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Features Departments Information |
 Rebecca Unger, MD  Adolfo Ariza, MD  Linda Somers, RD  Wendy Brickman, MD  Timothy Sentongo, MD |
Clinical Management of Childhood Overweight: Rebecca Unger, MD, Adolfo Ariza, MD, Linda Somers, RD, Wendy Brickman, MD, Timothy Sentongo, MD The number of overweight children and adolescents continues to rise, with alarming consequences. These children are at increased risk for overweight-related medical conditions and psychosocial difficulties. Particularly with the emergence of type 2 diabetes in the pediatric population, overweight can no longer be dismissed as purely an issue of appearance. Today, children tend to consume more junk food and sugary drinks, while spending more hours watching television and less time being active—a lifestyle that contributes to the development of overweight. Experts have found that parental role modeling of unhealthy eating habits and insufficient physical activity may strongly influence and perpetuate the behavioral patterns that lead to overweight and the associated medical problems. Given the current epidemic of childhood overweight, clinical management of nutritional issues needs to feature prominently in routine primary care. Clinicians working with children can prevent childhood overweight by helping patients and families understand overweight as a chronic illness that requires significant changes in eating and physical activity patterns to avoid serious complications. And the earlier we can intervene and initiate preventive measures, the more promising the outcomes can be. Recent surveys of management practices for pediatric overweight found that clinicians generally know what to advise patients and families, but want more guidance on how to counsel and motivate families to change daily habits.1 To address this common barrier to effective interventions, we will discuss here an ongoing case from the Nutrition Evaluation Clinic at Children’s Memorial Hospital. At the Nutrition Evaluation Clinic, we help children and their families make gradual, permanent changes in eating and physical activity that lead to a healthier lifestyle. The clinic’s multidisciplinary specialists—pediatricians, dietitians, a social worker, and an exercise physiologist—evaluate and address the numerous issues contributing to a persistent problem with overweight. The clinic specialists also work closely with other specialists at Children’s Memorial, including endocrinologists, cardiologists, and gastroenterologists. In reference to the case of a severely overweight boy seen at the clinic, we will focus on evaluation of the clinical problem, intervention, and prevention strategies. Family-centered behavior modification approach The Nutrition Evaluation Clinic’s general approach to management of childhood overweight can be effectively applied in general pediatric practice. We confront nutritional problems in children by focusing on the entire family. Isolating the overweight child as the only one in the family who must change can make the patient feel deprived, resentful, and more likely to relapse into unhealthy habits. On the other hand, long-term change is more feasible when all family members are engaged in adopting new behaviors. We particularly encourage parents and other caretakers to role model healthier behaviors by improving their own dietary patterns and increasing their level of physical activity. According to research, the behavioral family-centered model for managing overweight children and adolescents is essential to long-term success.2 At the Nutrition Evaluation Clinic, we do not promote weight loss as the ultimate goal for overweight children. Instead, we strive to maintain the child’s weight while his or her height increases. We view success as the family’s consistent adherence to healthier lifestyle patterns through which further weight gain is prevented. Definitions of childhood overweight: Correlation of weight and height Childhood overweight is identified through a relation of weight and height, in respect to norms for age and gender. In the literature, overweight is defined with reference to a body mass index (BMI), which is calculated by dividing weight in kilograms by height in meters squared. A child or adolescent is considered “overweight” when the BMI is at or above the 95th percentile in respect to the latest gender-specific BMI-for-age growth charts from the Centers of Disease Control and Prevention (CDC). When the BMI is at or above the 85th percentile and less than the 95th percentile, a child or adolescent is identified as being “at risk for overweight.”3 At the Nutrition Evaluation Clinic, we express the relationship between the child's weight and height in terms of percent of ideal body weight (IBW) for height. We arrive at this number by first determining the child’s “height-age.” The height-age is the age at which the child's height intersects the 50th percentile on the growth chart. The IBW is then determined by locating the weight that intersects at the 50th percentile for the height-age. Next, the IBW percentage is calculated by dividing the actual weight of the child by the IBW. The final number is expressed as % IBW. We define “mild overweight” as 120% to 139% IBW, “moderate overweight” as 140% to 160% IBW, and “severe overweight” as above 160% IBW. Working with IBW percentages lets us track success in smaller increments than the BMI calculations allow. As we will see in the case below, a severely overweight child may make substantial progress in decreasing his IBW percentage, although his BMI continues to be above the 95th percentile. 
Rebecca Unger, MD, notes acanthosis nigricans around a patient’s neck—a risk factor for insulin resistance syndrome—during an exam at the Nutrition Evaluation Clinic, Children’s Memorial Hospital. Case overview Juan (not his real name) is an 11-year-old from a Hispanic family. He has been treated at the Children’s Memorial Nutrition Evaluation Clinic for 6 months thus far. At presentation, he weighed 87.8 kg with a height of 152.3 cm, or 204% of IBW for his height-age and gender. His BMI calculates to 38 kg/m2, which is above the 95th percentile for his age and gender. The onset of excessive weight gain occurred when the patient was 4-5 years old. Previous attempts to control weight were not successful. Juan has many opportunities to eat with extended family members, which may have interfered with the mother’s efforts to set limits. The mother also is excessively overweight and suffers from high blood pressure and leg vein problems. The boy has not seen his alcoholic father in 8 years. The family’s socioeconomic status is relatively low. Juan’s medical history includes asthma, chronic ear infections, chest pain, back pain, restless sleep with snoring, and hospitalization for depression. His medications are Prozac, Flovent, and Albuterol. The patient’s dietary patterns included frequently skipped breakfast or lunch. Throughout the day he consumed many high-calorie snacks, such as chips and candy. At dinnertime, he frequently had large portions with extra helpings. He rarely ate fresh fruits and vegetables, and took in many extra calories in sweetened beverages. Daily, Juan typically drank 16 oz of juice, 8 oz of soda, and 8 oz of whole milk. He also ate fast food occasionally. The patient reported that although he likes being active, his physical activity was minimal and limited somewhat by asthma. The physical exam was unremarkable, except for the presence of acanthosis nigricans, or a darkening of skin around the neck. Juan was at Tanner stage III for puberty. Lab results indicated normal triglyceride level and an elevated glucose level (155 mg/dL). Recommendations for a healthier lifestyle were made to Juan and his family. Specific goals were identified through detailed discussion with the family and tailored to fit the family’s particular circumstance. All family members were asked to eliminate sugary drinks, switch to low-fat milk (skim or 1%), and to eat no more than 2 healthy snacks a day. They were advised to eat 3 regular meals with smaller portion sizes each day. The family was counseled to include fruits or vegetables with every meal and snack, and if second helpings are desired, to take only fruits or vegetables. Juan and his family were asked to include some form of physical activity in their daily routine. At each follow-up visit we reviewed and revised the goals for Juan and his family. We reinforced the behavioral changes and added another layer of goals that seemed attainable to the family. Gradually, Juan and his family reduced portion sizes, and switched to diet soda, artificially sweetened lemonade, and low-fat milk. Juan started walking to and from school (25 minutes each way), played basketball, and later added soccer to his daily physical activity. At each visit, we needed to revisit the importance of not skipping breakfast and eating more fruits and vegetables. After a month of treatment, Juan dropped his IBW from 204% to 194%, weighing 83.4 kg while maintaining the same height (152.3 cm). After 3 months, he reached 182% of his IBW, with the weight of 78.4 kg and the same height. At the 6-month follow-up, Juan dropped to 165% of his IBW, weighing 72.7 kg with a slight increase in height (154 cm). In the first 6 months of behavioral interventions at the clinic, he succeeded in coming close to the “moderate overweight” category, losing over 15 kg while growing 1.7 cm. Why treat childhood overweight? Before launching into further discussion of Juan’s case, we will review the compelling reasons to address childhood overweight. These considerations can be used to motivate patients and families to start modifying dietary and physical activity patterns. Increasing prevalence of pediatric overweight The growing numbers of overweight children and adolescents call for attention and action on the part of clinicians and families. Over 10% of 2-5-year-olds and over 15% of 6-19-year-olds are overweight, according to the 1999-2000 figures from the National Health and Nutrition Examination Survey.3 These figures represent a more than 2-fold rise in the numbers of overweight 2-5-year-olds and 6-11-year olds, and a more than 3-fold jump in the numbers of overweight 12-19-year-olds, compared to the 1976-1980 statistics. Sharing with families these dramatic increases in prevalence of childhood and adolescent overweight may help them see their own children’s overweight in the context of national trends. (See Table 1 for prevalence trends for the past 3 decades, listed by age and gender.)
Viewing Juan’s case in this context, we see that prevalence of overweight for boys in his age group (6-11) quadrupled in the past 3 decades, from 4.3% in the early 1970s to 16% in 1999-2000. The latest statistics and trends are even less encouraging for Hispanic boys in the age group that Juan will soon enter (12-19). Mexican American adolescent boys have the highest percentage of overweight, 27.5%, compared to 12.8% of non-Hispanic whites and 20.7% of non-Hispanic blacks. These statistics from 1999-2000 show that the numbers of overweight adolescent Mexican-American boys nearly doubled in less than a decade. As recently as the 1988-1994 survey period, 14.1% of Mexican-American adolescent boys were overweight. High risk for immediate and future medical complications Overweight children and adolescents confront damaging psychosocial difficulties, such as ostracism from their peers and even from their own families. The resulting emotional problems can affect these children through adolescence and into adulthood. When counseling families, clinicians need to approach overweight patients with extra sensitivity and empathy. Also, parents may not perceive their child’s overweight as a medical problem that demands treatment. This perception presents the biggest challenge to successful management of overweight in children. To educate family members and potentially impact their readiness for change, clinicians can explain the health risks of overweight, based on the latest research findings. Today, more and more children are diagnosed with type 2 diabetes, whereas only 2 decades ago it was practically nonexistent in pediatrics. This disturbing trend appears to be linked to the increasing numbers of overweight children, especially in the Hispanic communities. A recent study shows that children diagnosed with type 2 diabetes are at risk by early 30s for devastating complications, such as kidney failure and dialysis, miscarriages, blindness, amputations, and even death.4 In another study, impaired glucose tolerance, an asymptomatic risk factor for type 2 diabetes, was found in 25% of overweight 4-10-year-olds and in 21% of overweight 11-18-year-olds.5 The authors suggest that metabolic complications of overweight—insulin resistance and hyperinsulinemia—contribute to glucose tolerance deterioration. Overweight children may have other metabolic abnormalities that put them at high risk for cardiovascular disease—high blood pressure, low HDL cholesterol, and high triglycerides. They also may develop fatty streaks, which are precursors to atherosclerotic lesions. As early as age 3, these deposits can appear in the aorta. The fatty streaks have been found in the coronary arteries in overweight children by age 10.6 The early impact of childhood overweight on the endocrinologic and cardiovascular systems underscores the fact that overweight children face immediate health risks. As they mature, these children also are at increased risk for psychosocial problems, type 2 diabetes, cardiovascular diseases, hepatic steatosis, gallbladder disease, respiratory illnesses, and orthopedic disorders. Clinicians need to emphasize to patients and families that lifestyle changes can prevent progression of overweight to these serious medical problems. Clinical evaluation Juan underwent an in-depth medical exam, as is recommended for any child or adolescent with BMI at or above the 95th percentile.7 In children with weight gain and short stature or a height curve that shows decline in height percentiles, clinicians should consider checking at least serum free thyroxine and TSH (to exclude hypothyroidism), and a 24-hour urine for free cortisol and creatinine (to exclude Cushing’s syndrome). During evaluation, we discussed with Juan and his family their dietary and physical activity patterns, and tried to identify the family’s potential barriers to change. Interventions were then adapted to the family’s unique situation. We also checked for medical complications of overweight, including sleep apnea, insulin resistance, hyperinsulinemia, dyslipidemias, and hypertension. Ask about family’s dietary and physical activity patterns When evaluating eating and physical activity habits, clinicians can form an alliance with the family by asking about concrete behaviors.7 An objectively phrased question, such as “How many snacks do you eat?” is by far more productive than “Do you snack too much?” which sounds accusatory. In Juan’s case, the patient was asked:
These objective, nonjudgmental questions allow us to assess specific behavioral patterns that can be altered without shaming and alienating patients and families. Identify family’s barriers to changing dietary and physical activity patterns Parental perceptions of successful treatment of overweight tend to be the biggest barriers to initiating treatment and changing habitual behaviors. Clinicians need to ask the child and parents about attitudes toward overweight and address the issues that may arise as the family tries to make lifestyle changes. For example, the family may view the patient’s overweight as inevitable and not realize that it is a manageable condition. Or, the family may not fully appreciate that all family members need to be involved in modifying their typical patterns of eating and physical activity, even if other siblings are very thin. Clinicians should explain that nobody in the family benefits from keeping junk food at home, or spending hours before a television set. The family’s realization that the child’s outcome can be improved if the entire family commits to change can be particularly powerful. Juan’s case exemplifies other common barriers to successful treatment of overweight—family history of overweight, multiple caregivers, low socioeconomic status, asthma, and history of severe depression. The patient’s asthma and depression appeared to be well controlled by medication, and should not interfere with attempts to change lifestyle patterns. Multiple caregivers, however, could present difficulties, since a child might be eating more than 3 meals a day or snacking more often than the parents realize. These details can be uncovered while taking a history, and customized goals can be set. For instance, the family can try to ensure that when a child eats dinner at a caretaker’s house, he is not offered a second dinner at home. Also, a family’s low socioeconomic status may limit a child’s access to physical activities, and can be a significant barrier to the family’s ability to follow treatment recommendations. For example, the neighborhood may not be safe enough for the child to play outdoors unsupervised. In this situation, we would brainstorm with the family to find solutions, such as asking a neighbor to regularly oversee the child’s active play outdoors or identifying fun options for active indoor recreation. Assess potential complications of overweight In Juan’s case, the medical history revealed a sleep disturbance, which may signal sleep apnea that could be dangerous and put him at risk for cardiac problems. He was referred for a sleep study, which confirmed a diagnosis of mild, obstructive sleep apnea. This complication was discussed with Juan and his mother to reinforce their understanding that changes in dietary and physical activity patters are critical to the future health of the boy and the entire family. Childhood overweight also is considered to be the most conspicuous risk factor for “insulin resistance syndrome,” which includes decreased insulin sensitivity and a cluster of related metabolic abnormalities. Individuals with insulin resistance syndrome are at increased risk for type 2 diabetes and cardiovascular disease, which is why early detection and timely intervention are important. Risk factors for insulin resistance syndrome include:
Diagnostic criteria for insulin resistance syndrome in pediatrics are not yet as developed as in adults. However, a task force sponsored by the American Association of Clinical Endocrinologists recently suggested diagnostic guidelines (Table 2) for individuals at risk for insulin resistance syndrome.8 Children who meet these criteria need to start making lifestyle changes—healthy eating patterns, increased physical activity, and decreased sedentary behaviors.
As a screening test for type 2 diabetes and its precursors, the fasting glucose test is the easiest to obtain. However, studies have shown that children can have normal fasting glucose concentrations and still have impaired glucose tolerance or diabetes, based on the 2-hour post-glucose challenge criteria. Although the most cost-effective screening option is still under debate, clinicians should consider screening children who have multiple risk factors for insulin resistance syndrome with the 2-hour post-glucose challenge test. The 2-hour blood glucose at or greater than 140 mg/dL suggests impaired glucose tolerance, and a result greater than 200 mg/dL suggests diabetes. Since multiple risk factors for type 2 diabetes were present in Juan’s case, the patient was referred to the Children’s Memorial endocrinology clinic for the 2-hour post-glucose challenge test. The test was performed 2 months after Juan’s initial appointment at the Nutrition Evaluation Clinic, and the result indicated normal glucose tolerance. It is possible that Juan’s substantial weight loss within the first months of treatment was responsible for this fortunate outcome. No medication has been shown to be more successful than lifestyle changes in improving glucose tolerance.
Intervention approaches The foremost treatment goal for overweight children and adolescents should be establishing healthy eating and physical activity patterns.7 Clinicians need to stress to patients and families that management of overweight will not consist of short-term diets aimed at quick and drastic weight loss. The family should understand that recommendations are intended to promote a healthy lifestyle, aiming at permanent changes in behavior. Modifying behaviors gradually allows success to be achievable, which builds confidence and inspires the patient and family to continue confronting the problem of overweight. For example, small changes in eating habits can involve keeping only low-fat snacks at home, drinking fewer sugary beverages, or switching from fast food meals to healthier microwavable foods. Physical activity can be slightly increased by taking stairs whenever possible, or getting off the bus a stop earlier. Also, the family can start controlling its sedentary activities by limiting television viewing to 2 hours a day. Through their established relationships with families, community-based clinicians are in a perfect position to help children and parents identify opportunities for incorporating healthier habits into everyday life. Regular follow-up allows clinicians to foster lifestyle change in small steps, closely monitor intervention effectiveness, and provide repeated positive reinforcements. The family’s specific barriers to success also can be reassessed and goals further adapted to the family’s needs. At the Nutrition Evaluation Clinic, we tend to gradually increase the time between visits, depending on adherence to treatment recommendations. In Juan’s case, the intervals between visits were 1 month, then 2 months, and later 3 months. Since Juan’s family proved to be exceptionally committed to adopting healthier eating and physical activity habits, we concluded that maintaining the 3-month follow-up schedule would be appropriate. Throughout treatment, patients and families may need reminders that progress will be slow and that managing a chronic illness calls for perseverance. Even if Juan continues to meet goals at each follow-up visit, he will still need years of consistent, dedicated effort to reach his ideal weight or drop his BMI below the 85th percentile. Early prevention of overweight Prevention is the best strategy for managing overweight. Clinicians need to start management early—by counseling families on how to establish beneficial eating and physical activity patterns, and by intervening with younger overweight children and children who are not yet overweight but who exhibit a worrisome trend in the weight–height relationship. Counsel families on healthy lifestyle patterns Since overweight treatment is very difficult, might take years, and calls for high motivation to be successful, anticipatory guidance counseling is recommended in routine pediatric practice.9 Prevention can begin with advice to parents about breastfeeding, weaning, and healthy eating standards for toddlers.10 Families may also need ongoing guidance that would help them support beneficial behaviors in children and prevent the problem of overweight. Clinicians can reinforce with parents the following principles:
Intervene early Initiating overweight treatment as early as possible makes goals easier to reach and prevents overweight later in life. Interventions with overweight children can start as early as age 3 to prevent later overweight.7 With preschoolers, habits are more malleable, and parents can still effectively change eating and physical activity patterns. Also, with younger children, a smaller shift in energy balance can produce substantial progress in degree of overweight.11 Especially just before puberty, we have a golden opportunity to reduce the BMI percentile, since we can still take advantage of the rapid gain in linear growth to improve the weight-height relationship. In addition, research has identified ages 4-6 as a critical developmental period for interventions and preventive measures. During this period, called “adiposity rebound,” a child’s BMI reaches its lowest point before starting to increase steadily through adolescence.9 If adipose rebound occurs before age 5.5, the risk of overweight in adolescence and adulthood is higher.12 Also, early adipose rebound has been linked to adult overweight independent of other risk factors, such as excessive BMI at that period and parental overweight.13 So, by promoting healthy eating and physical activity habits at these early ages, we can more effectively manage overweight and prevent it in the future. Referral to specialists If weight management attempts are not working, clinicians may consider contacting a nutritionist as a consultant. Also, when a medical problem impedes physical activity, referral to an exercise physiologist who can determine a safe mode of exercise may be helpful. A multidisciplinary nutrition clinic, such as the Children’s Memorial Nutrition Evaluation Clinic, would be appropriate for children with complex barriers to successful treatment. Severely overweight children under age 2 also should be referred to specialists in pediatric overweight management.7 
Patient and her mother discuss eating patterns with Linda Somers, RD, dietitian at the Nutrition Evaluation Clinic, Children’s Memorial Hospital. When lifestyle changes are not enough Indirect calorimetry: Newly available tool for managing difficult cases Very recently, Children’s Memorial added indirect calorimetry as a tool to assist in management of extremely difficult cases of childhood overweight. Indirect calorimetry is a method of measuring an individual’s metabolism, and therefore daily energy (calorie) requirements.14,15 During normal health, the food we eat is metabolized to meet the body’s energy requirements—maintaining basal metabolism (the minimum level of energy necessary to sustain life), digestion of food (thermic effect of food), thermoregulation (maintenance of normal body temperature), growth (birth to completion of puberty), and physical activity. The only discretionary components of an individual’s energy balance (i.e., energy intake compared to energy expenditure) are the daily calories consumed and the level of physical activity. A daily caloric intake that is consistently in excess of the energy expended by the body will lead to a positive energy balance and storage of the excess calories as body fat. Conversely, a caloric intake that is less than the total energy expended will result in a negative energy balance, mobilization of the body’s energy stores (fat tissue), and ultimately weight loss. The indirect calorimeter is a computerized metabolic cart that measures the oxygen consumed and the carbon dioxide produced by an individual at rest, in order to derive the body’s caloric requirements. The principle behind the indirect calorimeter is based on the first law of thermodynamics and Hess’ law of constant heat summation. The first law of thermodynamics states that energy is conserved in its conversions from one form to another. And according to Hess’ law of constant heat summation, no matter how a reaction proceeds, the energy released is the same. Therefore, regardless of the multiple steps required to metabolize carbohydrates, proteins, and fats, the amounts of utilized oxygen, and the produced carbon dioxide and heat are the same. The initial approach to treatment of overweight children and adolescents should be to emphasize healthy eating habits and increased physical activity, as opposed to counting calories. However, in severe situations with poor response to the first-line approach, indirect calorimetry can be used to measure energy expenditure so as to provide a basis for prescribing an individualized dietary caloric intake to attain a desired level of energy deficit and ultimately weight maintenance or loss. Indirect calorimetry is performed in the Nutrition Assessment Unit of the Gastroenterology Laboratory at Children’s Memorial Hospital. Is medication an option? Pharmacotherapy for overweight children and adolescents is controversial. First of all, no medication can work alone to treat overweight. And there is concern that lifestyle changes, which are much more difficult and time-consuming to both coach and perform, will be given only cursory attention if there is an alternative pill. Second, the seriousness of side effects of weight loss medication in pediatrics is unknown, and the “fen-phen” story haunts us. In adults, a combination therapy of 2 appetite suppressants (fen-phen), both amphetamine analogues, appeared to be successful therapy for weight loss. However, severe valvular heart disease and an increase in pulmonary hypertension were found in people taking these medications. So far no weight loss medication has been shown to be effective and safe in the pediatric population. Orlistat and sibutramine, neither of them an ideal option, are currently being tested in nationwide studies on adolescents. Orlistat inhibits lipase action and blocks absorption of fat, leading to decreased caloric intake. However, this medication may only work if carbohydrate and protein calories are not substituted. And with fat intake, orlistat can cause embarrassing side effects, such as fecal incontinence. Without fat absorption, there is also a concern about vitamin deficiencies. Sibutramine is a serotonin-noradrenaline reuptake inhibitor that causes a sense of fullness and increases energy expenditure. Known side effects in adults include hypertension, increases in heart rate, dry mouth, insomnia, and constipation. The Food and Drug Administration is reviewing the potential for severe side effects of using this medication in children. Should surgery be considered for extremely overweight kids? The increasing prevalence of overweight children, adolescents, and adults has led to a renewed interest in surgery as a means for achieving dietary restriction. Surgery for overweight adults was first described in the 1950s and consisted of bowel resection and anastomosis to bypass approximately 90% of the small intestine.16 Despite success in achieving weight loss, this approach had to be abandoned because of severe and unacceptable complications including diarrhea, dehydration, electrolyte abnormalities, and liver disease. In the mid-1960s, gastric bypass surgery was designed to restrict stomach capacity, leading to early satiety and reduced food intake.17 This procedure had fewer complications than the intestinal bypass, but perioperative morbidity remained high, at 10% to 15%. In the 1970s, another surgical approach was developed whereby the stomach is partitioned into small pouches that drain into the main body of the stomach through small channels (i.e., vertical banded gastroplasty).18,19 More recently modifications of the above techniques are being performed using laparoscopy, with encouraging success.20 However, the successes of surgical therapy for overweight cannot be generalized because only few select patients pass the screening tests to qualify. Prerequisites include a combination of the following—weight above 200% IBW, BMI over 40 kg/m2, repeated failure to control weight despite supervised dietary programs, and comorbidity with diabetes, hypertension, or sleep apnea. Patients with psychiatric illness, substance abuse, and other self-destructive behaviors are excluded. Additional requirement is a lifelong commitment to comply with a modified diet and lifestyle after the surgery. The long-term safety and effects of surgery still need to be well studied and understood before considering this approach for treatment of overweight children and adolescents. Conclusion Pediatric overweight needs to be viewed by clinicians and families as a chronic medical condition that leads to other serious disorders. Complications, however, can be prevented through lifestyle changes that involve the entire family. The family’s consistent adherence to a healthier dietary and physical activity patterns can prevent further weight gain while the child gets taller, improving the weight-height correlation and potentially attaining ideal body weight. REFERENCES 1. Barlow SE, et al. Treatment of child and adolescent obesity: reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics 2002;110(1):229-235. 2. Epstein LH, et al. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990;264:2519-2523. 3. Ogden CL, et al. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002;288(14):1728-1732. 4. Dean H, Flett B. Natural history of type 2 diabetes diagnosed in childhood: long-term follow-up in young adult years. Abstract presented at: American Diabetes Association, 62nd Scientific Session; June 2002; San Francisco, CA. 5. Sinha R, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. NEJM 2002;346(11):802-810. 6. Williams CL, et al. Cardiovascular health in childhood. American Heart Association statement. Circulation 2002;106:143-160. 7. Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. Pediatrics 1998;102(3):e29. 8. Results from American College of Endocrinology (ACE)/American Association of Clinical Endocrinologists (AACE) Insulin Resistance Syndrome Conference; August 2002; Washington, DC. Available at: http://www.aace.com/pub/irscc/irscwrapup.php. Accessed November 29, 2002. 9. Dietz WH, Gortmaker SL. Preventing obesity in children and adolescents. Annual Review of Public Health 2001;22:337-353. 10. Gill T. Key issues in the prevention of obesity. British Med Bulletin 1997;53(2):359-388. 11. Christoffel KK, Ariza A. Epidemiology of overweight in children: relevance for clinical care. Pediatrics 1998;101(1):103-105. 12. Rolland-Cachera MF, et al. Adiposity rebound in children: a simple indicator for predicting obesity. American Journal of Clinical Nutrition 1984;39:129-135. 13. Whitaker RC, et al. Early adiposity rebound and the risk of adult obesity. Pediatrics 1998;101(3):e5. 14. Stallings VA. Resting energy expenditure. In: Altschuler SM, Liacouras CA, eds. Clinical Pediatric Gastroenterology. Philadelphia, Pa: WB Saunders; 1998:607-611. 15. Norgan NG. Measurement and interpretation issues in laboratory and field studies of energy expenditure. American Journal of Human Biology 1996;8:143-58. 16. Kremen AJ, et al. An experimental evaluation of the nutritional importance of the proximal and distal intestine. Annals of Surgery 1954;140:439-48. 17. Mason EE, Ito C. Gastric bypass in obesity. Surgical Clinics of North America 1967;47:1345-52. 18. Mason EE. Vertical banded gastroplasty for obesity. Archives of Surgery 1982;117:701-6. 19. Brolin RE, et al. Weight loss and dietary intake after vertical banded gastroplasty and roux-en-bypass. Annals of Surgery 1994;220:782-90. 20. Lonroth H, Dalenback J. Other laparoscopic bariatric procedures. World Journal of Surgery 1998;22:964-68. |
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