childhood overweight childhood overweight and type 2 diabetes
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Childhood Overweight Childhood Overweight and Type 2 Diabetesand Type 2 Diabetes
Turning the Titanic and other Turning the Titanic and other Sisyphean tasksSisyphean tasks
Terry Raymer MD, CDEAlaska Native Diabetes Program
Overweight in ChildhoodOverweight in Childhood• Brief overview of epidemiology and etiology
childhood • Evaluation of overweight in children • Medical Consequences • Management recommendations and
communication with families regarding overweight in childhood & case study
• Briefly (if time permits): roles of society – Community and Schools
Source: Behavioral Risk Factor Surveil lance System, CDC.
19961991
2003
Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2003
(*BMI ≥30, or about 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ¡ 25%
“the average weight gain among subjects (20-40 years old) in the population is 1.8 to 2.0 pounds/year.”Science. 299:7;853-855 (2003)
Prevalence of Overweight Among U.S. Prevalence of Overweight Among U.S. Children and Adolescents Ages 6Children and Adolescents Ages 6--19 Years19 Years
45
4
67
5
11 11
15.8 16.1
02468
1012141618
Perc
ent
1963-70 1971-74 1976-80 1988-94 1999-02
6-11 Years 12-19 Years
3 FoldIncrease
SOURCE: CDC/NCHS, NHES and NHANESSOURCE: CDC/NCHS, NHES and NHANES
ANMC Overweight Prevalence Report 2004ANMC Overweight Prevalence Report 2004--20072007
0
10
20
30
40
50
60
70
80
2-4 5-14 15-19 20-24 25-44 45-64 65-74
Perc
ent
BMI over 25 BMI over 30 CombinedRPMS DataBMI is for adult population, for ages 2-19…
Defining overweight in ChildrenDefining overweight in Children
• Ages 2-19: 'At Risk for Overweight' is defined as BMI >=85th% but <95th%
• 'Overweight' is defined as BMI >= 95th%• National Center for Health Statistics in
collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000).
Percentage of Overweight Children and Percentage of Overweight Children and Youth who become overweight AdultsYouth who become overweight Adults
Preventive Medicine 1993; Vol. 22:pp. 167-177Arch Pediatr Adolesc Med Vol. 158 May 2004 pp. 449-452
10
3550
80
0102030405060708090
100Pe
rcen
tage
Infan
tsPres
choo
lSch
ool A
geAdole
scent
Pima IndiansPima Indians Current Prevalence of Type 2 Current Prevalence of Type 2
Diabetes in ChildrenDiabetes in Children10-14 years 22.3/1000
1515--19 years19 years 50.9/100050.9/1000
Prevalence for all American Indian children 4.5/1000
Prevalence for all 0 – 19 y/o children in US 1.7/1000
•
Altered Dietary Intake
•
Decreased Physical Activity
•
Increased Sedentary Behaviors
•
Parenting Styles
•
Gestational Diabetes
Childhood Overweight Behavioral Childhood Overweight Behavioral Risk FactorsRisk Factors
Genes are not destiny
A small behavior change over time A small behavior change over time can prevent some weight problems.can prevent some weight problems.
Energy Input vs Energy Output
2% Error Leads to Overweight125 kj /day or 15 Minutes of Play
Instead of TelevisionMichael Goran , Am J Clin Nutr 1999;70
Infant & Toddler OverweightInfant & Toddler Overweight Behavioral Risk FactorsBehavioral Risk Factors
• Breastfeeding rates at 12 months of age are 7%• 17% of infants consume juice before 6 months• 10% of infants consume French fries and soda
before 12 months of age• WIC toddlers consume more 100% juice and
less whole fruit than non-WIC toddlers• WIC toddlers consume 40% more calories than
their energy requirements
Pediatrics October 2004, Vol 114,No. 4 pp. 1146-1173Feeding Infants and Toddlers Survey (FITS) 2004
Billboard on the edge of the Navajo ReservationCourtesy of Tim Gilbert/ANTHC
Why pick on soda?Why pick on soda?
Clear Evidence of Negative effectsClear Evidence of Negative effects• Children’s Hospital in Boston
– Increased consumption definitively linked to weight, increased calories (~300 a day)
• HFCS (sweetener) may contribute to the development of diabetes, particularly in children due to “carbonyl” formation
• Higher insulin resistance and fasting blood levels of insulin even in healthy adults
• Evidence that “diet sodas” are not protective
Childhood OverweightChildhood Overweight Behavioral Risk FactorsBehavioral Risk Factors
• The average consumption of soft drinks by 12- 19 year olds is over 20 ounces per day
• 80% of 5th, 7th and 9th graders in California fail to meet the minimum fitness standards.
• More than 25% of children in CA reported averaging > 4 hours of TV watching per day
• In California, of 7th, 9th and 11th graders surveyed less than half reported eating fruits or vegetables at least once per day in past week.
Fitness and Academic PerformanceFitness and Academic Performance2001 Grade 7 SAT 9 and Physical Fitness
California Department of Education 12/10/02http://www.cde.ca.gov/news/releases2002/rel37.asp
26283132 3436
4144
5054
6066
0
10
20
30
40
50
60
70
1 2 3 4 5 6
ReadingMath
Number of Fitness Standards Achieved
SAT
9 Pe
rcen
tile
Determining the BMIDetermining the BMI• (First you gotta) Measure BMI Annually• Measure BMI at Well Child Care Visits
2-18 years (hint – plot on growth chart)• BMI (English):[ weight (lb) ÷ height (in)
÷ height (in) ] x 703• BMI (metric):[ weight (kg) ÷ height (cm)
÷ height (cm) ] x 10,000• Calculation Tools: www.cdc.gov/ and
www.nhlbisupport.com/bmi/
Determine the DiagnosisDetermine the Diagnosis
Make a weight diagnosis using BMI percentile for age:
• < 5%-ile Underweight• 5-84%-ile: “Healthy Weight”• 85-94%-ile: “at risk for overweight”• > 95%-ile: “Overweight”
Measurement example:
Age=3 y 3 wks
Height=100.8 cm (39.7 in)
Weight=18.6 kg (41 lb)
BMI=18.3
BMI-for-age= >95th%-ile
Boys: 2 to 20 years
BMI BMI
BMI BMI
“Overweight”
Boys: 2 to 20 years
BMI BMI
BMIBMI
BMI
Shape of BMI-for-Age Growth Curve: “Adiposity”
Rebound
• Risk factor for Adult overweight
• Linked to Parental weight
• A Key Intervention AgeExample: Early AR
Age (mos) BMI26 18.232 17.438 18.541 18.7
Conveying the DiagnosisConveying the Diagnosis
For Patient Communication...• Weight or Excess Weight• Body Mass Index (BMI)• Emphasize weight “stabilization”• Focus on healthy habits, not weight loss• Risk for Diabetes & Heart Disease• Better to assign risk, non-pejorative terms
Childhood Overweight Medical Childhood Overweight Medical Assessment: Medical HistoryAssessment: Medical History
• Developmental delay (Genetic disorders)• Poor linear growth (Hypothyroidism, Cushing’s,
Prader-Willi syndrome)• Headaches (Pseudotumor cerebri)• Daytime somnolence (Sleep apnea, hypoventilation)• Nighttime breathing difficulty (Sleep apnea)• Abdominal pain (Gall bladder disease)• Hip or knee pain (Slipped capital femoral epiphysis)• Oligomenorrhea or amenorrhea (Polycystic ovary
syndrome)
Medical Assessment: Medical Assessment: Family HistoryFamily History
• Overweight• Hypertension• Type 2 Diabetes• Dyslipidemia• Cardiovascular disease• Gall bladder disease
Medical Assessment: ExamMedical Assessment: Exam• Height, weight, Blood pressure and BMI• Truncal obesity (Risk of cardiovascular
disease; Cushing’s syndrome)• Acanthosis nigricans (Type 2 DM, insulin
resistance)• Hirsutism (Polycystic ovary syndrome;
Cushing’s syndrome)• Tonsils (Sleep apnea)• Limited hip range of motion (Slipped
capital femoral epiphysis)
AcanthosisAcanthosis
NigricansNigricans
on the Neckon the Neck
Acanthosis NigricansAcanthosis Nigricans
Laboratory AssessmentLaboratory Assessment• BMI 85-94%-ile Without Risk Factors
– Fasting Lipid Profile + Insulin? • BMI 85-94%-ile Age 10 Years or puberty & Older
With Risk Factors Every 2 Years– Fasting Lipid Profile– ALT and AST– Fasting Glucose
• BMI >= 95%ile Age 10 Years & Older Every 2 Years– Fasting Lipid Profile– ALT and AST– Fasting Glucose– Other Tests as Indicated by Health Risks
* Diabetes Care, volume 31, Supplement 1; January 2008: S14
TestingTesting for Diabetes in Kids*for Diabetes in Kids*
• Asymptomatic, age 10 or puberty with BMI > 85%-ile with any 2 of the following:– Family History: type 2 DM in a 1st or 2nd
degree relative– Ethnic Group: Native American, African
American, Hispanic, Asian/Pacific Islander– Signs of Insulin Resistance: acanthosis
nigricans, hypertension, dyslipidemia, PCOS– Maternal History of GDM (consider LGA)
* Diabetes Care, volume 31, Supplement 1; January 2008: S14
TestingTesting
for Diabetes in Kids*for Diabetes in Kids*• Preferred test is a Fasting Plasma
Glucose• Diagnostic Criteria: plasma glucose
–Fasting (8+ hour) > 126 mg/dl–Oral glucose tolerance test: 2-hour
plasma glucose > 200 mg/dl–Casual (random) plasma glucose
> 200 mg/dl WITH symptoms• Confirm on subsequent day/test
Laboratory evaluation• Other tests based on history and physical...• Family History, Symptoms or Signs of
Thyroid Disease• TSH
• Oligomenorrhea or Amenorrhea• Free Testosterone• LH• FSH• TSH• Prolactin
Medical Complications of OverweightMedical Complications of Overweight
Phlebitis:venous stasis
Insipient CVD
Pulmonary disease:obstructive sleep apnea
Gall bladderdisease
Gynecologic:PCOS, Infertility
Diabetes
Joints: Arthritis, Slipped Capital Femoral Epiphysis
Cancer Risk Increase
Liver disease: steatosisSteatohepatitis, NAFLD Hypertension
Dyslipidemia
Skin
Idiopathic intracranial hypertension, pseudotumor c.
Pancreatitis
Overweight Associated Overweight Associated Psychological ConditionsPsychological Conditions
• Depression• Anxiety• Low self esteem• Teasing/Bullying• Adverse socioeconomic outcome• Other social prejudices
““The Metabolic SyndromeThe Metabolic Syndrome””
Adiposity, visceral
Type 2 diabetesHypertension
Dyslipidemia Impaired glucose tolerance
Acanthosis nigricans
Polycystic ovary disease
InsulinResistance
Adapted from Consensus Development Conference of the American Diabetes Association, Diabetes Care, 1997
Childhood Hypertension Predicts Childhood Hypertension Predicts Adult HypertensionAdult Hypertension
• 20%-30% of overweight children have high blood pressure
• Overweight adolescents have 8.5 fold risk of hypertension as adults.**– Cardiac hypertrophy/LVH on ultrasound. – Long term risk of CVD and stroke.
• Treatment– Weight loss, low salt diet, pharmacotherapy
**Srinivasan Metab 1996;45:235-240.
Adolescent Overweight Predicts Adolescent Overweight Predicts Adult Adult HyperlipidemiaHyperlipidemia
Overweight during adolescence associated with:• 2.4 X increase in prevalence of
cholesterol > 240mg/dl, • 3 X increase in LDL-C values >160mg/dl• 8 X increase in HDL-C values < 35 mg/dl
in adults 27-31 yo.
Srinivasan Metab 1996;45:235-240.
Atherosclerosis begins in Childhood:Atherosclerosis begins in Childhood: Autopsy StudiesAutopsy Studies
• Bogalusa Heart Study: 2-15 yo• Pathological Determinants of Atherosclerosis in
Youth (PADY): 15-30• Raised coronary lesions in
– 7% Bogalusa– 24% PADY
• Correlates of coronary atherosclerosis– Body mass index – VLDL, LDL-C, HDL-C, triglycerides– Blood pressure
Berenson GS, et.al. N Engl J Med Jun 4; 338(23):1650-1656. Malcolm GT, Oalmann MC,. Annals New York Academy of Sciences pp 179-188
Treatment and PreventionTreatment and Prevention
““ItIt’’s hard to know if yous hard to know if you’’re re failing unless you set yourself failing unless you set yourself
some goalssome goals…”…”Yogi Berra
Recommended Weight GoalsRecommended Weight Goals
Weight loss approx. 1 pound/monthWeight goal: BMI< 85%
Sarah E. Barlow and William H. Dietz, Obesity Evaluation and Treatment: Expert Committee Recommendations, Pediatrics 1998 102: e29 http://www.pediatrics.org/cgi/content/full/102/3/e29
AMA Prevention StrategiesAMA Prevention Strategies• Annually, measure height, weight, and calculate
BMI plus BMI percentile (level of evidence, C). • Encourage all children to participate in at least 60
minutes of moderate to vigorous physical activity on most, and preferably all, days of the week (level of evidence, A).
• Advise no more than 1 serving per day of sweetened beverages, such as fruit juice, fruit drinks, regular-calorie soft drinks, sports drinks, energy drinks, sweetened or flavored milk, or sweetened iced tea (level of evidence, B).
AMA Prevention StrategiesAMA Prevention Strategies• Advise families to limit children's television
viewing and other screen time to 2 hours per day or less (level of evidence, B).
• Recommend that children's fast-food consumption be limited to no more than once per week (level of evidence, C).
• Advise families to eat meals together as often as possible, on most, and preferably all, days of the week (level of evidence, C).
Prevention of Pediatric Overweight and Prevention of Pediatric Overweight and Obesity: American Academy of Obesity: American Academy of
Pediatrics Policy StatementPediatrics Policy Statement• Prevention Summary:
http://www.pediatrics.org/cgi/content/full /120/Supplement_4/S229
• Very similar Strategies to AMA recommendations
• Treating GDM may reduce risk as well*
*Diabetes Care. 2007;30:2287-2292.
And now for something And now for something completely differentcompletely different……
““7521075210””
• Eat Breakfast 7 days a week–Could add eat together 7 days a week
• Eat 5 servings of Fruits and Veggies• Limit screen time to 2 hours or less daily• Participate in 1 hour of Physical Activity
daily• Drink 0 sodas or sweetened beverages on
a typical day*
*Yes, you can exclude the Chuck E Cheese birthday parties…
AMA: Treatment StagesAMA: Treatment Stages• Stage I (Prevention-Plus Protocol): Make specific
dietary and physical activity recommendations, with monthly follow-up. If BMI does not improve in 3 to 6 months, consider stage II.
• Stage II (Structured Weight Management Protocol). Low–energy-dense, balanced diet; structured meals; supervised physical activity of at least 60 minutes daily; limiting television-watching and other screen time to 1 hour per day or less; and use of logs to self- monitor these behaviors. Family clinicians may require assistance from allied care professionals to implement this step, and children should be followed up as often as needed. If BMI does not improve in 3 to 6 months, stage III is appropriate.
AMA: Treatment StagesAMA: Treatment Stages• Stage III (Comprehensive, Multidisciplinary
Intervention) and Stage IV (Tertiary-Care Intervention) More intensive interventions administered by highly trained teams expert in overweight management. Specialized centers can provide effective, intensive counseling programs that promote behavior modification for overweight children. Especially indicated for severely overweight children and for those with co-morbidities.
• Stage IV: tertiary care referral. • Many recommendations can be carried out by family
physicians for treatment and prevention. These include advice to limit consumption of sweetened beverages and fast food, limit screen time, engage in physical activity for at least 60 minutes per day, and encourage family meals on most (if not all) days of the week.
Expert Committee Recommendations Expert Committee Recommendations Regarding the Prevention, Assessment, and Regarding the Prevention, Assessment, and
Treatment of Child and Adolescent Treatment of Child and Adolescent Overweight and Obesity:Overweight and Obesity:
• Summary:http://www.pediatrics.org/cgi/content/full/120/Supplement _4/S164
• Assessment: http://www.pediatrics.org/cgi/content/full/120/Supplement _4/S193
• Treatment:http://www.pediatrics.org/cgi/content/full/120/Supplement _4/S254
Medications and SurgeryMedications and Surgery????• None Approved for Children Under 16, experimental only • Orlistat (Xenical®)
• Lipase inhibitor: decreased fat absorption• Adverse reactions: flatus, diarrhea
• Sibutramine (Meridia®)• Serotonin and norepinephrine reuptake inhibitor• Promotes feeling of fullness, increase calorie
expenditure• Adverse reactions: increases heart rate, increases BP• Adolescents 13-17 years: sibutramine + behavior
therapy lost 7.8 kg at 6 months compared to 3.2 kg for placebo and behavior therapy .
• Bariatric Surgery for Severely OverweightJAMA. 2003;289:1805-1812
Overweight Children and Your Overweight Children and Your PracticePractice
• How will you improve the care of overweight children in your practice?
• What tools will you need?• What training will be needed?• How will measure the success of your
efforts?
• Child Rearing
– Anglo-American: parent-focused responsibility
– Native American: community-focused child rearing - children are to be shared; discipline and nurturing responsibility of all
• Education
– Anglo-American: formal education stressed, individual achievement is stressed
– Native American: education occurs in all facets of life, individuals should learn from one another
• Implications for Intervention: Community based, Health Aides
Pediatrics Vol. 91 (5) Supp, May 1993 pp. 1063-1070
Cultural ConsiderationsCultural ConsiderationsNative Americans/Alaska NativesNative Americans/Alaska Natives
No cultural advice applies to everyone in a particular culture
Cultural/Group SupportCultural/Group Support• Pima Pride/Action
-DPP pilot studyPeople randomized to “Action” group:
-Structured diet/exercise meetingsPeople randomized to “Pride” control group:
-Unstructured activities emphasizingPima culture and history
- “Pima Pride” group showed more positive outcomes on every biological parameter measured
Ann Bullock MDNarayan et al, Diabet Med 1998;15:66-72
• Overweight adolescents have been shown to be more likely to skip breakfast and consume a few large meals per day than their leaner counterparts. (1)
• Although medically supervised weight control may be beneficial for overweight youths, some research suggests that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain. (2)
Adolescents and DietingAdolescents and Dieting
(1) J Am Diet Assoc. Vol. 101, 2001, pp. 798-802(2) Pediatrics Vol. 112 (4) 2003, pp. 900-906
Overweight Children and Your Overweight Children and Your PracticePractice
• Do you routinely provide advice or counseling for overweight children and their parents?
• What communication techniques do you use?
• How effective is your counseling?
Overweight SensitivityOverweight Sensitivity“First Do no harm”
•
“Obesity”•
Ideal Weight
•
Personal Improvement
•
Focus on Weight•
Diets or “Bad Foods”
•
Exercise
•
Overweight•
Healthier Weight
•
Family Improvement•
Focus on Lifestyle
•
Healthier Food Choices
•
Play or Activity
Prochaska & Di Clemente: Transtheoretical Model of Behavior Change
Action
Preparation
Contemplation
Relapse &Recycle
Maintenance
Pre-contemplation
Integrated Behavior
Stages of Behavior ChangeStages of Behavior Change
Positive Family AttitudesPositive Family Attitudes
• Over a healthy weight is not a fault.• Avoid classifying “good” food or
“bad” food.• Emphasize staying physically active
rather than “exercising”• There is no ideal weight or body
shape.
ParentsParents’’
ResponsibilitiesResponsibilities
• Have [pleasant?!] family meals.• Purchase and offer healthy foods and portion
sizes.• Role model good eating and activity behaviors.• Avoid using food as a reward.• Set limits on TV and video games.• Be flexible and understanding.• Encourage and show affection.
ChildsChilds’’
ResponsibilitiesResponsibilities• To eat as much or as little as they need of the
foods available• To eat 3 meals a day with healthy snacks• To make activity fun• To try to be active every day• To be responsible for TV and video game
limits• To do things that they enjoy, give joy• To choose goals and areas to improve on
How do you talk with parents who do not How do you talk with parents who do not consider their child overweightconsider their child overweight??
• “National experts have recommended using BMI to identify children who are overweight.”
• Show child’s BMI on BMI-for-age growth curve. “This means your child is at increased risk of becoming overweight as an adult and developing diabetes.”
• Ask them: “What do you think?”• “The good news is that making simple
changes in eating and physical activity can really reduce this risk. Are you interested in talking more about making family changes?”
Additional Key Messages for Additional Key Messages for Parents of Overweight ToddlersParents of Overweight Toddlers• Change to low-fat or non-fat milk at 2 years
old.• Avoid telling your child to “clean the plate”.• Do not use food as a reward.• Keep offering foods that your child refuses
to eat. Praise your child for trying new foods.
• Wean from the bottle at 12-18 months. No bottle in bed.
Case Study: Where from success??Case Study: Where from success??• 14 y/o BMI 40.3 (Ht = 5’ 1”, Wt = 213 lb)• 40.3 = BMI >>> 95%-ile• Acanthosis Nigricans• Both parents with type 2 diabetes• Seen in March of 2004, discussed healthy
eating habits, physical activity• Very soft sell, scheduled f/u 3 months• “Lost to follow up”
Case Study: Where from success??Case Study: Where from success??
• Presented with mother following Spring• Lost 80 pounds, Acanthosis – gone!• BMI now 22.9 or 85%-ile• Stopped drinking sodas• Made modest changes in his own eating
habits• Voluntarily increased his physical activity
–Activities he enjoyed, martial arts• Engaged family in his changes
Treatment of Type 2 in children?Treatment of Type 2 in children?
• MNT and Lifestyle changes• Insulin: always the safe first alternative• Metformin: approved, use enough• Other oral agents?? Byetta?• Beware the Type 1/Type 2 conundrum
–Check antibodies and C-peptide (later)
Case Study: Type 1 Case Study: Type 1 vsvs
Type 2?Type 2?
• 16 year old presents in DKA• Treated with i.v. insulin, responds well• BMI 39.1, >> 95%-ile• Acanthosis Nigricans• Grandfather, type 2 diabetes, mom s/p
gastric bypass, BMI > 40.
Case Study: Type 1 Case Study: Type 1 vsvs
Type 2?Type 2?
• Further work-up: + Islet Cell antibodies• Marginal BG’s on insulin, but
markedly improved metabolic balance• Addition of Metformin (titrated)
resulted in further BG improvement, decrease in basal insulin requirements
• What kind of diabetes does he have?
What about Lipids? AAP says:What about Lipids? AAP says:• “For patients 8 years and older with an LDL
concentration of 190 mg/dL (or 160 mg/dL with a family history of early heart disease or 2 additional risk factors present or 130 mg/dL if diabetes mellitus is present), pharmacologic intervention should be considered.”
• Goal = 160 mg/dl, 110-130 mg/dl if FHx CVD• Treatment options: Fibrates, Niacin, Statins• http://www.pediatrics.org/cgi/content/full/122/
1/198
Childhood OverweightChildhood Overweight
The Role of Schools The Role of Schools and Communitiesand Communities
Overweight Prevention in SchoolsOverweight Prevention in SchoolsAn Opportunity for Parent AdvocacyAn Opportunity for Parent Advocacy
• Salad bars and other low cost healthy meal options.
• Bans on soda contracts.
• More PE (200 minutes every 10 school days).
• More fun PE, non-competitive activities.
• Walk to school events (www.cawalktoschool.com)
• Integrate health promotion into curriculum.
• Link activities – school and home.
Preventing childhood obesity by reducing Preventing childhood obesity by reducing consumption of carbonated drinks: consumption of carbonated drinks:
Cluster Randomized Controlled TrialCluster Randomized Controlled Trial• Setting: Six primary schools in southwest England. • Participants: 644 children aged 7-11 years• Intervention: Focused educational program on nutrition
over one school year.• Results: Consumption of carbonated drinks over three
days decreased by 0.6 glasses in the intervention group but increased by 0.2 glasses in the control group. At 12 months the percentage of overweight children increased in the control group by 7.5%, compared with a decrease in the intervention group of 0.2%.
BMJ 2004;328:1237 (22 May)
Prevention of Overweight and Type 2 DiabetesPrevention of Overweight and Type 2 Diabetes• Multifaceted, multi-sector interventions may be more effective
(schools, communities, health care, work-site).• Evidence based strategies with local adaptation may be an
effective approach.• Sustained interventions (over 5 years) may be needed.• Key intervention strategies include:
• Increasing physical activity and breastfeeding.• Decreasing sedentary behavior and sweetened beverage
consumption.• Evaluation, sustainability and dissemination need to be
considered.• Behavior change strategies can be augmented with policy and
built environment changes.Pediatrics Vol. 112 No. 4 October 2003, pp. e328-346
Pediatrics Vol. 115 No. 4 April 2005, pp. 1142-1147
Questions? Questions? Final thoughtsFinal thoughts……
““You've got to be careful if you don't You've got to be careful if you don't know where you're going, because know where you're going, because
you might not get there.you might not get there.”” SoSo……“…“…if you get to a fork in the road,if you get to a fork in the road,
take it.take it.””Yogi Berra