A Clinical Guide to Pediatric Weight Management and Obesity, 1st Edition

16

Practice Management Strategies for Obesity

When 25% to 50% of children and adolescents are affected by overweight or obesity, every clinician caring for children will need to develop strategies for dealing with obesity prevention, identification, early intervention, and treatment. Although obesity treatment without question needs to be individualized, there are clear practice-based strategies that will help in prevention, identification, and early intervention.

Factors of time and cost have to be considered as practice patterns change to meet the demands of caring for the obese child. In addition, physicians, nurses, and ancillary staff will need to be educated, to allow incorporation of this “new work” into day-to-day practice management.

Definitions

• Underweight—Body mass index (BMI) less than the 5th percentile
• Normal weight—BMI between the 5th and 85th percentiles
• Overweight—BMI between the 85th and 95th percentiles
• Obese—BMI greater than the 95th percentile

Prevention

One should monitor height, weight, and BMI for all children at every encounter.

Primary prevention of obesity is a goal shared by everyone in pediatric health care. From the beginning, achieving energy balance with appropriate growth in a setting of optimal nutrition, activity, and inactivity should be the goal. With this goal

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in mind, the following principles could be followed as a way to address obesity prevention in practice.

The practice of monitoring growth beginning at birth, plotting weight-for-length charts for infants (Figs. 16.1 and 16.2) and BMI charts for children older than 2 years

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(Figs. 16.3 and 16.4), and sharing these measurements with families is a good way to introduce your concern about optimal growth as well as to begin to discuss energy balance.

FIG. 16.1. Weight-for-length percentiles: girls 0 to 36 months. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

FIG. 16.2. Weight-for-length percentiles: boys 0 to 36 months. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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Routine recommended preventive care screening should be performed for children following a normal growth trajectory with no obesity or obesity comorbidity risk factors. Periodic review of family history, growth trajectory, and nutrition and activity habits should be incorporated into these well care visits.

FIG. 16.3. Body mass index-for-age percentiles: girls 2 to 20 years. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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Opportunities to plot height, weight, and BMI should be taken advantage of at all possible visits, reinforcing good nutrition and activity habits.

FIG. 16.4. Body mass index-for-age percentiles: boys 2 to 20 years. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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Weight and length/height (stature) charts are given in Figures 16.5, 16.6, 16.7, 16.8, 16.9, 16.10, 16.11 and 16.12.

FIG. 16.5. Weight-for-age percentiles: girls 0 to 36 months. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.6. Length-for-age percentiles: girls 0 to 36 months. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.7. Weight-for-age percentiles: girls 2 to 20 years. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.8. Stature-for-age percentiles: girls 2 to 20 years. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.9. Weight-for-age percentiles: boys 0 to 36 months. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.10. Length-for-age percentiles: boys 0 to 36 months. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.11. Weight-for-age percentiles: boys 2 to 20 years. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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FIG. 16.12. Stature-for-age percentiles: boys 2 to 20 years. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease.)

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Identify Growth Patterns

Patterns of growth can be important indicators of risk for overweight and obesity. Although birth weight is largely dependent on maternal weight, newborns who are large for gestational age with a maternal history of diabetes or gestational diabetes are at increased risk for obesity and require close attention in achieving optimal energy balance. Conversely, newborns who are small for gestational age or who are from pregnancies complicated by cigarette smoking or other risk factors for intrauterine growth retardation, are also at increased risk for obesity and require close monitoring of growth.

In a study of California children under the age of 5, it was found that 39% of children from birth to 6 months of age, 6% to 15% of children between 6 and 24 months of age, and 1% to 5% of children 24 to 60 months of age crossed two major weight-for-age percentiles. Even more striking, 62% of children from birth to 6 months of age crossed two major weight-for-height percentiles, with 80% moving to higher percentiles. In addition, 20% to 27% of children 6 to 24 months of age and 8% to 15% of children 24 to 60 months of age crossed two major BMI-for-age percentiles About 14.5% of children between ages 2 and 3 years crossed two major BMI percentiles, down to 10.6% by age 4 years and 8.4% by age 5 years (1).

When it is determined that a child has crossed growth percentiles on the BMI chart, it is often useful to ask the family and child about any health, environmental, family, or psychosocial events that may have occurred around the time of the increase in BMI (Table 16.1). Although you may not always be able to identify inciting events, frequently this type of history gives you a glimpse of possible trigger points in the individual child and family that may have altered energy balance.

Identify children at risk for obesity between the 85th and 95th percentiles of BMI.

Children with Body Mass Index Between the 85th and 95th Percentiles

Family History Focused on Obesity-Related Comorbidities

At this point, a family history of obesity and obesity-related comorbidities should be obtained if not done previously and can be used as a starting point for discussion with the family and child. For example, a family concerned about type 2 diabetes and complications in a grandparent can give information about the links to weight

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and lifestyle as well as be given a chance to express their concerns if this topic is introduced in a way that avoids blame and guilt. Parents, grandparents, siblings, and extended family may have had these conditions identified or may be having symptoms of the comorbidities outlined in Table 16.2.

TABLE 16.1. Trigger points that may be associated with an increase in body mass index

Parental separation/divorce School change Death of family member Child's illness or hospitalization Parental illness Change in caregivers Onset of depression Family move

If the family history is positive for familial hyperlipidemia or if parents or grandparents have had coronary atherosclerosis, myocardial infarction, angina pectoris, peripheral vascular disease, cerebrovascular disease, or sudden cardiac death or stroke at age 55 years or younger or cholesterol levels higher than 240 mg/dL, lipid screening should be performed. Factors such as diabetes, physical inactivity, cigarette smoking, and extended family with cardiovascular disease also contribute to risk and would indicate screening (2). A fasting plasma glucose should be obtained and repeated every 2 years if a child has a BMI greater than the 85th percentile and is 10 years old or has had onset of puberty with a family history of type 2 diabetes in parents, siblings, or grandparents; is of nonwhite race; has acanthosis nigricans; or has hypertension, dyslipidemia, or polycystic ovary syndrome (3).

Behavioral Changes

It is important to remember that physicians can have a direct impact on behavior changes. Literature on smoking cessation would suggest that assessment of patient readiness to quit smoking and provision of information on smoking cessation strategies in a primary care office can result in an increased number of patients who stop smoking (4). It is also important to note that in a study of overweight and obese children and adolescents from the National Health and Nutrition Examination Survey (NHANES) 1999–2000 only 36.7% of overweight children and adolescents ages 2 to 19 report being told by their physician or any health care provider that they were overweight. Children or their parents were more likely to be told they were overweight at older ages, with 17.4% of 2 to 5 year olds, 32.6% of 6 to 11 year olds, 39.6% of 12 to 15 year olds, and 51.6% of 16 to 19 year olds being told they were overweight (5).

Identify Children with Body Mass Index Greater than the 95th Percentile

Children with BMI greater than the 95th percentile need evaluation and treatment for obesity. It goes without saying that the earlier in the obesity trajectory children

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are identified, the more time is available to integrate lifestyle and behavioral change. Family history in this group of children is also a good starting point for discussion. In addition, a thorough review of systems for obesity-related comorbidities should be carried out (Table 16.3).

TABLE 16.2. Family history of obesity-related comorbidities

Obesity Liver disease (NASH) Sleep apnea Polycystic ovarian syndrome Asthma Slipped capital femoral epiphysis Gastroesophageal reflux Blount's disease Type 2 diabetes Osteoarthritis Hypertension Cancer Dyslipidemia NASH, nonalcoholic steatohepatitis.

TABLE 16.3. Review of systems for obesity-related comorbidities and obesity-associated conditions

· Severe obesity-related emergencies · Cardiomyopathy of obesity o Shortness of breath, orthopnea, dyspnea on exertion, pedal edema, rales, cardiomegaly · Diabetic ketoacidosis, hyperosmolar hyperglycemic state o Polyuria, polydipsia, recent weight loss, blurred vision, abdominal pain, vomiting, vaginitis, prolonged infection, acanthosis nigricans, stupor, coma · Pulmonary emboli o Recent immobilization, lower extremity surgery, chest pain, dyspnea, hypoxia · Obesity-related comorbidities requiring immediate attention · Slipped capital femoral epiphysis o Hip, knee, or thigh pain; limp; uneven, painful gait · Blount's disease o Tibial bowing; uneven, painful gait · Pseudotumor cerebri o Headache, vomiting, papilledema, visual field cuts · Nonalcoholic steatohepatitis o Anorexia, abdominal discomfort, hepatomegaly · Cholelithiasis o Right upper quadrant pain, jaundice, vomiting · Chronic obesity-related comorbidities · Type 2 diabetes o Polyuria, polydipsia, recurrent infections, vaginitis, recent weight loss, blurred vision · Asthma o Shortness of breath, exercise-induced wheezing or cough · Obstructive sleep apnea syndrome o Snoring, apnea, upright sleep position, daytime somnolence, poor school performance · Polycystic ovarian syndrome o Acne, hirsutism, irregular menstrual periods or oligomenorrhea, acanthosis nigricans, history of premature adrenarche · Dyslipidemia o Acanthosis nigricans, family history of lipid disorder · Hypertension o Headache, systolic and/or diastolic blood pressure greater than the 90th percentile for age and gender · Depression o Poor school performance, depressed affect, family history of depression, anger/behavioral issues · Binge eating disorder o Out of control eating, sneaking, and guilt after eating · Bulimia o Erosion of dental enamel, history of self-induced vomiting · Prader-Willi syndrome o Neonatal hypotonia, small hands and feet, hyperphagia, skin picking, hypogonadism, developmental delay · Bardet-Biedl syndrome o Polydactyly, renal anomalies, retinitis pigmentosa, developmental delay · MC4R mutations o Severe childhood obesity and polyphagia

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Screening

Screening laboratory studies should include a fasting lipid profile (2,6). Screening for type 2 diabetes also should be performed. Fasting glucose and insulin levels have been recommended (7), as are liver function studies (8). Other laboratory evaluation and further testing are based on the family history, review of systems, and physical examination.

Identify Children with Elevated Body Mass Index and Short Stature or Height Deceleration

Children with elevated BMI and short stature or height deceleration need immediate attention. These children should be evaluated for associated findings consistent with central nervous system (CNS) tumor (9) or hypothalamic lesion (10,11). History of hypothalamic injury; irradiation or surgery; genetic syndrome; endocrinologic disorders such as Cushing's syndrome, hypothyroidism, or growth hormone deficiency; or other systemic illnesses or pharmacologic treatment should also be addressed.

Evaluation of these children should include appropriate endocrinologic, genetic, and neurologic imaging studies and referral to a pediatric neurologist, geneticist, and/or endocrinologist.

It is important to remember that obese children and adolescents have the same needs for preventive care, ongoing health care, mental health services, and attention to behavioral issues as normal weight children, in addition to the increased risk conferred by obesity. It is vital to discuss obesity-related issues and problems in the context of overall well and illness-related care.

Treatment

Once a child is identified as obese, energy balance must be re-established. Initial goals for therapy can vary, depending on the magnitude of the obesity, the comorbidities that are present, and the age of the child. Table 16.4 illustrates categories of potential initial therapeutic goals.

It is important to identify the medical goals and outcome but to remember that the pathway to achieving these goals and restoring energy balance is individual, and

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goals for lifestyle change should be set in collaboration with the family, based on their motivation, skills, and resources. A good review of strategies for achieving weight control is outlined by Dietz and Robinson (12), whose summary of weight control strategies include the following:

• Goal setting
• Control of the environment
• Monitoring and rewarding successful behavior
• Problem solving and parenting skills

TABLE 16.4. Potential initial therapeutic goals

· Slowing of rate of weight gain · Stabilizing weight · Reducing weight · Restoring metabolic parameters to normal · Reducing or eliminating obesity-related comorbidities · Changing targeted nutrition or activity behavior · Instituting family-based change · Improving the nutritional/activity environment

Goal Setting

Goal setting (12) is achieved jointly with the family. Goals are based on detailed knowledge of the child's or adolescent's:

• Daily nutrition
• Activity and inactivity routine
• The family's approach to nutrition and activity
• Child's temperament
• Parenting style
• Parental and family belief that change can occur
• Value for the outcome of the behavior change

The role of the pediatrician and primary care physician is to provide sound medical evaluation of the child's current risk for disease, offer a menu of strategies that have proven effective in weight control based on the child's developmental stage, and work with the child and family to achieve these goals.

Goals should be short term, that is, what will happen by the next visit, and measurable, that is, minutes of outdoor play per day.

Goals should be achievable. Many families want to change every aspect of nutrition all at once, or have the adolescent “lose 50 lb by the prom.”

Reassurance that stepwise change is effective and tends to be more long lasting is important to avoid setting up a situation of repeated failure.

Goals should be family oriented. Whenever possible, the whole family should participate in the behavioral change. For example, if television and computer use is being limited, this applies to the whole family, not just the obese child or adolescent. This strategy creates a partnership between the child and family and can limit the child's feeling of deprivation or resentment.

Goals should be incremental. Change is difficult under the best of circumstances. Setting one or two goals at a time can help solidify change and create stable habits to build on. Families should be reassured that you will partner with them as long as it takes to achieve weight control and good health for their child.

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Control of the Environment

Control of the environment (12) is a strategy that focuses the family on the external environment and removes the intense focus some families have on the obese child. It may be helpful to compare the creation of an optimal nutritional and activity environment for the child with the time when the family “child proofed the house” for safety reasons. It can also be useful to help the family members see themselves as the interface between the child and the societal environment, which is obesity promoting. Families can begin to see that changing the home environment and helping the child or adolescent make healthy decisions about the nutritional and activity environment outside the home is a major teaching role for the adults in the family. Some environmental changes that have been found useful in weight control and in achieving healthy energy balance are listed in Table 16.5.

Self-Monitoring and Problem Solving

Setbacks are a normal part of lifestyle change.

TABLE 16.5. Environmental changes to restore healthy energy balance

· Engage entire family in the desired environmental change · Limit availability of highly palatable, calorie-dense foods · Limit or eliminate juice, soda, sports drinks, and calorie-containing beverages (13) · Replace high-calorie snack food with healthy food choices that complete the food group requirements, such as fruits and vegetables · Eliminate “unconscious eating,” i.e., eating in front of the television or computer, and instead have snacks and meals at the table · Increase meal structure · Have regular meal and snack times; avoid grazing and late night eating · Serve age-appropriate portions · Limit eating out and ordering in meals · Limit sedentary activity · Limit television and computer use to no more than 2 hours/day; no television or computer for children younger than 2 years (14) · Choose day care and after school care settings that provide activity opportunities when possible · Plan family activities around physical activity instead of sedentary behavior · Limit stroller use in toddler-aged child · Increase physical activity · Provide opportunity and time for outdoor play · Encourage parents to value extracurricular sports as opportunities for participation, not only competition · Help parents choose a variety of sport and physical activities to expand the child's and adolescent's physical repertoire · Increase the physical component of daily activities, e.g., park farther away from stores, walk from school or bus stop Reprinted from Dietz WH, Robinson TN. Clinical practice: overweight children and adoles-cents. N Engl J Med. 2005; 352(20):2100-2109, with permission.

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Preparing parents and family members in advance to expect some setbacks is helpful in sustaining change. Offering to be a partner in problem solving can relieve anxiety when setbacks occur. Building self-monitoring skills in conjunction with problem solving allows behavioral and lifestyle change to be maintained over time. Problem solving can be targeted to the specific goals that have been agreed on—for example, if the family decided to eliminate soda and juice from the house but the child gets sweetened drinks at grandmother's house after school, a family meeting that includes grandmother might be helpful to reset goals and develop a strategy to achieve them that whole family can support. Table 16.6 illustrates some common setbacks or problems that can arise in implementing a weight control plan (12).

Parenting Style and Skills

By definition, making behavioral change involves a close interaction between family members, parents, and the child or adolescent. Initiating change may trigger behavior in the child or adolescent that parents need to respond to, may cause friction between family members, and may necessitate an examination of parenting skills and style (12).

Communication

• Parents or responsible adults in charge need to agree on and be willing to participate in the desired behavior change.
• Desired changes need to be communicated to the child and family in a clear, authoritative, but not authoritarian, manner.
• Self-monitoring and frequent feedback needs to be communicated between the parent and child.
• Communication should be positive, with praise for success and a neutral and helpful approach when there are setbacks.
• Discussion about food, television, and computer should be limited to desired change, and the focus should be on the other areas of the child's life, such as friends, school, and family, to avoid overfocusing the parent-child communication on one area.

TABLE 16.6. Common setbacks and problems

· Family members disagreeing on nutrition and activity changes · Child or adolescent getting extra meals, snacks, and food at school, day care, relatives and friends, and corner store · Free access to food after school · Family schedule that interferes with meal timing and structure · Television and computer in child's room, multiple televisions in house · Limited availability of resources for physical activity, limited knowledge of community resources

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Setting Boundaries

• Parents need to see themselves as providers of good nutrition and children and adolescents as deciders of how much of the correct portion to eat.
• Parents can think of nutrition and activity decisions as health decisions in the same way they think of decisions about safety. This may help them maintain boundaries in the face of resistance.
• It is appropriate for parents to encourage participation in physical activities in the same way they support the child's success at school and with other extracurricular activities.
• Parents are the gatekeepers in terms of environmental, societal, and cultural influences on eating and activity and should decide how they want to maintain healthy behaviors rather than adopting the norm.

Setting Examples

• Parents and responsible adults should behave in the same way they would like the child or adolescent to behave, even if they do not have a weight problem.
• Parents should examine their own lifestyle choices and be willing to change if necessary.
• Parents can model ways of dealing with problems and setbacks.
• Parents can model optimal communication around the often emotionally charged issues of eating and physical activity change.

Practice-Based Change

To help patients and families affected by and at risk for obesity, practices will have to change workflow to incorporate this “new work of pediatrics.” In many ways, the same principles for making behavior change in families apply to making change in practice.

Possible Practice-Based Strategies to Consider

Timing

It is important to decide how the practice will incorporate obesity-related issues into the visit schedule. Some possibilities include the following:

• Prenatal visit

Breastfeeding should be encouraged as the optimal nutrition source for all infants but has also been shown to have a small but significant effect on later obesity (15).

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Parental obesity is a risk for childhood and adolescent obesity, and families in which one or both parents are obese can be identified and supported in assessing family nutrition and activity patterns as early as possible (16).

• Well visits

Establish a routine of plotting height, weight, and BMI and reviewing growth with parents at every well visit. A quick diet and activity history can target areas for discussion of optimal nutrition and activity habits. Establishing a routine review will normalize the discussion about BMI for parents.

• Illness-related visits

A visit relating to a comorbidity of obesity can also be an opportunity to briefly assess progress on lifestyle change or to suggest a follow-up visit to continue work on weight control.

Tracking

Once a child is identified as obese or at risk for obesity, the practice should have a routine for scheduling revisits to initiate treatment and track progress. It is helpful to have all practitioners agree to a similar routine in assessing and treating obesity so families experience a consistent approach to this problem.

Triggers

Children whose BMI is between the 85th and 95th percentiles, children with a BMI greater than the 95th percentile, and children crossing growth percentiles should trigger an evaluation of family history, review of systems, laboratory testing, identification of any obesity-related comorbidities, and a plan for follow-up visits.

Emergencies

Staff education should include information about obesity-related emergencies and comorbidities, including signs and symptoms, and a plan of action.

References

1. Mei Z, Grummer-Strawn LM, Thompson D, Dietz WH. Shifts in percentiles of growth during early childhood; analysis of longitudinal data from the California Child Health and Development study. Pediatrics.2004;113:e617–e627 (accessed 8/12/06 at http://pediatrics.aappublications.org/cgi/content/full/113/6/e617/F3).
2. American Academy of Pediatrics Committee on Nutrition. Cholesterol in childhood. Pediatrics.1998;101:141–147.
3. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care.2000; 105(3Pt1):671–680.
4. Milch CE, Edmunson JM, Beshansky JR, Griffith JL, Selker HP. Smoking cessation in primary care: a clinical effectiveness trial of two simple interventions. Prev Med.2004;38:284–294.
5. Ogden CL, Tabak CJ. Children and teens told by doctors that they were overweight–United States, 1999–2002. MMWR.2005;54(34):848–849.

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6. Bao W, Srinivasan SR, Wattigney WE, Bao W, Berencon GS. Usefulness of childhood low-density lipoprotein cholesterol level in predicting adult dyslipidemia and other cardiovascular risks. The Bogalusa Heart Study. Arch Intern Med.1996;156:1315–1320.
7. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics.1998;102(3):e29.
8. Strauss RS, Barlow SE, Dietz WH. Prevalence of abnormal serum aminotransferase values in overweight and obese adolescents. J Pediatr.2000;136(6):727–733.
9. Muller HL, Emser A, Faldum A, Bruhnken G, Etavard-Gorris, N, Gebhardt U, Oeverink R, Kolb R, Sorensen N. Longitudinal study on growth and body mass index before and after diagnosis of childhood craniopharyngioma. J Clin Endocrinol Metab.2004;98:3298–3305.
10. Cianfarani S, Nicholl RM, Medbach S, Charlesworth MC, Savage MO. Idiopathic hypothalamus pituitary dysfunction: review of five cases. Horm Res.1993;39(1–2):47–50.
11. Mehta S, Boyd T, Weinstein D. Ganglioneuroblastoma in children with rapid weight gain and obesity: an infrequently recognized paraneoplastic syndrome. Abstract International Endocrine Meetings, Lyon, France, 2005.
12. Dietz WH, Robinson TN. Clinical practice: overweight children and adolescents. N Engl J Med.2005;352(20):2100–2109.
13. Berkey CS, Rockett HR, Field AE, Gillman MW, Colditz GA. Sugar-added beverages and adolescent weight change. Obes Res.2004;12:778–788.
14. American Academy of Pediatrics. Children, adolescents and television. Committee on Public Education. Pediatrics.2001;107:423–426.
15. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta analysis. Am J Epidemiol.2005;162:397–403.
16. Whitaker RC, Wright JA, Pep MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med.1997;337:869–873.