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.

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]

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.

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.

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) ( 62 KB) BMI Females 2-20 Years (CDC) ( 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]

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]

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).

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]

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).

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.”

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.

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.