodontal health can impact an individual's ability to consume an adequate diet. A poor diet can result in limited intake of nutrients crucial to systemic health and well-being. The provision of medical nutrition therapy that incorporates total health, including oral health, is a component of the Standards of Practice for RDNs and DTRs. Inclusion of didactic and clinical practice concepts that illustrate the role of nutrition in oral health is essential in education programs for both professional groups. The multifaceted interactions between diet, nutrition, and oral health in practice, education, and research in both dietetics and dentistry merit the need for collaborative efforts to ensure comprehensive patient care.     

The Weight and Fitness Status of United States Children

Although the prevalence of overweight and obesity among US children is a concern for many health care professionals, incidence rates over time seem to be variable, depending on the assessment measurements used. It is difficult to determine the associated health implications of pediatric obesity or overweight, especially the type that might result in adult obesity or overweight. This review examines the various factors that contribute to the weight and fitness status of children, including anthropometric factors, nutrient intake, the level of physical activity, and nutrition knowledge. Nutrient intake data of the past decade show that the energy and fat intakes of children in the United States have been fairly constant. However, data also indicate that their physical activity has declined. The data strongly suggest that the apparent prevalence of pediatric overweight may not be so much a function of nutrient intake as of a decrease in physical activity leading to an imbalance of energy input and output.     

The effect of participation in school-based nutrition education interventions on body mass index: A meta-analysis of randomized controlled community trials

ObjectiveThe aim of this study was to evaluate the effectiveness of school-based nutrition education interventions in reducing or preventing overweight and obesity among children and adolescents.MethodsWe conducted a systematic search of 14 databases until May 2010 and cross-reference check in 8 systematic reviews (SRs) for studies published that described randomized controlled trials conducted in schools to reduce or prevent overweight in children and adolescents. An additional search was carried out using PubMed for papers published through May 2012, and no further papers were identified. Body mass index (BMI) was the primary outcome. The title and abstract review and the quality assessment were performed independently by two researchers. The software EPPI-Reviewer3 was used to store, manage and analyze all data. This SR is registered at ClinicalTrials.gov (NCT00985972).ResultsFrom the 4888 references initially retrieved, only 8 met the eligibility criteria for a random-effects meta-analysis. The total population consisted of 8722 children and adolescents. Across the studies, there was an average treatment effect of ? 0.33 kg/m² (? 0.55, ? 0.11 95% CI) on BMI, with 84% of this effect explained by the highest quality studies.ConclusionThis systematic review provides evidence that school-based nutrition education interventions are effective in reducing the BMI of children and adolescents.     

中国学龄儿童营养健康状况及改善措施建议

学龄儿童处于生长发育和行为培养的关键时期.中国学龄儿童在营养健康状况逐步改善的同时,也面临超重肥胖迅速增加、营养不足依然存在、微量营养素摄入不足的多重挑战.不仅与膳食结构不合理、身体活动不足及行为生活方式不健康密切相关,也受到社会生活环境的影响.中国各部门陆续出台了一系列营养健康相关政策和行动,从贫困农村儿童营养改善、...     

Demographic and Placement Variables Associated with Overweight and Obesity in Children in Long-Term Foster Care

Overweight and obesity is a growing problem for children in foster care. This study describes the prevalence of overweight and obesity in an urban, ethnic minority population of children ages 2–19 in long-term foster care (N = 312) in Los Angeles, California. It also investigates whether demographics or placement settings are related to high body mass index. The estimates of prevalence of overweight/obesity (≥85th percentile) and obesity (≥95th percentile) were presented for gender, age, ethnicity, and placement type. Multiple logistic regression was used to examine potential associations between demographic and placement variables and weight status. The prevalence of overweight/obesity was almost 40 % and obesity was 23 % for the study population. Children placed in a group home had the highest prevalence of overweight/obesity (60 %) and obesity (43 %) compared to other types of placement. Within this study, older children (ages 12–19) were more likely to be overweight/obese than normal weight compared to children between 2 and 5 years old when controlling for gender, ethnicity and placement (OR = 2.10, CI = 1.14–3.87). These findings suggest that older age and long-term foster care in general may be risk factors for obesity. Child welfare agencies and health care providers need to work together to train caregivers with children in long-term foster care in obesity treatment interventions and obesity prevention strategies.     

超重和肥胖学生膳食与运动的知·信·行分析

目的了解超重和肥胖学生膳食与运动的知、信、行现状,为儿童肥胖的预防和控制提供理论依据.方法采用分层整群随机抽样方法,对北京、武汉、深圳3个城市小学三～四年级的超重和肥胖学生进行统一问卷调查.结果 41.07%的学生正确回答了6项以上知识问题,答对率在75%以上的比例仅为1.83%;87.48%的学生不知道肥胖对健康的影响,80.48%的学生不了解如何控制体重增长趋势.超重和肥胖学生对膳食与运动的正确态度持有率为53.13%.75%以上的学生表示愿意获取有关膳食与运动的知识,并愿意在获得相关知识的前提下,做出积极健康的行为改变.在15项行为中,65%左右的超重或肥胖学生只能保持3～5种正确行为,而能保证体育课外健身运动时间的学生只有25.04%.结论超重和肥胖学生对膳食与运动的认识比较缺乏,但有强烈的求知欲望.