Utah Medical Home Portal - Childhood Obesity Screening & Prevention

Childhood obesity rates in the United States have remained around 17% for the past decade. Obese children and adolescents may face considerable physical and psychological morbidity while they are young; yet, the primary public health concern is that more than 80% of obese children will become obese adults and suffer the associated conditions of diabetes and cardiovascular disease. [Mullis: 2004] [Ludwig: 2016] If present trends continue, the current generation of children may be the first in US history to have a shorter life expectancy than that of their parents. [Olshansky: 2005] Because treatment of children with established obesity is usually not very successful, most experts agree that prevention is essential. [Davis: 2007] [Gillman: 2013]

Role of the Medical Home

Two children walking down a dirt path with trees on either side

The medical home is the ideal place for initiating prevention. 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 is designed to prevent the consequences of obesity and would be considered treatment. Treatment details can be found in the Portal's Obesity in Children module.

Screening for Risk Factors

Screening children for risk factors associated with obesity is the principal method of determining which children are candidates for secondary prevention efforts. Screening involves assessing factors from the history and observing an infant or child’s growth pattern.

History

Family history of obesity and type 2 diabetes

Obesity is one of the most heritable conditions. A child born to 2 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.

Excessive weight gain during pregnancy

There is strong and convincing evidence that the intrauterine environment of an obese woman increases the risk of obesity in her offspring. [Hemond: 2016]

Intrauterine growth restriction and infants small or large for gestational age

These children are at increased risk of obesity, and some studies suggest that the first 2 groups are at increased risk of hypertension, diabetes, and cardiovascular disease independent of their risk of obesity.

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. [Hemond: 2016] [Gungor: 2010] Infants whose body mass index (BMI) is above the 97th percentile at 2 months are significantly more likely to be obese at age 2 years. A recent study showed that BMI was a better predictor of obesity than weight for length. Although the Centers for Disease Control and Prevention (CDC) infant growth charts do not provide a BMI chart for this age group, those provided by the World Health Organization (WHO), which are recommended by the CDC and others, do allow for an assessment of the BMI percentile at 2 months. [Roy: 2016]

Early or excessive adiposity rebound

It is important to determine and plot the BMI beginning at age 2. The CDC growth charts for children age 2-20 demonstrate that the BMI (an indicator of the amount of adipose tissue) decreases from age 2 to about ages 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 ages 2 and 6-8) are most likely developing excess adipose tissue and are at risk for obesity. [Hughes: 2014] [Taylor: 2005]

Graph Showing Early Adiposity Rebound and Childhood Obesity — **Early Adiposity Rebound**

Graph showing Excessive Adiposity Rebound and Childhood Obesity — **Excessive Adiposity Rebound**

Overweight

A child with a BMI between the 85th and 95th percentile is considered to be overweight rather than obese, but children with BMIs in this range are at increased risk of moving into the obese range—particularly if their BMI has shown an accelerating trajectory from one below the 85th percentile to one above the 85th percentile in the past few years.

Children and Youth with Special Health Care Needs (CYSHCN)

CYSHCN may be at higher risk than typically developing children to become overweight or obese. For example, CYSHCN may have less healthy dietary and physical activity patterns because of medical conditions (e.g., spina bifida or cerebral palsy) that limit or restrict opportunities to be physically active. [Minihan: 2011] They may be taking medications such as atypical antipsychotic medications (e.g., risperidone), antidepressants, mood stabilizers, and anticonvulsants that increase their risk of excess weight gain. [Vanina: 2002] It is important to carefully monitor the growth patterns of CYSHCN to recognize which of them may be showing a trajectory that may lead to obesity.

Screening for Obesity

The US Preventive Services Task Force recommends that clinicians screen children 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. Height and weight, from which BMI is calculated, are routinely measured during health maintenance visits. [US: 2010]

Body Mass Index (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] Most electronic health records applications calculate BMI automatically. Also, a variety charts (BMI Males 2-20 Years (CDC) ( PDF Document

62 KB) BMI Females 2-20 Years (CDC) ( PDF Document

68 KB)), websites (BMI Percentile Calculator for Children and Teens (CDC)), and computer and smart phone applications 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.

Most 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 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 used, particularly for children and adolescents who appear to be muscular and whose BMI is minimally elevated. [Morgan: 2010] [Simmonds: 2016]

Waist Circumference

Circumference is used in adults to provide an estimate of excess adipose tissue and is becoming more widely used in children and adolescents. Because waist circumference increases as a child grows, it is better to calculate the ratio of children's waist circumference to their height. (WC/Ht). Ratios that exceed 0.5 are considered to be abnormal and indicate excess adiposity. [Li: 2006] Obtaining an accurate waist circumference in children can be 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. [Martin-Calvo: 2016]

Visual Assessment

Many clinicians feel that they can reliably determine whether a child is obese or not 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. However, in conjunction with an appropriately assessed BMI, a clinician’s assessment of whether the child looks “fat” or not may be some value. The CDC has an exercise to show the difficulty in visually assessing overweight in children: Visual Assessment vs. Calculation of BMI (CDC).

Skinfold Measures

Assessing skinfold 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] [Simmonds: 2016]

Preventing Obesity

The following have moderately convincing evidence or expert consensus to support their role in prevention, and they likely have health benefits beyond obesity prevention. [Lumeng: 2015] [Davis: 2007]

Encourage breastfeeding

Observational studies have suggested a lower prevalence of obesity in children who are breastfed. These studies are challenging because of potential confounding factors, but most experts agree that exclusive breastfeeding for 6 months with continued breastfeeding for the next 6 months can reduce the risk of obesity. [Oddy: 2014] The mechanism is unknown, but one explanation is that the baby is eating to satisfy his/her own internal cues rather than an amount based on what the feeder thinks he/she should take in. The components of breast milk also may influence body composition and feelings of satiety. Comparing the CDC and WHO growth charts reveals that, in the first few months of life, the WHO curves show a faster rate of weight gain than the CDC charts. Beginning at approximately age 3 months, WHO curves show a slower rate of weight gain than the CDC charts. Because the WHO growth charts reflect a population of largely breastfed infants, this pattern is considered to represent the optimal pattern of growth. See the Growth Charts for Ages 0-2 Years (WHO) and for Ages 2-18 (CDC).

5-2-1-0 A DAY

The 5-2-1-0 message is widely disseminated and supported by a number of groups and organizations. It is a simple message that clinicians can deliver to parents and children:

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.

Increase intake of fruits and vegetables

Modest evidence indicates that consumption of fruits and vegetables can help to prevent obesity. The recommendation of at least 1 ½ cups of fruit and 2 cups of vegetables a day is based on evidence collected by the Academy of Nutrition and Dietetics.

Restrict screen time

Watching television is not only a sedentary, non-active behavior, but also exposes the child to advertisements for high-calorie, mostly unhealthy foods. The American Academy of Pediatrics (AAP) advises no TV for children less than 2 years old and no more than 2 hours of all screen time for older children.

Promote physical activity

Because obesity results from an excess of calories taken in compared with those expended, it makes sense that physical activity would reduce the risk of obesity. However, for growing children, at least, physical activity may have additional benefits 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.) every day will model this until the child is old enough to walk and play on his/her own.

No or almost no sweetened beverages

Strong evidence associates the intake of sweetened beverages to obesity or excess adiposity. Sweetened beverages include soda, sports beverages, and sweetened fruit drinks. 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 1 serving (4-6 oz.) per day for children between 1 and 6 years old. Some pediatricians have questioned the benefits of juice and have recommended that its consumption be even more limited—perhaps to “none.”

Healthy Eating Habits

Clinicians may wish to consider additional advice that had either consistent or modest evidence for preventing obesity: [Barlow: 2007]

Breakfast

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. [Odegaard: 2013] [Szajewska: 2010] Overweight and obese adolescents are more likely than those of normal weigh to skip breakfast, and when they do eat breakfast, it is smaller and of a lower nutritional quality. Although no evidence demonstrates that eating breakfast will prevent obesity, no evidence suggests that such a strategy would be harmful.

Fast Food

Consumption of fast food gives little nutritional benefit and is associated with obesity. 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 Sizes

Larger than recommended portion sizes, particularly of calorically dense foods that are high in fat, are associated with obesity. A convenient estimate of portion size is one that approximates the size of the infant or child’s fist.

Family Meals

There is modest evidence that dietary “quality” is better when most meals are eaten as a family and that the frequency of family dinners might be inversely associated with the prevalence of overweight. [Anderson: 2010] Although conclusive evidence is lacking, eating together likely has additional benefits with minimal risks.

Nutrition & Weight for CYSHCN

Parents of CYSHCN are often concerned about whether their child’s nutritional needs are being met. Some of these children may have difficulty with achieving adequate calories to support appropriate growth, and parents may offer foods that are higher in “empty” calories in the hope that their child will gain weight. Achieving the recommended 5 servings a day of fruits and vegetables may be particularly challenging. It is important to individualize recommendations for calories and dietary constituents based on the child’s condition and potential for physical activity. Careful monitoring of growth trajectories to ensure that the child’s growth is consistent and that weight gain is not excessive for the child’s height is probably the best way of knowing whether more specific recommendations regarding the child’s diet are necessary. It may be appropriate to refer the family to a registered dietician for specific advice regarding the child’s unique needs.

Resources

Information & Support

The Portal's Obesity in Children provides management information. Prader-Willi Syndrome and Complications from Obesity discusses the particular risks and management strategies for this population.

For Professionals

Obesity & Children with Special Needs (AbilityPath.org) ( PDF Document 1.7 MB)
Excellent presentation detailing the particular risks for CYSCHN and obesity. Includes practical approaches for parents and health care professionals.

Disability and Obesity (CDC)
Summarizes the factors that contribute to some individuals with disabilities being at higher risk for obesity and provides guidance on possible interventions; Centers for Disease Control and Prevention.

Adolescent Obesity Time Tool (ACPM)
A 1-hour, free, educational activity that assists providers in managing adolescent obesity issues. Offers CME; American College of Preventive Medicine.

Weight Goals and Intervention Stages (AAP)
A table that includes goals and interventions according to age and BMI categories; from the Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report; American Academy of Pediatrics.

Pediatric Obesity Interventions: Information for Providers
Blog with resources and guidance for providers about the prevention and treatment of childhood obesity; written by Amber Baker (DNP).

For Parents and Patients

Live Well (Intermountain Healthcare)
Education for families about healthy lifestyles; Intermountain Healthcare.

MyPlate (USDA)
Offers personalized eating plans and interactive tools to help plan and assess food choices; US Department of Agriculture.

Let's Move! (obamawhitehousearchives.gov)
Resources for families, parents, children, communities, and health care providers for providing healthy food in schools, improving access to healthy, affordable foods, and increasing physical activity; First Lady Michelle Obama’s initiative for healthy families.

Nutrition & Fitness (KidsHealth)
Nutrition, fitness, and overall health information for parents, kids, teens, and educators. Includes recipes, safety tips, and discussion of feelings; sponsored by the Nemours Foundation.

Tools

BMI Males 2-20 Years (CDC) ( PDF Document 62 KB)
Body mass index for age percentiles; Centers for Disease Control.

BMI Females 2-20 Years (CDC) ( PDF Document 68 KB)
Body mass index for age percentiles; Centers for Disease Control.

BMI Percentile Calculator for Children and Teens (CDC)
The calculator provides BMI, BMI-for-age percentile, and an easy-to-read interpretation. Results can also be viewed on a CDC BMI-for-age growth chart; Centers for Disease Control & Prevention.

Clinical Growth Charts (CDC & WHO)
Provides links to 2 comprehensive sets of growth charts: the CDC Clinical Growth Charts (preferred for use with children 24 months and older) and the World Health Organization (WHO) Charts (preferred for children under 24 months); Centers for Disease Control and Prevention.

Services for Patients & Families in Utah (UT)

Service Categories	# of providers* in:	UT	NW	Other states (4)  (show)		NM	NV	OH	RI
Nutrition Assessment Services		6				3	1	2

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Barlow SE.
Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120 Suppl 4:S164-92. PubMed abstract / Full Text
While not a formal practice guideline, these recommendations represented expert consensus when published in 2007. No formal guidelines have been published for children in the US since then.

US Preventive Services Task Force, Barton M.
Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement.
Pediatrics. 2010. PubMed abstract / Full Text

Olson RE.
The dietary recommendations of the American Academy of Pediatrics.
Am J Clin Nutr. 1995;61(2):271-3. PubMed abstract / Full Text

Krebs NF, Jacobson MS.
Prevention of pediatric overweight and obesity.
Pediatrics. 2003;112(2):424-30. PubMed abstract / Full Text

Authors & Reviewers

Current Authors and Reviewers:

Author:	Paul Young, MD
Reviewer:	Paul Young, MD

Page Bibliography

Anderson SE, Whitaker RC.
Household routines and obesity in US preschool-aged children.
Pediatrics. 2010;125(3):420-8. PubMed abstract

Barlow SE.
Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120 Suppl 4:S164-92. PubMed abstract / Full Text
While not a formal practice guideline, these recommendations represented expert consensus when published in 2007. No formal guidelines have been published for children in the US since then.

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
From a special supplement to Pediatrics; it has numerous references and provides a rigorous review of current evidence. It also addresses the complex issue of influencing behavior through the use of Motivational Interviewing and the Chronic Care Model.

Gillman MW, Ludwig DS.
How early should obesity prevention start?.
N Engl J Med. 2013;369(23):2173-5. PubMed abstract

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

Hemond J, Robbins RB, Young PC.
The Effects of Maternal Obesity on Neonates, Infants, Children, Adolescents, and Adults.
Clin Obstet Gynecol. 2016;59(1):216-27. PubMed abstract

Hughes AR, Sherriff A, Ness AR, Reilly JJ.
Timing of adiposity rebound and adiposity in adolescence.
Pediatrics. 2014;134(5):e1354-61. 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

Ludwig DS.
Lifespan Weighed Down by Diet.
JAMA. 2016;315(21):2269-70. PubMed abstract

Lumeng JC, Taveras EM, Birch L, Yanovski SZ.
Prevention of obesity in infancy and early childhood: a National Institutes of Health workshop.
JAMA Pediatr. 2015;169(5):484-90. PubMed abstract

Martin-Calvo N, Moreno-Galarraga L, Martinez-Gonzalez MA.
Association between Body Mass Index, Waist-to-Height Ratio and Adiposity in Children: A Systematic Review and Meta-Analysis.
Nutrients. 2016;8(8). PubMed abstract / Full Text

Minihan PM, Must A, Anderson B, Popper B, Dworetzky B.
Children with special health care needs: acknowledging the dilemma of difference in policy responses to obesity.
Prev Chronic Dis. 2011;8(5):A95. PubMed abstract / Full Text

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

Oddy WH, Mori TA, Huang RC, Marsh JA, Pennell CE, Chivers PT, Hands BP, Jacoby P, Rzehak P, Koletzko BV, Beilin LJ.
Early infant feeding and adiposity risk: from infancy to adulthood.
Ann Nutr Metab. 2014;64(3-4):262-70. PubMed abstract

Odegaard AO, Jacobs DR Jr, Steffen LM, Van Horn L, Ludwig DS, Pereira MA.
Breakfast frequency and development of metabolic risk.
Diabetes Care. 2013;36(10):3100-6. PubMed abstract / Full Text

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

Roy SM, Spivack JG, Faith MS, Chesi A, Mitchell JA, Kelly A, Grant SF, McCormack SE, Zemel BS.
Infant BMI or Weight-for-Length and Obesity Risk in Early Childhood.
Pediatrics. 2016;137(5). PubMed abstract / Full Text

Simmonds M, Llewellyn A, Owen CG, Woolacott N.
Simple tests for the diagnosis of childhood obesity: a systematic review and meta-analysis.
Obes Rev. 2016. PubMed abstract

Szajewska H, Ruszczynski M.
Systematic review demonstrating that breakfast consumption influences body weight outcomes in children and adolescents in Europe.
Crit Rev Food Sci Nutr. 2010;50(2):113-9. 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

US Preventive Services Task Force, Barton M.
Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement.
Pediatrics. 2010. PubMed abstract / Full Text

Vanina Y, Podolskaya A, Sedky K, Shahab H, Siddiqui A, Munshi F, Lippmann S.
Body weight changes associated with psychopharmacology.
Psychiatr Serv. 2002;53(7):842-7. PubMed abstract