Home > For Physicians & Professionals > Screening and Prevention > Childhood Obesity
Childhood Obesity
Screening and Prevention of Childhood Obesity in the Medical Home
In this section we will describe prevention approaches that can be incorporated into well child care. In another area, approaches for evaluating and treating children who are overweight or obese are described.
Current approaches to obesity prevention are based on influencing behavior—those related to a child’s eating and those related to his/her level of physical activity. Obesity prevention, like all prevention activities can be divided into primary, secondary and tertiary strategies. [Fletcher: 1996] Primary prevention includes efforts to influence, in healthy directions, the eating and activity behavior of all children. Secondary prevention efforts are those that are directed toward children who, for whatever reason, are at greater than average risk of becoming obese. Tertiary prevention includes those that are designed to prevent the consequences of obesity and would, in this context, be considered treatment.
- History
- Family History of Obesity and Type 2 Diabetes. Obesity is one of the most heritable conditions. A child born to two obese parents has about an 80% risk of developing obesity. [Reilly: 2005] Determining whether there is a history of obesity and/or type 2 diabetes in first and second degree relatives is a potentially very useful approach to identifying children at greater than average risk of becoming obese.
- LGA, SGA, and IUGR infants are at increased risk of obesity and some studies suggest that the latter two groups are at increased risk of hypertension, diabetes and cardiovascular disease independent of their risk of obesity. It has been suggested that these abnormal growth patterns are associated with the development of insulin resistance, which leads to these outcomes. [Morgan: 2010]
- Assessment of Growth Patterns
- Rapid Early Weight Gain. Infants whose weight at 4 months is significantly greater than twice their birth weight are more likely to become obese as children and adults. [Reilly: 2005], [Gungor: 2010]
-
Early Adiposity rebound. It is important to determine and plot the Body Mass Index (BMI) beginning at age 2. The CDC growth charts for children 2-20
demonstrate that the BMI (which is an indicator of the amount of adipose tissue) decreases from age 2 to about age 6-8 depending
on the child’s percentile at age 2. Children whose BMI does not decrease, i.e., does not stay in the same percentile between
2 and 6-8 are most likely developing excess amounts of adipose tissue and are at risk for obesity. [Whitaker: 1998], [Taylor: 2005]. See the CDC Adiposity Rebound (AR) chart below.
-
BMI >85% <95th for age. A child with a BMI over the 85th% is considered to be “overweight” while one over the 95th% is considered to be “obese.”
Children with BMI’s between the 85th and 95th % are at increased risk of moving into the obese range—particularly if their
BMI has shown an accelerating trajectory from one below the 85th to one above the 85th in the past few years.
- Screening for Obesity
- BMI. Obtaining accurate measures of height and weight and calculating and plotting the BMI is the most practical method of screening for obesity. [Krebs: 2007] , [Cole: 2000] A variety of charts (Printable BMI Chart for Girls, Printable BMI Chart for Boys), wheels (Body Mass Index (BMI) Wheel), websites (Online BMI Calculator), and computer and smart phone applications (BMI Calculator for Blackberry Smartphone) are available to assist with calculating the BMI and assessing the percentile; however, it is critical that both the height and weight be obtained accurately. See the CDC WHO Growth Charts. It is important to note that most of the health risks associated with obesity are related to the presence of excessive amounts of adipose tissue as well as its distribution. An elevated BMI is strongly correlated with excess adiposity, but the correlation is not perfect. Moreover, BMI does not provide any information regarding whether the distribution of the excess adipose tissue is central (visceral) or not. Central or visceral obesity is more highly correlated with insulin resistance, type 2 diabetes and increased cardiovascular disease risk. Clinical judgment and longitudinal patterns of BMI must be utilized, particularly for children and adolescents who appear to be muscular and whose BMI is minimally elevated. [Morgan: 2010]
- Waist Circumference is used in adults to provide an estimate of excess adipose tissue. It is becoming more widely used in children and adolescents. Because waist circumference increases as a child grows, it is probably better to calculate the ratio of the child’s waist circumference to his height. (WC/Ht). Ratios that exceed 0.5 are considered to be abnormal. [Li: 2006] Obtaining an accurate WC in children is challenging. In research settings, using a cloth, non-stretchable tape at the level of the umbilicus with the child relaxed is recommended, and this is probably appropriate for clinical settings.
- Visual Assessment. Many clinicians feel that they can reliably determine whether a child is obese or by simply looking at the child and assessing the apparent presence of excess adiposity. Although no studies have compared the sensitivity and specificity of visual assessment compared with plotting on a BMI chart, most experts agree that visual assessment is an insensitive tool for recognizing overweight or obesity. The CDC has an exercise to show the difficulty in visually assessing overweight in children (best viewed in Internet Explorer): Visual Assessment vs Calculation of BMI. However, in conjunction with an appropriately assessed BMI, a clinician’s assessment of whether the child looks “fat” or not may be some value.
- Skin Fold Measures Assessing skin fold thickness with the use of calipers at various sites (usually the triceps or subscapular areas) is commonly used in research settings and in some obesity specialty clinics to provide an estimate of adiposity. Because of the difficulty of obtaining these accurately unless special training has been received, it cannot be recommended for routine screening in primary care settings. [Krebs: 2007]
Why primary prevention?
- Our ability to determine which infants and children are, for genetic, epigenetic or other reasons, have an increased risk to become obese is imperfect. [Whitaker: 2010]
- The behaviors being recommended have health benefits beyond obesity prevention
- They are extremely unlikely to be harmful
- Breast Feeding. Observational studies have suggested a lower prevalence of obesity in children who are breast-fed. These studies are challenging because of potential confounding factors but most experts agree that exclusive breast-feeding for 6 months with continued breast-feeding for the next 6 months can reduce the risk of obesity. The mechanism is unknown, but one possible explanation is that the baby is eating to satisfy his own internal cues rather than an amount based on what the feeder thinks he/she “should” take in. There may be components of breast milk that influence body composition and a feeling of satiety. Comparing the CDC and WHO growth charts for the first two years reveals a more rapid pattern of weight gain in the first several months and a slower weight gain after that. Because the WHO growth charts reflect a population of largely breast fed infants, this pattern is considered to be healthier. See the CDC WHO Growth Charts.
- Encourage physical activity and decrease sedentary activity, especially screen time. Because obesity results from an excess of calories taken in compared with those expended, it makes sense that a high level of physical activity would reduce the risk of obesity. However, for growing children, at least, physical activity may have additional benefits in terms of influencing immature pluripotent stem cells to differentiate into lean body mass rather than adipose tissue. [Gutin: 2010] Since the behavior of infants and young children is strongly influenced by parental behavior, parents should be encouraged to model regular physical activity from early infancy. There are a number of devices that allow parents to “wear” their baby while they walk or hike. Taking a baby outside using a jogger, strollers, backpacks, etc. everyday will model this until the child is old enough to walk and play on his/her own. Watching TV is not only a sedentary, non-active behavior but exposes the child to a variety of advertisements for a wide variety of high calorie, mostly unhealthy foods. The American Academy of Pediatrics advises no TV for children under two and a less than two hour limit on all screen time for older children
- No or almost no sweetened beverages. There is strong evidence of an association between the intake of sweetened beverages and obesity or excess adiposity. Sweetened beverages include soda, sports beverages and sweetened fruit drinks among others. Current evidence does not support an association between 100% fruit juice and obesity unless consumed in “large quantities.” The AAP currently recommends that consumption of 100% fruit juice be limited to one serving (4-6 oz) per day for children between 1 and 6. Some pediatricians have questioned the benefits of juice and have recommended that its consumption be even more limited—perhaps to “none.”
- Fruits and Vegetables. There is modest evidence that consumption of fruits and vegetables can help to prevent obesity. The recommendation of five servings per day of fruits and vegetables is based on evidence collected by the American Dietetic Association.18 for some reason I can’t get this website to show up in the references (www.adaevidencelibrary.com/topic.cfm?cat_1046.) In their review the evidence was better for fruits and vegetables but this may be because the category of “vegetables” included French fries and potato chips, which are unlikely to be an effective food group for preventing obesity!
- five servings of fruits and vegetables
- less than two hours of screen time
- more than one hour of exercise
- zero sweetened beverages
Consistent with the AAP approval of a serving of 100% juice, some have modified this to “5-2-1-almost none.” The "5-2-1-0" message is available in a prescription format at "5-2-1-0 Prescription" (
586 KB)
.
In addition to recommending exclusive breast-feeding and the "5-2-1-0" message as primary prevention strategies, clinicians
may wish to consider additional advice that the expert committee 5 found had either consistent or modest evidence for preventing
obesity. These include:
- Breakfast skipping. Skipping breakfast has been associated with more metabolic dysfunction including greater waist circumference, higher fasting insulin, higher total cholesterol and higher LDL, even after adjusting for other potential confounders.19 There is also evidence that overweight and obese adolescents are more likely those of normal weigh to skip breakfast than their non-obese peers, and that when they eat breakfast, it is smaller and of a lower nutritional quality.18 Although there is no definite evidence that eating breakfast will prevent obesity, particularly in an infant of child who is higher than average risk of obesity, there is no evidence at all that such a strategy would be harmful.
- Eating Out, especially Fast Food. There is fairly convincing evidence that consumption of food at Fast Food Restaurants is associated with obesity.5 Although some children can probably eat at Fast Food restaurants and not develop obesity, there seems to be little benefit to doing so. Parents of children who are at higher risk based on genetics or other factors (see above) should be advised of this association and encouraged to limit their Fast Food Restaurant outings.
- Portion Size. Larger than recommended portion sizes—particularly of calorically dense foods, e.g., those high in fat—are associated with obesity. Appropriate portion sizes vary with age; recommendations for size and number of portions can be found at USDA Food Pyramid. A convenient estimate of appropriate portion size is one that approximates the size of the infant or child’s fist.
- Family Meals. There is modest evidence that, for adolescents at least, dietary “quality” is better when most meals are eaten as a family. One study reported that among children between 9 and 14, the frequency of family dinners was inversely associated with the prevalence of overweight. 20 Although evidence is lacking that families regularly eating together is an effective primary prevention strategy, there are likely to be additional benefits and minimal risk.
Resources
Information & Support
For Professionals
Weekly 5-2-1 Log
( 99 KB)
Growing Up Healthy and Strong Is as Easy as 5-2-1! Eat 5 servings of fruits and veggies each day. Limit your screen time
to 2 hours or less. Get 1 hour or more of activity. Track your progress every day. Record each amount in the chart. From
Jump Up & Go!
Jump Up & Go! Youth Wellness Resources list
( 246 KB)
Links to websites and organizations with health & wellness information about and for kids. From Jump Up & Go!, a youth wellness
program developed in Massachusetts.
A Menu for Action
( 270 KB)
Adapted from the Jump Up & Go! Physical Activity and Nutrition Survey and the Maine Center for Public Health Keep Me Healthy
Goal Setting Worksheet.
For Parents and Patients
A Menu for Action
( 270 KB)
Adapted from the Jump Up & Go! Physical Activity and Nutrition Survey and the Maine Center for Public Health Keep Me Healthy
Goal Setting Worksheet.
Tools
Anticipatory Guidance to Prevent Childhood Obesity
( 68 KB)
Anticipatory guidance to prevent childhood obesity for prenatal to 6 years and up Well Child Checkups.
BMI Calculator for Blackberry Smartphone
Free Blackberry smartphone application to calculate BMI.
BMI Surveillance and clinical decision support for immunization screening registry
Michigan has developed a system that integrates BMI surveillance and clinical decision support for screening into Michigan’s
immunization registry. All providers are already mandated to report immunizations to the system, so by just adding height
and weight, Michigan providers will have access to all these tools.
BMI females 2-20 years
( 68 KB)
From the Centers for Disease Control Growthcharts, http://www.cdc.gov/growthcharts accessed 9/1/2009.
BMI males 2-20 years
( 62 KB)
From the Centers for Disease Control Growthcharts, http://www.cdc.gov/growthcharts accessed 9/1/2009.
Body Mass Index (BMI) Wheel
A CD-sized wheel to align height and weight values to determine patient's body mass index. One side calculates BMI for children
20 to 80 pounds, while the other calculates BMI for adolescents and adults from 80 to 350 pounds.
Encounter Documentation Tool
( 128 KB)
Key Elements to Include in an Encounter Form. Taken from Jump Up & Go! and NICHQ
Online BMI Calculator
Parents often wonder if their children are overweight, underweight or just right. Using this body mass index calculator, you
can figure out if your child is at an appropriate weight for his or her height.
Printable BMI Chart for Boys
Body Mass Index (BMI) percentiles for boys, from two to twenty years, so that you can track a child's growth curve and see
if they are underweight, overweight or just right. Download, view or print out the chart.
Printable BMI Chart for Girls
Body Mass Index (BMI) percentiles for girls, from two to twenty years, so that you can track a child's growth curve and see
if they are underweight, overweight or just right. Download, view or print out the chart.
Services
Recreation Programs/Activities
See all Recreation Programs/Activities services providers (176) in our database.
For other services related to this condition, browse our Services categories or search our database.
Helpful Articles
Davis MM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, Resnicow K.
Recommendations for prevention of childhood obesity.
Pediatrics.
2007;120 Suppl 4:S229-53.
PubMed abstract
Mullis RM, Blair SN, Aronne LJ, Bier DM, Denke MA, Dietz W, Donato KA, Drewnowski A, French SA, Howard BV, Robinson TN, Swinburn
B, Wechsler H.
Prevention Conference VII: Obesity, a worldwide epidemic related to heart disease and stroke: Group IV: prevention/treatment.
Circulation.
2004;110(18):e484-8.
PubMed abstract
Whitaker RC.
The infancy of obesity prevention.
Arch Pediatr Adolesc Med.
2010;164(12):1167-9.
PubMed abstract
Authors
| Author: | Paul Young MD, 1/2011 |
Page Bibliography
Cole TJ, Bellizzi MC, Flegal KM, Dietz WH.
Establishing a standard definition for child overweight and obesity worldwide: international survey.
BMJ.
2000;320(7244):1240-3.
PubMed abstract / Full Text
Davis MM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, Resnicow K.
Recommendations for prevention of childhood obesity.
Pediatrics.
2007;120 Suppl 4:S229-53.
PubMed abstract
Fletcher RH, Fletcher SW, Wagner EH.
Clinical Epidemiology: The Essentials.
Third ed. Baltimore: Williams and Wilkins;
1996.
Gungor DE, Paul IM, Birch LL, Bartok CJ.
Risky vs Rapid Growth in Infancy: Refining Pediatric Screening for Childhood Overweight.
Arch Pediatr Adolesc Med.
2010;164(12):1091-7.
PubMed abstract
Gutin B.
Diet vs exercise for the prevention of pediatric obesity: the role of exercise.
Int J Obes (Lond).
2010;.
PubMed abstract
Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D.
Assessment of child and adolescent overweight and obesity.
Pediatrics.
2007;120 Suppl 4:S193-228.
PubMed abstract
Li C, Ford ES, Mokdad AH, Cook S.
Recent trends in waist circumference and waist-height ratio among US children and adolescents.
Pediatrics.
2006;118(5):e1390-8.
PubMed abstract
Morgan AR, Thompson JM, Murphy R, Black PN, Lam WJ, Ferguson LR, Mitchell EA.
Obesity and diabetes genes are associated with being born small for gestational age: results from the Auckland Birthweight
Collaborative study.
BMC Med Genet.
2010;11:125.
PubMed abstract / Full Text
Mullis RM, Blair SN, Aronne LJ, Bier DM, Denke MA, Dietz W, Donato KA, Drewnowski A, French SA, Howard BV, Robinson TN, Swinburn
B, Wechsler H.
Prevention Conference VII: Obesity, a worldwide epidemic related to heart disease and stroke: Group IV: prevention/treatment.
Circulation.
2004;110(18):e484-8.
PubMed abstract
Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. .
Prevalence of overweight and obesity in the United States, 1999-2004.
JAMA.
2006;295((13)):1549-1555.
PubMed abstract / Full Text
The increase in the prevalence of overweight among children and adolescents and obesity among men suggest that the increases
in body weight are continuing in men and in children and adolescents while they may be leveling off in women.
Olshansky SJ, Passaro DJ, Hershow RC, Layden J, Carnes BA, Brody J, Hayflick L, Butler RN, Allison DB, Ludwig DS.
A potential decline in life expectancy in the United States in the 21st century.
N Engl J Med.
2005;352(11):1138-45.
PubMed abstract
Reilly JJ, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I, Steer C, Sherriff A.
Early life risk factors for obesity in childhood: cohort study.
BMJ.
2005;330(7504):1357.
PubMed abstract / Full Text
Silventoinen K, Sans S, Tolonen H, Monterde D, Kuulasmaa K, Kesteloot H, Tuomilehto J.
Trends in obesity and energy supply in the WHO MONICA Project.
Int J Obes Relat Metab Disord.
2004;28(5):710-8.
PubMed abstract
Swinburn B, Gill T, Kumanyika S.
Obesity prevention: a proposed framework for translating evidence into action.
Obes Rev.
2005;6(1):23-33.
PubMed abstract
Taylor RW, Grant AM, Goulding A, Williams SM.
Early adiposity rebound: review of papers linking this to subsequent obesity in children and adults.
Curr Opin Clin Nutr Metab Care.
2005;8(6):607-12.
PubMed abstract
Whitaker RC.
The infancy of obesity prevention.
Arch Pediatr Adolesc Med.
2010;164(12):1167-9.
PubMed abstract
Whitaker RC, Pepe MS, Wright JA, Seidel KD, Dietz WH.
Early adiposity rebound and the risk of adult obesity.
Pediatrics.
1998;101(3):E5.
PubMed abstract