Windows of OpportunityWindows of Opportunity

Obesity Prevention in ChildhoodObesity Prevention in Childhood

Alan M. Lake, M.D.Alan M. Lake, M.D.Taskforce on Obesity Prevention in ChildhoodTaskforce on Obesity Prevention in ChildhoodMaryland Chapter, American Academy of Maryland Chapter, American Academy of PediatricsPediatrics

Prevention vs. Prevention vs. TreatmentTreatment

Why Prevention?Why Prevention? Appeal, indeed mantra, in Appeal, indeed mantra, in

Pediatrics Pediatrics Opportunities begin in-utero or Opportunities begin in-utero or

beforebefore Greatest and Quickest impact Greatest and Quickest impact Low risk Low risk Poor ability to recognize increased Poor ability to recognize increased

risk in time to make a differencerisk in time to make a difference

Why bother?Why bother?

David Katz: YaleDavid Katz: Yale

“ “ Today’s kids may become the first Today’s kids may become the first generation in the history of man to generation in the history of man to have a life expectancy projected to have a life expectancy projected to be less than that of their parents.”be less than that of their parents.”

Definition of ObesityDefinition of Obesity

0 -2 years: Wt/Ht > 95%ile0 -2 years: Wt/Ht > 95%ile 2 – 18 years: BMI > 95%ile2 – 18 years: BMI > 95%ile

– At Risk: BMI 85 – 95%ileAt Risk: BMI 85 – 95%ile AdultAdult Overweight: BMI > 25 – 30Overweight: BMI > 25 – 30

– Obesity Class 1:Obesity Class 1: BMI 30 – 34.9 (30#)BMI 30 – 34.9 (30#)– Obesity Class 2:Obesity Class 2: BMI 35 – 39.9 (50#)BMI 35 – 39.9 (50#)– Obesity Class 3:Obesity Class 3: BMI > 40BMI > 40 (100#) (100#)

Physiology of FatPhysiology of Fat

Excess energy intake relative to Excess energy intake relative to energy consumedenergy consumed

Excess 3500 kcal yields one Excess 3500 kcal yields one pound of fatpound of fat

Excess 50 kcal a day yields 5# fat Excess 50 kcal a day yields 5# fat gain in one year.gain in one year.

Where we are nowWhere we are nowChildhood Obesity: Childhood Obesity:

Past 40 YearsPast 40 YearsPercent with BMI > 95%ilePercent with BMI > 95%ile

AGEAGE 6 – 11 6 – 11 12 - 12 - 1919

1963 – 1970 4 % 5 %1963 – 1970 4 % 5 % 1971 – 19741971 – 1974 4 4 6 6 1976 – 1980 71976 – 1980 7 5 5 1988 – 1994 111988 – 1994 11 11 11 1999 – 20001999 – 2000 15 15 15 15

Teen Obesity Teen Obesity YRBS survey:YRBS survey: 2005 2005 28.8% have BMI above the 85%ile28.8% have BMI above the 85%ile

– ““at risk or already obese”at risk or already obese”

Hospital Costs for Obesity Related Hospital Costs for Obesity Related complications:complications:

1979 – 19811979 – 1981 $35 million/year$35 million/year 1997 – 1999 $127 million/year1997 – 1999 $127 million/year

Where we are nowWhere we are nowMaryland WIC age 2 – 5Maryland WIC age 2 – 5

June, 2006June, 2006Total Children Total Children 33,15433,154

BMI:BMI: < 5%ile < 5%ile 3%3%

BMI: 5 – 85%ileBMI: 5 – 85%ile 64%64%

BMI: 85 – 95%ileBMI: 85 – 95%ile 17%17%

BMI: > 95%ileBMI: > 95%ile 16%16%

( one in three at risk or obese)( one in three at risk or obese)

Where we are nowWhere we are nowAdult Obesity IncreaseAdult Obesity Increase

% With BMI > 35 (Class % With BMI > 35 (Class 2)2) AgeAge 19911991 19981998

%Inc%Inc 18 – 2918 – 29 7.1 % 7.1 % 12.1%12.1% 69.969.9 30 – 3930 – 39 11.311.3 16.916.9 49.549.5 40 – 4940 – 49 15.815.8 21.221.2 34.334.3 50 – 5950 – 59 16.116.1 23.823.8 47.947.9 60 – 6960 – 69 14.714.7 21.321.3 44.944.9 > 70> 70 11.411.4 14.614.6 28.628.6

Distribution of Adult Distribution of Adult Obesity:Obesity: 20042004 Adult Females:Adult Females: 57% have 57% have

BMI> 25BMI> 25 Adult Males:Adult Males:

– BMI > 25BMI > 25 67%67%– BMI > 30BMI > 30 32%32%– BMI > 40BMI > 40 8%8%

Represents a 350% increase in 15 Represents a 350% increase in 15 yrsyrs

Adult Obesity Prevention Adult Obesity Prevention Strategies: Surgeon Strategies: Surgeon GeneralGeneral Increase Physical activity to 30 – 60 Increase Physical activity to 30 – 60

minutes a dayminutes a day Reduce portion sizes of mealsReduce portion sizes of meals Reduce soda, fruit drinks, and Reduce soda, fruit drinks, and

dessertsdesserts Eat 5 – 9 servings of fruits and Eat 5 – 9 servings of fruits and

vegetables a day.vegetables a day. Reduce t.v. and video time to no Reduce t.v. and video time to no

more than one hour a daymore than one hour a day

Relevance of Early Relevance of Early ObesityObesity If >95% wt/ht at one year, 3 fold greater If >95% wt/ht at one year, 3 fold greater

risk of >95% BMI at 3 yearsrisk of >95% BMI at 3 years If > 95%ile BMI at 3 – 6 years, 50% If > 95%ile BMI at 3 – 6 years, 50%

remain obese as adultsremain obese as adults If > 99%ile at age 9, 100% risk of adult If > 99%ile at age 9, 100% risk of adult

obesity and early complications of obesity and early complications of obesityobesity

If > 95%ile BMI at 16 years, >80% If > 95%ile BMI at 16 years, >80% remain obese as adults.remain obese as adults.

The <20% of teens who lose weight do The <20% of teens who lose weight do not reduce increased cardiovascular risk not reduce increased cardiovascular risk

Windows of OpportunityWindows of OpportunityPrevention in Prevention in

ChildhoodChildhood Prenatal and pre-prenatalPrenatal and pre-prenatal Peri-natal “catch-up growth”Peri-natal “catch-up growth” Infancy, via breast feedingInfancy, via breast feeding Toddler self-regulationToddler self-regulation Preschool habit intakePreschool habit intake Elementary “wellness education”Elementary “wellness education” Adolescent diet and exerciseAdolescent diet and exercise

Intrauterine:Intrauterine: “Thrift Gene” “Thrift Gene”

More than 250 obesity-associated genesMore than 250 obesity-associated genes We all have at least oneWe all have at least one Only 2 lean-associated genesOnly 2 lean-associated genes 15 single gene mutations predict obesity15 single gene mutations predict obesity If one parent obese, increase risk 3 foldIf one parent obese, increase risk 3 fold If both parents obese, increase risk 13 foldIf both parents obese, increase risk 13 fold Gene marker: MC4R causes >5% of obesityGene marker: MC4R causes >5% of obesity Genes set threshold of receptor responseGenes set threshold of receptor response

Intrauterine Intrauterine “Programming”“Programming”

Barker HypothesisBarker Hypothesis Alterations in fetal nutrition and Alterations in fetal nutrition and

endocrine status result in endocrine status result in permanent developmental permanent developmental adaptations in structure, adaptations in structure, physiology, and metabolism physiology, and metabolism thereby predisposing the fetus to thereby predisposing the fetus to cardiovascular, metabolic, and cardiovascular, metabolic, and endocrine disease in adult life.endocrine disease in adult life.

Intrauterine:Intrauterine:Proof of Barker Proof of Barker HypothesisHypothesis 16,000 subjects born 1911 – 193016,000 subjects born 1911 – 1930 For birth weights below 8#, lower For birth weights below 8#, lower

the weight, the higher the risk of the weight, the higher the risk of cardiovascular disease and cardiovascular disease and mortalitymortality

Birth weights above 9#, higher the Birth weights above 9#, higher the weight, greater the riskweight, greater the risk

If weight gain in first year too great If weight gain in first year too great or too slow, risk is increasedor too slow, risk is increased

Intrauterine: Role of Intrauterine: Role of caloric deprivationcaloric deprivation Holland, World War 2Holland, World War 2 Babies born IUGR, greatest risk of Babies born IUGR, greatest risk of

obesity, diabetes, hypertension.obesity, diabetes, hypertension. Greatest risk if maternal malnutrition Greatest risk if maternal malnutrition

is in the first trimester in lower socio-is in the first trimester in lower socio-economic classes.economic classes.

Lower risk with caloric deprivation in Lower risk with caloric deprivation in last trimester when fetal body fat last trimester when fetal body fat normally increases from 5% to 16% of normally increases from 5% to 16% of body weight.body weight.

Intrauterine:Intrauterine:Other FactorsOther Factors

Over the past ten years, increased Over the past ten years, increased birth weights noted, primarily due to birth weights noted, primarily due to increased pre-pregnancy maternal wt.increased pre-pregnancy maternal wt.

Maternal smoking reduces birth Maternal smoking reduces birth weight, increases risk of adult obesityweight, increases risk of adult obesity

Highest risk for early Type 2 diabetes: Highest risk for early Type 2 diabetes: birth weight in lowest 30%, weight at birth weight in lowest 30%, weight at age 8 in highest 50%.age 8 in highest 50%.

Intrauterine: Intrauterine: Other factorsOther factors

Maternal obesity and birth weight Maternal obesity and birth weight above 8# 8oz increases 5 fold the above 8# 8oz increases 5 fold the risk for subsequent leukemia in risk for subsequent leukemia in the child.the child.

Attributed to increased IGF 1 Attributed to increased IGF 1 stimulation of stem cells to stimulation of stem cells to predispose to leukemia.predispose to leukemia.

Intrauterine:Intrauterine:NutrigenomicsNutrigenomics

The science of interaction of The science of interaction of nutrition and gene expression in nutrition and gene expression in uteroutero

Role of “priming” of metabolic Role of “priming” of metabolic responses that persists into responses that persists into adulthoodadulthood

Goal of optimal maternal nutrition Goal of optimal maternal nutrition prior to and during pregnancyprior to and during pregnancy

Intrauterine: Intrauterine: Options for Options for InterventionIntervention Reduce pre-pregnancy obesityReduce pre-pregnancy obesity Address maternal diet and exercise Address maternal diet and exercise

especially in first trimesterespecially in first trimester Reduce glycemic index of intake to Reduce glycemic index of intake to

reduce intrauterine insulin and reduce intrauterine insulin and IGF1 levels IGF1 levels

Establish new nutrition and weight Establish new nutrition and weight gain goals for pregnancygain goals for pregnancy

The Glycemic IndexThe Glycemic Index

Determined by rate of glucose metabolismDetermined by rate of glucose metabolism Glycemic load = index x intakeGlycemic load = index x intake High glycemic = glucose, sucroseHigh glycemic = glucose, sucrose Lower glycemic = complex starchesLower glycemic = complex starches High glycemic intake induces High glycemic intake induces

hyperglycemia at 4 – 6 hours, increases hyperglycemia at 4 – 6 hours, increases insulin, epinephrine, and thus increases insulin, epinephrine, and thus increases appetiteappetite

In past 20 years, maternal diet stable in In past 20 years, maternal diet stable in protein, reduced in fat, increased in carbs protein, reduced in fat, increased in carbs by 65 grams a day. Calories up 270 kcal/dby 65 grams a day. Calories up 270 kcal/d

Perinatal FactorsPerinatal Factors

Obesity risk correlates with weight Obesity risk correlates with weight gain in first week of life gain in first week of life

In IUGR, rapid weight gain in first In IUGR, rapid weight gain in first year increases risk of obesity, year increases risk of obesity, diabetes and cardiovascular disease, diabetes and cardiovascular disease, especially if outpaces height gain. especially if outpaces height gain. Need to adjust caloric intake to Need to adjust caloric intake to optimize growth not weight gain. optimize growth not weight gain.

Infancy: OpportunitiesInfancy: Opportunities

Encourage breast feeding to allow Encourage breast feeding to allow infant to self-regulate intake and infant to self-regulate intake and increase flavor preferenceincrease flavor preference

Delay introduction of solid foods Delay introduction of solid foods until after 4 – 6 monthsuntil after 4 – 6 months

Wean from bottle use by 18 Wean from bottle use by 18 months of agemonths of age

Improve WIC wellness educationImprove WIC wellness education

Role of Breast FeedingRole of Breast Feeding

8 of 11 studies of > 100 breast fed 8 of 11 studies of > 100 breast fed babies followed more than 3 years babies followed more than 3 years revealed lower rates of childhood revealed lower rates of childhood obesityobesity

If “ever” breast fed, reduction of 15%If “ever” breast fed, reduction of 15% Recent retrospective study at Recent retrospective study at

Harvard, no sustained benefit into Harvard, no sustained benefit into adulthoodadulthood

Value of Breast Value of Breast feedingfeeding Slower weight gain in first weeksSlower weight gain in first weeks Self regulated caloric intakeSelf regulated caloric intake Lower insulin levels in first yearLower insulin levels in first year Wider food preferences after 2 Wider food preferences after 2

years of age, lower sugar, lower years of age, lower sugar, lower salt.salt.

Reduced or delayed development Reduced or delayed development of Type 2 diabetes in Pima Indiansof Type 2 diabetes in Pima Indians

FITS study, 3000 FITS study, 3000 infantsinfants

Gerber and ADAGerber and ADA Daily caloric intake relative to estimated needDaily caloric intake relative to estimated need 3 day diet histories, prospective, at 3 month intervals3 day diet histories, prospective, at 3 month intervals

AgeAge Est NeedEst Need Actual IntakeActual Intake %excess%excess 4 – 6 mo4 – 6 mo 629 629 690 690 +10% +10% 7 – 11 mo7 – 11 mo 739 739 924 924 +23% +23% 1 – 2 yrs1 – 2 yrs 950 950 1249 1249

+31%+31%

27% of infants in WIC, at 11 mos +32%, at 2 years, + 27% of infants in WIC, at 11 mos +32%, at 2 years, + 40%40%

FITS data on solid FITS data on solid foodsfoods 29% of infants fed solids before 4 29% of infants fed solids before 4

momo By age 2, 30% ate no fruit, 20% By age 2, 30% ate no fruit, 20%

no veges in the three days no veges in the three days documenteddocumented

By age 2, 37% drinking juice By age 2, 37% drinking juice daily, 27% eating potato chips daily, 27% eating potato chips dailydaily

Role of extended Role of extended bottlesbottles 20% of 2 year olds, 10% of 3 year 20% of 2 year olds, 10% of 3 year

olds, 2.5% of 4 year olds use olds, 2.5% of 4 year olds use bottle daily.bottle daily.

From NHANES III data, for every From NHANES III data, for every month past 18 months, that a month past 18 months, that a child uses a bottle, there is a 3% child uses a bottle, there is a 3% increase in risk of having BMI > increase in risk of having BMI > 95%ile at 10.95%ile at 10.

Toddler: Self Toddler: Self regulationregulation From 18 months to 3 – 4 years, a From 18 months to 3 – 4 years, a

toddler will self regulate their toddler will self regulate their intake. If food of higher caloric intake. If food of higher caloric density is served, they eat less. If density is served, they eat less. If food of reduced caloric density is food of reduced caloric density is served, they eat more.served, they eat more.

Parent chooses food to offer, child Parent chooses food to offer, child regulates intakeregulates intake

Toddler: Food choicesToddler: Food choices

A toddler, on average, must be A toddler, on average, must be offered a new food 10 – 12 times offered a new food 10 – 12 times before they will eat it. Most before they will eat it. Most parents offer it no more than 3 parents offer it no more than 3 times and give up.times and give up.

Do not mix new food with existing Do not mix new food with existing preferred food, the toddler will preferred food, the toddler will stop eating both.stop eating both.

Toddler activityToddler activity

75% of 3 year olds still in 75% of 3 year olds still in strollers, with 39% of 4 year olds strollers, with 39% of 4 year olds still in strollers while “at the park”still in strollers while “at the park”

If a toddler is bored and fussy, If a toddler is bored and fussy, take them out to play, do not turn take them out to play, do not turn on a video.on a video.

Minimize video or screen timeMinimize video or screen time

Preschool Preschool OpportunitiesOpportunities Community access to improve Community access to improve

wellness education and role wellness education and role modeling through Head Start and modeling through Head Start and licensed day care programslicensed day care programs

Preschool children at play devote Preschool children at play devote only 11% of free time to only 11% of free time to moderate exercisemoderate exercise

Routine BMI ScreeningRoutine BMI Screening

American Academy of Pediatrics American Academy of Pediatrics and American Academy of Family and American Academy of Family Practice favor screening all childrenPractice favor screening all children

U.S.P.S.T.F.: Evidence insufficient U.S.P.S.T.F.: Evidence insufficient to recommend for or against.to recommend for or against.

Bill Dietz: You can’t have evidence-Bill Dietz: You can’t have evidence-based practice until you have based practice until you have practice-based evidence. Screen practice-based evidence. Screen on!!!!!on!!!!!

The Adiposity The Adiposity “Rebound”“Rebound”

The nadir of the BMIThe nadir of the BMI Normal BMI declines at 2 years to Normal BMI declines at 2 years to

nadir at 3 to 5 years, then climbs nadir at 3 to 5 years, then climbs through puberty (and beyond)through puberty (and beyond)

If child enters high on the curve or If child enters high on the curve or rebound begins early, greater risk of rebound begins early, greater risk of adult obesity and Type 2 diabetesadult obesity and Type 2 diabetes

Occurs in transition from “self-Occurs in transition from “self-regulated” intake to “habit intake”regulated” intake to “habit intake”

Physiology of the Physiology of the Adiposity ReboundAdiposity Rebound From age 1 to 3 years, child’s From age 1 to 3 years, child’s

length increases and fat cell size length increases and fat cell size declines with a stable number of declines with a stable number of fat cellsfat cells

From age 4 to 6 years, there is an From age 4 to 6 years, there is an increase of fat cell number and increase of fat cell number and size that may be predictive of size that may be predictive of future obesityfuture obesity

The “window” in preschoolThe “window” in preschool

Community access via existing Community access via existing programsprograms

First real value for role modelsFirst real value for role models Sustain self-regulated intakeSustain self-regulated intake Establish habit of daily exercise, 60 Establish habit of daily exercise, 60

to 90 minutes a day, half to 90 minutes a day, half unstructuredunstructured

Enter adiposity rebound on the Enter adiposity rebound on the lower end lower end

Elementary SchoolElementary School

Diet influenced by media and Diet influenced by media and parent role modelparent role model

Average USA child spends 75% of Average USA child spends 75% of waking time inactive, 12 minutes waking time inactive, 12 minutes a day in vigorous activitya day in vigorous activity

In average elementary school In average elementary school gym class, child is active for only gym class, child is active for only 3 minutes3 minutes

Elementary SchoolElementary School

Obesity risk can be reduced by Obesity risk can be reduced by 10% for every hour less watching 10% for every hour less watching televisiontelevision

Obesity risk can be reduced by Obesity risk can be reduced by 10% for every hour more in 10% for every hour more in moderate exercisemoderate exercise

By age 5 – 10 years, 50% of obese By age 5 – 10 years, 50% of obese children have a positive risk factor children have a positive risk factor for early cardiovascular diseasefor early cardiovascular disease

Elementary SchoolElementary School

Physical education goal of 30 Physical education goal of 30 min/day or 150 min/wk with 50% of min/day or 150 min/wk with 50% of time in moderate to vigorous time in moderate to vigorous activityactivity

Only one county in Maryland Only one county in Maryland provides this timeprovides this time

Providing time for physical activity Providing time for physical activity does not lead to reduced school does not lead to reduced school performance or test results in NCLBperformance or test results in NCLB

The “window” in The “window” in elementary schoolelementary school Reduce screen time to less than 2 Reduce screen time to less than 2

hours a dayhours a day Reducing t.v. time alone of no valueReducing t.v. time alone of no value Increase physical activity to 30 – 60 Increase physical activity to 30 – 60

minutes a dayminutes a day Establish wellness agenda of Establish wellness agenda of

improved nutrition and physical improved nutrition and physical activityactivity

Family and School-based role modelsFamily and School-based role models

Secondary School Secondary School ConcernsConcerns 30% of obese teens have 2 or 30% of obese teens have 2 or

more features of metabolic more features of metabolic syndrome presentsyndrome present

High LDL-C at age 15 – 18 years High LDL-C at age 15 – 18 years associated with 5 fold increase in associated with 5 fold increase in adult obesity, hyperlipidemia, and adult obesity, hyperlipidemia, and hypertensionhypertension

Secondary School Secondary School ConcernsConcerns 30% of teens and 40% of adults eat 30% of teens and 40% of adults eat

fast food on a daily basis. Fast food fast food on a daily basis. Fast food adds 187 kcal/day to intake. (22#/yr)adds 187 kcal/day to intake. (22#/yr)

Average teen consumes 870 cans of Average teen consumes 870 cans of soft drink a year.soft drink a year.

Only 65% of teens have any vigorous Only 65% of teens have any vigorous activity more than 3 days a week and activity more than 3 days a week and only 27% more than 5 days a weekonly 27% more than 5 days a week

Secondary School Secondary School Physical ActivityPhysical Activity Daily gym class: 6.4% of middle Daily gym class: 6.4% of middle

schools, 5.8% of high schools in U.S.schools, 5.8% of high schools in U.S. Only 17% of students walk to schoolOnly 17% of students walk to school Every half mile walked by teen Every half mile walked by teen

reduces obesity risk by 5%reduces obesity risk by 5% Girls age 9 to 19, 83% decline in Girls age 9 to 19, 83% decline in

habitual physical activityhabitual physical activity

The “window” for The “window” for teensteens Increase responsibility for food Increase responsibility for food

choices and food preparationchoices and food preparation Healthy breakfast, 3 balanced Healthy breakfast, 3 balanced

mealsmeals Avoid after school “chicken box”Avoid after school “chicken box” Support exercise, dance, and family Support exercise, dance, and family

activities in evenings and weekendsactivities in evenings and weekends Support school phys ed 225 min/wkSupport school phys ed 225 min/wk

Office Monitoring for Office Monitoring for ComplicationsComplications Determine and plot BMI %ile and Determine and plot BMI %ile and

share with student and familyshare with student and family Discuss pace of change, not blameDiscuss pace of change, not blame Document blood pressure and Document blood pressure and

waist circumferencewaist circumference Lab screening if >85%ile to Lab screening if >85%ile to

document status and riskdocument status and risk

Lab screeningLab screening

Urine analysis for glucose and proteinUrine analysis for glucose and protein Fasting lipid profileFasting lipid profile Chemistry profile, Vitamin B-12 Chemistry profile, Vitamin B-12 Fasting glucose, insulin, HgbA1CFasting glucose, insulin, HgbA1C Androgen levels if concern for PCOSAndrogen levels if concern for PCOS Hepatic sonogram for Hepatic sonogram for

steatohepatosissteatohepatosis

Psychological Psychological ScreeningScreening Monitor school performanceMonitor school performance Discuss bullyingDiscuss bullying Reduced self-esteem/depressionReduced self-esteem/depression

– 34% of teens with BMI >95%ile are 34% of teens with BMI >95%ile are depresseddepressed

– 8% of teens with normal BMI %ile8% of teens with normal BMI %ile

Treatment in Treatment in ChildhoodChildhood Age 2 – 7 years, emphasis on Age 2 – 7 years, emphasis on

maintaining weight unless maintaining weight unless established complicationestablished complication

Age 7 – 18, weight loss if >95%ile or Age 7 – 18, weight loss if >95%ile or >85%ile with complication>85%ile with complication

Seek goal of 1 pound loss a month.Seek goal of 1 pound loss a month. Combined diet and exercise programCombined diet and exercise program

Bariatric surgery:Bariatric surgery: Gastric banding Gastric banding

Failure of > 6 months of Failure of > 6 months of supervised weight loss programsupervised weight loss program

Age greater than 13 yearsAge greater than 13 years BMI > 40 in presence of significant BMI > 40 in presence of significant

obesity-related co-morbidityobesity-related co-morbidity BMI > 50 with any obesity-related BMI > 50 with any obesity-related

complicationscomplications

Goals in Adult: Goals in Adult: Identification of Risk Identification of Risk Genetic risk profiles now studiedGenetic risk profiles now studied Biologic age vs Chronologic AgeBiologic age vs Chronologic Age Coronary inflammation: CRP, Coronary inflammation: CRP,

cardiac calcification on CT scancardiac calcification on CT scan 75% of asymptomatic adults under 75% of asymptomatic adults under

45 with first MI have lipid profile 45 with first MI have lipid profile not qualifying for statin therapynot qualifying for statin therapy

ReferencesReferences

American Academy of Pediatrics: American Academy of Pediatrics: Policy Statement: Prevention of Policy Statement: Prevention of Pediatric Overweight and Obesity: Pediatric Overweight and Obesity: Pediatrics 2003: 112; 424 – 430. Pediatrics 2003: 112; 424 – 430.

Dietz, W.H. and Robinson, T.N. Dietz, W.H. and Robinson, T.N. Overweight Children and Overweight Children and Adolescents: NEJM 2005;352: Adolescents: NEJM 2005;352: 2100 – 2109.2100 – 2109.

References:References:

AAP Endorsed Policy Statement with AAP Endorsed Policy Statement with AHA: Dietary Recommendations for AHA: Dietary Recommendations for Children and Adolescents: A Guide for Children and Adolescents: A Guide for Practitioners. Pediatrics 2006: 117, Practitioners. Pediatrics 2006: 117, 544 – 559.544 – 559.

AAP Policy Statement: Active Healthy AAP Policy Statement: Active Healthy Living: Prevention of Childhood Obesity Living: Prevention of Childhood Obesity Through Increased Physical Activity. Through Increased Physical Activity. Pediatrics 2006: 117, 1834 – 1841.Pediatrics 2006: 117, 1834 – 1841.

References:References:

U.S. Preventive Services Task Force: U.S. Preventive Services Task Force: Screening and Interventions for Screening and Interventions for Overweight in Children and Adolescents: Overweight in Children and Adolescents: Recommendation Statement. American Recommendation Statement. American Family Physician 2006: 73; 115 – 119.Family Physician 2006: 73; 115 – 119.

Hassink, S.G., Klish, W.J., Robinson, T.N. Hassink, S.G., Klish, W.J., Robinson, T.N. and Freedman, M. Take a comprehensive and Freedman, M. Take a comprehensive approach to obesity control and approach to obesity control and prevention. Contemporary Pediatrics prevention. Contemporary Pediatrics 2006: 23; 101 – 110.2006: 23; 101 – 110.

References:References:

AHA Scientific Statement: AHA Scientific Statement: Overweight in Children and Overweight in Children and Adolescents, Circulation 2005; lll: Adolescents, Circulation 2005; lll: 1999 – 2012.1999 – 2012.

AHA Scientific Statement: Promoting AHA Scientific Statement: Promoting Physical Activity in Children and Physical Activity in Children and Youth. A Leadership Role for Youth. A Leadership Role for Schools. Circulation 2006; 114: 1 -Schools. Circulation 2006; 114: 1 -11.11.

ReferencesReferences

American Medical AssociationAmerican Medical Association– Roadmaps for Clinical PracticeRoadmaps for Clinical Practice– Assessment and Management of Adult Assessment and Management of Adult

Obesity: A Primer for PhysiciansObesity: A Primer for Physicians 9 Booklets, downloaded from AMA website9 Booklets, downloaded from AMA website

– www.ama-assn.org www.ama-assn.org Adapted from Serdula et al, Weightloss Adapted from Serdula et al, Weightloss

counseling revisited: JAMA 289:1747-1750. counseling revisited: JAMA 289:1747-1750. 2003.2003.

Web Sites for Web Sites for InformationInformation www.aap.org/obesitywww.aap.org/obesity www.mdaap.org/obesitywww.mdaap.org/obesityresourcesresources www.cdc.gov/nccdphp/dnpawww.cdc.gov/nccdphp/dnpa www.VERBparents.comwww.VERBparents.com www.shapingamericasyouth.orgwww.shapingamericasyouth.org www.kidshealth.orgwww.kidshealth.org www.shapeup.orgwww.shapeup.org www.brightfutures.orgwww.brightfutures.org www.eatright.orgwww.eatright.org