During many years of work at the Nutrition Evaluation Clinic (NEC), a nutrition referral site for the Chicago metropolitan area, we have observed children of all ages becoming increasingly overweight. We have been challenged by the rising popularity of video games, television, and the Internet over active lifestyles, the increasing marketing of high-fat, low-cost foods to children, and other societal changes that foster excessive weight gain. Throughout these changing times, our clinic's philosophy has remained the same: young children require familybased management.
We recognize that early childhood is a critical period in the development of obesity due to the adi- ; pose rebound (AR).1 This is the time, usually between ages 4 and 6, when a child's adiposity begins to increase after a low point in the early, years of life. Studies reveal that the younger and heavier children are at AR, the more likely they are to become overweight as adults.1 The American Academy of Pediatrics (AAP) also endorses early intervention. The AAP recommends yearly calculation of body mass index (BMI), nutritional assessment, and counseling at every health maintenance visit.2
Despite these facts, young, overweight children are often not identified.3 In this paper, we seek to encourage early intervention in rapid weight gain by outlining practical approaches to the management of overweight in young children.
EARLY INTERVENTION IS EASIER
The advantage to treating overweight children at early ages is that they seem to respond to interventions more readily than older children.4 This success may be due to the dependence of young children on parental dietary and activity planning, a child's relatively short-lived habits, or a child's smaller body size, which allows a greater weight change for smaller adjustments in energy balance.4,5
As a result, pediatricians who are prepared to treat overweight in young children are likely to be rewarded by greater success.6 As they develop a management approach, pediatricians must remember that they are racing the AR; the adipose cells accumulated during this period will forever call out to be fed. For this reason, our discussion focuses on children younger than age 7.
EVALUATION OF OVERWEIGHT IN CHILDREN BEFORE AND DURING THE ADIPOSE REBOUND
The first step in the clinical evaluation of the nutritional status of any child is to obtain accurate weight and height measurements. Height should be measured against a sturdy surface such as a wall, or by using a stadiometer. Weight is more accurate if the child is undressed. These measurements should be plotted on the growth chart to assess the weight and height relationship. Plotting weight versus height is essential for accurately identifying subtle changes in the weight-forheight relationship.
Clinical definitions of childhood overweight are based on the relationship of weight to height using age- and genderspecific references from national databases. Once a child is identified as overweight or at risk for overweight, a pediatrician should perform a detailed clinical evaluation. This is a multi-step process that should include an assessment of family patterns, especially those relating to eating practices. Physical activity and sedentary behaviors, including parental modeling and family dynamics, should also be assessed. The pediatrician should also investigate possible definable causes and common co-morbidities of overweight.7
Family Patterns, Dynamics, and Risk Assessment
Several aspects of the home and family environment affect the odds that a young child will be overweight.
Activity. Studies have demonstrated that children with active parents are likely to be active themselves, while inactive parents have children who are more sedentary.8 Activity is also enhanced by parents who are supportive of their children's activities.9 The assessment of frequency and patterns of physical activity should therefore include questions about the parents as well as the child. It is also important to assess time spent outdoors, neighborhood safety, and accessibility to local parks.10
Young children now often spend more time watching screens (ie, television, computer, video) than performing any other activity besides sleeping." More television time means more overweight in young children; for adults, more television viewing means less fitness.,2',3Thus, it is important to ask about time spent watching television or playing video games, and the presence of television units in children's bedrooms.14
Diet. Food preferences of children aged 2 to 3 correlate significantly with their mothers' food preferences.15 Children prefer foods that they are served most often at home, and they eat more fruits and vegetables when these are more available at home.16,17 Children's preferences concerning the time and place of eating also correlate with parental preferences. Therefore, pediatricians need to target the family's eating practices, not only those of the overweight young child. It is important to ask specific questions about family routines for meals and snacks and intake of fruit and vegetables, sugary beverages, junk food, and fast food. It is necessary to determine what is eaten in the household, where it is eaten, how it is offered, and who is in charge. It is also useful to assess parental understanding of proper nutrition and attitudes about family eating behaviors.
Although it is often difficult to obtain information about dietary intake in the midst of a busy primary care practice, key dietary habits, such as low fruit and vegetable consumption or high intake of sweetened beverages (eg, juice, soda, lemonade, iced tea), are associated with nutritional problems that merit assessment and counseling.18
The next step is to ascertain parents' attitudes toward health and nutrition, perceptions of their child's weight and fitness level, and concerns about their child's sizes, as these may aid in gauging the family's view of their child's health. Appropriate questions to ask include, "How concerned are you about your child's weight?" or "Do you think your child is growing the same as other children his/her age?" Because of the negative emotional aspects of the words "overweight" and "obesity," pediatricians should be sensitive and use them cautiously.
Ultimately, it is important to identify all family interactions that promote high caloric intake, low activity levels, or a large-body-image ideal. Parents often employ the television as a babysitter. Many caretakers still consider plumpness as a sign of good health in children, use food as a means of controlling tantrums, or promise sweet treats for "cleaning the plate." Such interactions may be obesigenic and must be identified and discussed.
A family history of obesity, diabetes, coronary heart disease, hypertension, and dyslipidemia should be obtained for all children who are overweight or at risk for overweight. Overweight children with strong family histories of overweight and related morbidities will be the most challenging to manage, yet they are the ones who most need such management.
The Medical Examination
The physical examination should focus on identifying co-morbid conditions and identifiable causes of obesity. Blood pressure should be obtained, making sure the cuff is the appropriate size.20 The presence of acanthosis nigricans (darkening of the skin), possibly associated with insulin resistance, should be noted.22 Since hypothyroidism is a cause for weight gain, palpation of the thyroid should be done. If there is a history of snoring or sleep apnea, me tonsillar size should be evaluated. Postural abnormalities that limit physical activity, such as flat feet or genu varum, should be assessed.
The presence of dysmorphic features, abnormal genitalia, developmental delay, poor linear growth, hirsuitism, and striae should be noted, as they may be associated with rare genetic or endocrine causes for overweight. Based on the risk assessment flowchart developed by Barlow et al.7 and our own clinical experiences, we have created a flowchart to guide further clinical assessment and laboratory evaluations (Figure 1, see page 35).
OVERWEIGHT MANAGEMENT IN YOUNG CHILDREN
Research on the management of early childhood overweight includes actions in four realms: encouraging family behavior modifications, increasing physical activity, decreasing sedentary behaviors, and improving eating practices.23 All require frequent follow up.
For young children, most interactions happen at the family level. Unlike older children, young children are completely dependent on adults for nourishment and activity planning, and mimic their parents' attitudes towards health. Thus, family-based changes are always needed, and die parent should be considered the primary agent of change.24 Any effective intervention must emphasize parental involvement and will depend on the parents' willingness and ability to institute suggested changes within the family.
Family Behavior Modifications
The first step in family-based management of child overweight is to help parents realize their positions as role models whose attitudes and behaviors directly affect their children's actions.24 It is then possible to focus constructively on specific actions the family can take. Parents should be encouraged to model healthy behaviors to set a good example for their young child, such as eating balanced meals, exercising regularly, and watching television sparingly.
Young children have a natural drive to explore, Ieam, and be physically active.25 They possess an innate tendency to be active and, given the opportunity, will often perform large amounts of vigorous activity on their own, interspersed with frequent rest periods.25 However, because of their short attention spans and clumsy coordination, young children often defy approaches for encouraging physical activity that can work with teens and adults. Promoting physical activity in young children is therefore based on activity patterns that are short, spontaneous, and intermittent.26 Success requires that a parent appreciate a young child's inherent activeness, create opportunities for physical activity (sometimes at unusual times and places), and allow extended periods for unstructured active play.
The keys to promoting physical activity in young children are incorporating physical activity into daily life and creating and maintaining an environment conducive to active play. Incorporating physical activity into daily life can include using the stairs whenever possible, walking to the store, taking daily trips to a community park, walking the dog, and playing active games.
To provide an environment conducive to active play, a parent can be encouraged to designate an area of the house or garage for free play so that children, even during bad weather, have a place to play active games. Increasing playtime outdoors is another way to improve physical activity in young children.10 Clinicians must take into account the way some families must limit outdoor activities due to attributes of communities in which they live, including traffic, crime, or limited funding of community parks and recreation programs. Pediatricians should provide families with information about local parks, activity centers such as YMCAs and Boys & Girls Clubs, and other community programs.
The AAP recommends that children younger than 2 watch no television and that children 2 and older limit viewing to less than 2 hours each day.5 Restricting children's access to television can certainly decrease viewing time; however, some evidence suggests children who are reinforced for not spending time watching television participate in more physical activities and gain a greater liking for these activities than children who are simply restricted from television.27
To encourage non-sedentary behaviors, parents can contract with their child that the child will receive a gold star for each day the child spends an hour actively playing outdoors or indoors with the television off. When the child earns a set number of gold stars, the family could reward the child with an active family outing, such as going to a public park, zoo, or community pool.
The first priority in dietary counseling for young children is parental nutrition education that explains principles on which required changes are based. The parents' willingness to incorporate family-wide dietary changes should be evaluated, and the importance of such changes should be emphasized.
Short-term diets seeking quick, drastic weight loss are unrealistic and unhealthy for young children. Rather, incorporating small, gradual changes into the family's daily routine provides for successes that build confidence and inspire die patient and family to continue to develop healthy eating and activity patterns.
Some straightforward suggestions for families with young children are:
*Serve fruits and/or vegetables at every meal.
* Set a daily meal schedule (three balanced meals and two healthy snacks each day).
*Make simple dietary substitutions, such as eliminating sugary sodas and serving low-fat milk to children 2 and older.
* Keep only low-fat snacks in the house.
* Limit fast food consumption.
* Eat all meals at a table with the television off.
* Do not put enough food on the table to provide multiple servings.
The manner in which food is presented to me child, as well as meal habits, are also important. There is increasing evidence that parents who tightly control their children's feedings are more likely to have overweight children.28 This may be because overly controlling parents hinder energy selfregulation by children, placing the children at greater risk for becoming overweight later in life.28
Setting and Reaching Goals
In managing overweight in young children, the pediatrician can focus on weight maintenance rather than weight loss. Young children have the benefit of linear growth to facilitate normalization of weight for height. Regular follow up should be arranged every 1 to 2 months for close monitoring of intervention effectiveness and providing repeated positive reinforcements. The family's specific barriers to change must be reassessed at every visit and realistic goals further adapted to the family needs. Eventually, follow-up visits can become less frequent.
FUTURE RESEARCH NEEDS
Our knowledge of the treatment and prevention of overweight in young children is vastly inadequate. Current methods for assessing the eating habits, physical activities, and sedentary behaviors of young children remain inexact, as do management outcome standards. Research should focus on defining practical, inexpensive, and accurate techniques for measuring the dietary intake and physical activity of young children.
When it comes to management, no one approach seems to suffice. In practice, however, when multiple approaches are applied together, they seem to create a synergy that can work. More research is needed to evaluate multipronged approaches. Outcome measures for management interventions should broaden in scope to include not only weight reduction, but also the long-term effects of modest lifestyle modifications without weight reduction in growing children.
Because parental modeling and family dynamics play an important role in the formation of eating and physical activity patterns, culturally sensitive strategies for incorporating parents in the management of overweight must be created and tested. Research is needed on the effectiveness of counseling by primary care providers on developing and maintaining healthy family lifestyles, starting during the preschool years.
Management of overweight in young children may be our best opportunity for confronting the nationwide epidemic of childhood obesity. Doing so will require all health care providers to improve dieir identification, assessment, and guidance on this issue. As a group, we must make it a priority to obtain height and weight measurements on every child and to interpret them correctly. We must be comprehensive in our medical investigation in order to uncover identifiable causes and recognize comorbidities. Most of all, we must motivate families, as a whole, to confront this issue with us by increasing physical activity, decreasing sedentary behaviors, and improving eating practices. As health professionals in a society that is not yet poised to fight this epidemic, we must lead the way.
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