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Practical Application of the Nutrition Recommendations
for the Prevention and Treatment of Obesity in Pediatric Primary Care
1. Identify the nutrition recommendations for the prevention and treatment of childhood overweight and obesity. 2. Discuss the best use of behavioral strategies to implement changes in nutrition and feeding behaviors. 3. Deﬁne the major challenges to adhering to nutrition recommendations and provide strategies to address these challenges. Elizabeth Prout Parks, MD, is a Fellow in Nutrition, The Children’s Hospital of Philadelphia. Shiriki Kumanyika, PhD, MPH, is with the University of Pennsylvania School of Medicine. Nicolas Stettler, MD, MSCE, is with the The Children’s Hospital of Philadelphia, and University of Pennsylvania School of Medicine. Address correspondence to: Elizabeth Prout Parks, MD, The Children’s Hospital of Philadelphia, 3535 Market St., Ste. 1587, Philadelphia, PA 19104; or fax: 215-5900604; or e-mail firstname.lastname@example.org. Dr. Prout has disclosed no relevant ﬁnancial relationships. doi: 10.3928/00904481-20100223-05
hildhood obesity is epidemic and has tripled over the past 3 decades, making the need for effective prevention and treatment strategies of paramount importance.1 Major targets for prevention and treatment of childhood obesity include nutrition and feeding be-
haviors, physical activity, and sedentary behavior.2 Recommendations for physical activity and sedentary behavior have been reviewed elsewhere in this series.3,4 This article focuses on the nutrition recommendations for the prevention and treatment of childhood overweight and obesity.
Elizabeth Prout Parks, MD; Shiriki Kumanyika, PhD, MPH; and Nicolas Stettler, MD, MSCE
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MyPyramid. these meals tend to be consumed with sugar-sweetened beverages. Prepare more meals at home rather than purchasing restaurant food. The Dietary Guidelines for Americans 2005 provides recommendations for healthy nutrition. salt or sugar) can be used in addition to fresh. prevention.6 The sixth edition of the American Academy of Pediatrics (AAP) Pediatric Nutrition Handbook also provides guidelines regarding age-appropriate portion sizes and daily recommended amounts of speciﬁc food groups based on the Dietary Guidelines and MyPyramid.6 and fruits daily.5.com PEDIATRIC ANNALS 39:3 | MARCH 2010 3903Prout.PediatricSuperSite. therefore. soup and sandwich).5 Additionally. and activity level of children. especially for mothers who are obese or are at a higher risk for having difﬁculty breastfeeding. Family meals are associated with lower saturated and trans fat intake. gov.6.12 Encourage the consumption of ﬁve or more servings of vegetables 148 | www. encourage parents not to drink SSB in front of the children.6 Additionally fruits and vegetables contain vitamins. make the rest vegetables (see www.17 Remind parents that meals at home can be simple and quick (eg.13 Fruit juices do not have the same beneﬁcial effects as intact fruit because juice has concentrated calories similar to sugar sweetened beverages and lacks the ﬁber and many other important nutrients. The recommendations focus on speciﬁc behaviors. in 2005.6 Recommend replacement with skim or 1% milk. water. SSB are a major source of energy intake in adolescents.5.8 Additionally.2. breastfeeding is a pediatric issue. parents can be referred to www. Parents should serve vegetables and fruits with meals and for snacks.6 NUTRITION AND FEEDING RECOMMENDATIONS FOR THE PREVENTION OF OBESITY Obesity prevention is a priority for overweight children (BMI 85th percentile and < 95th percentile) and of children of obese parents. Additionally. Table 1 (see page 150) provides age-speciﬁc nutrition and feeding recommendations for obesity prevention during the well-child visit and tips for implementing dietary guidelines. Breastfeed exclusively for 6 months and continue breastfeeding for up to 1 year and beyond.CM E NUTRITION RECOMMENDATIONS The nutrition recommendations for the prevention of childhood overweight are equivalent to those for normal growth and development for healthy children and adolescents.7 Prenatal breastfeeding education and lactation support in the hospital.16 Additionally. height.2 and the American Heart Association (AHA) provides guidelines for the prevention of cardiovascular disease in adults and children.6 Fruits and vegetables are high in ﬁber and are thought to displace high energy-dense (high sugar or high fat) foods in the diet. been combined in the Sidebar (see page 149). and phytochemicals thought to be helpful in lowering blood pressure and preventing other chronic diseases. weight. as well as clinical expertise when evidence did not exist. some of which are added to the guidelines for children in the general population. AHA nutrition guidelines.6 Meals purchased outside of the home tend to be energy-dense and have large portions.16 SSB add calories without inducing satiety.18 Eat- Meals purchased outside of the home tend to be energy-dense and have large portions. Eat at the table as a family ﬁve to six times per week with the television turned off. Evaluation of whether families are adhering to these dietary and feeding guidelines listed in the Sidebar should be included during every well-child visit. including soda. and treatment of childhood obesity. and juice drinks. and increased consumption of fruits and vegetables.gov recommendations for a sedentary child. convened an Expert Committee charged with providing recommendations regarding the assessment.15 Encourage families to remove SSB. gov).12 Support for the continuation of breastfeeding and plans for returning to work should be discussed during the prenatal visit and the early well-child visits. sports drinks.mypyramid. As mothers do not see their obstetrician until 6 weeks post-partum. in collaboration with the Health Resources and Services Administration and the Centers for Disease Control and Prevention (CDC). Limit the consumption of sugarsweetened beverages (SSB). Children should consume no more than two fruits per day. The goal of therapy is to maintain weight as the child grows in height for younger children or to facilitate slow weight loss in adolescents (1 lb/mo). from the house. the Dietary Guidelines for Americans 2005.6 The new recommendations were based on current evidence. and other non-caloric beverages.14 SSB have been strongly linked to an increased BMI. and the Expert Committee nutrition recommendations for the prevention of childhood obesity are highly congruent and have. minerals.indd 148 3/3/2010 3:26:54 PM . Remind families that frozen and canned vegetables (without added sauces. and during the ﬁrst 2 weeks postpartum should be provided. the American Medical Association (AMA). lower intakes of sugar-sweetened beverage consumption. for speciﬁc food and beverage portion sizes based on age.
26 Motivational interviewing (MI) allows families to evaluate necessary changes SIDEBAR.com | 149 3903Prout. healthy. to prevent diabetes in high-risk children.22 All aspects of the nutrition recommendations — whether intended to promote normal growth and development. Appropriate calcium intake is important for bone health and is frequently not achieved by children and adolescents.CM E ing in front of the television is associated with higher energy intakes. Parental restriction of children’s food intake during meals is associated with overeating when children are not hungry in between meals. Involve the whole family in lifestyle changes. The 2005 Dietary Guidelines for Americans. parents should avoid overly restrictive feeding behaviors. Department of Agriculture (USDA) on its Website: www.usda. evaluate the reason. hypertension.19 Consume a healthy breakfast every day. and soft margarines instead of butter and animal fats • Limit the consumption of energy-dense foods • Choose and prepare foods with little sugar and caloric sweeteners • Limit the consumption of sugar-sweetened beverages • Choose and prepare food with little salt and avoid salt from processed foods • Eat breakfast daily • Limit eating out at restaurants • Consume family meals Recommendations adapted from the Expert Committee Guidelines for the prevention of childhood obesity. the treatment for obesity is the lifestyle change. legumes. Determine if the child is full from staying up late and eating at night. As opposed to other childhood diseases.4 this weight loss requires an eating plan with balanced macronutrients and controlled portions.21 In fact.6 BEHAVIOR MODIFICATION Preliminary studies have shown motivational interviewing to be an effective strategy in pediatric primary care for the management of obesity.6 In addition to physical activity and sedentary behavior goals described elsewhere. Nutrition Guidelines for Prevention of Obesity and Related Risk Factors • Encourage exclusive breastfeeding up to 6 months and maintenance of breastfeeding up to 12 months and beyond7 • Avoid intake of calories in excess to what is recommended for age8 • Limit portion sizes • Choose a variety of vegetables and fruits each day and limit juice intake • Choose from each of the subgroups of vegetables (dark green.indd 149 3/3/2010 3:26:55 PM . elevated LDL cholesterol > 110 mg/dL. type 2 diabetes. Children 2 to 8 years should consume two cups of fat-free milk or low-fat milk per day. obesity treatment interventions directed toward the parents alone were found to be equally effective as interventions directed toward the family and the child if the child is prepubertal and to be superior to interventions directed toward the child. such as those provided by the U. nuts. on-the go breakfast ideas. rather than the primary focus of treatment centering on the child with added parental support. Diets low in calcium have been associated with higher adiposity and with high blood pressure in children. and children older than 9 years should consume three cups (or equivalent). impaired glucose tolerance [pre-diabetes]. and all other) • Make half of all your grains whole grains. For many children.24 Eat a diet rich in calcium.3. Additionally. MI allows families to assess their level of conﬁdence in making a change and the PEDIATRIC ANNALS 39:3 | MARCH 2010 www. If the reason for skipping breakfast is lack of time. obstructive sleep apnea [OSA].PediatricSuperSite.pdf. Evaluate for frequent nighttime awakenings secondary to restless sleep from obstructive sleep apnea.20 In older children. fns. and how to overcome them.gov/TN/Resources/EatSmart/ start_smart. or to treat childhood obesity — should center on the family. • Keep total fat calorie intake to between 30% to 35% of all calories in children 2 to 3 years and between 25% to 30% in children 4 to 18 years • Make most fats unsaturated fats from ﬁsh. polycystic ovary syndrome) require structured weight management with the goal of weight loss (no more than 2 lb/wk). Allow the child to self-regulate the quantity of food ingested.25 although it is not clear whether this association is causal. because this will result in a signiﬁcant reduction in calorie intake. elevated liver enzymes more than twice the upper limit of normal. Other children will require a speciﬁc reduced-calorie eating plan under the guidance of a nutritionist. and eat a diet high in ﬁber • Eat a diet rich in calcium. orange. a more successful approach is to target the family as a whole.23 Parents should provide well-balanced. negotiate removal of naps and an earlier bedtime. In addition. and the AHA Nutrition Recommendations for the Prevention of Cardiovascular Disease and potential barriers to change. NUTRITIONAL TREATMENT OF OBESE CHILDREN AND THEIR FAMILIES Obese children (BMI 95th percentile) and overweight children with an obesity-related comorbidity (elevated cholesterol 200 mg/dL.S. portion-controlled meals. If a child skips breakfast. enforcing portioncontrolled eating of three meals and one to two snacks (depending on the age) will result in weight loss. vegetable oils. but how much of the food that is consumed should be left up to the child. or a diagnosis of nonalcoholic fatty liver disease [NAFLD]. Patients with obstructive sleep apnea who also had night eating were shown to discontinue night eating after the obstructive apnea was treated. provide quick. where lifestyle changes are an adjunct to a pharmaceutical treatment. starchy.
high fat. keep foods high in fat and sugar out of the house. and high sugar foods. binge and purge behaviors †Adapted from Pediatric Obesity: Prevention. preparation. avoid high salt. Discuss the role of the parent in behavioral change.27 which is a key element of success in motivational interviewing. 7. PRACTICAL STEPS Here are some practical steps for initiating lifestyle nutrition behavior change counseling in the overweight and obese child.10. toddler decides how much to eat Preschool Do not use food as reward or punishment School age Eat meals at the table with the television off.PediatricSuperSite. 2 cups of low-fat milk or equivalent per day. contemplation. encourage diet with high ﬁber and whole grains 3 cups of low-fat milk or equivalent per day Feeding Behaviors Review hunger and satiety cues 6-11 months Sit in high chair with back support at table with no television > 12 months-toddler years Healthy modeling of variety of foods by parents. Resources for formal training in motivational interviewing are available in the article by Schwartz (see page 154. 3. Intervention and Treatment Strategies for Primary Care unless otherwise indicated.html).at the table without television in the presence of a parent. 5.com PEDIATRIC ANNALS 39:3 | MARCH 2010 3903Prout. have a healthy snack ready for afterschool Adolescence Watch for emotional eating.CM E TABLE 1. Allow child/family to decide which target behaviors they are willing to change. maintenance). introduce a variety of vegetables and fruits Continue reduced fat milk.org/clinical/index. Parents decide what food and portion size served. 6. Give no more than 6 oz of fruit juice per day Encourage correct portion sizes. “What do you usually eat for lunch?”) When reviewing information from the 24-hour recall. Nutrition Assessment Step 1 is to understand the daily routine and eating habits of the child and family. “What did the patient eat and drink in the past 24 hours?” Another approach is to ask about regular intake of food (eg. night eating. The role of the provider is to assess readiness to change and to attempt to motivate the patient to a higher level of change.9 One approach is to ask for a 24-hour dietary recall.26 When a family is ready for action.gov. Assess readiness for change.motivationalinterviewing. see www. important items for consideration in addition to the actual food and portion sizes include the following: ● Breakfast: yes/no at home/school or both 150 | www.8 1. Schedule a follow-up visit. Each additional month of bottle feeding past 15 months is associated with a 3% increase in the odds of being in a higher BMI category9 * A Finnish study that followed 1.032 infants from 7 months through age 13 years weaned infants from breast milk to skim milk supplemented with vegetable oil lowered BMI and cholesterol without any adverse effects on growth. 3 meals and 1 snack. eat meals at the table. Even without special training.11 level of importance of the behavioral change. wean bottle by 15 months17**. action. emphasize no soda or sugar-sweetened beverages. 4. Have the child/family establish speciﬁc goals for change. mypyramid. continue breastfeeding. 3 meals and 2 snacks. vitamin D supplement 400 IU/day for breastfed infants6 Introduce complementary foods. 8.indd 150 3/3/2010 3:26:55 PM . and www.8.6. 2. Nutrition and Feeding Behaviors Points of Consideration by Age Group for Obesity Prevention Age Birth-6 months Nutrition Recommendations Breast milk only if possible. any provider can incorporate assessment of the stage of readiness to change (pre-contemplation. Assess the nutrition and feeding behavior of family. give less than 12 oz of 100% fruit juice per day.8** Prolonged bottle feeding has been associated with increased BMI. may introduce no more than 4-6 oz of 100% fruit juice in a cup served during a meal10 May introduce reduced fat milk11*. Summarize the nutritional behavior change plan and provide self-monitoring tools. Assess level of importance and conﬁdence of the child/family in making the change. the provider can proceed through the steps for behavioral change listed below.
as she is not sure her daughter will eat the yogurt. presence of lunch sharing Snacks: when/how many-from home. It is not a 4 because she does not want to stay at her current weight. constant snacking. reported that. convenience stores. increasing vegetable and fruit intake. and “go” foods (fruits and vegetables. and practitioners can be downloaded at http://wecan. Ratings of 4 or less indicate the family is probably not ready to make this change. after 22 months.m. high fat). multiple helpings. such as watching television. POPULAR DIETS AND EATING PLANS A review comparing low-fat diets.29 A dietary plan that has been successful in research studies is the Trafﬁc Light Diet.30 A similar plan sponsored by the National Heart Lung and Blood Institute of the National Institutes of Health is “We Can! (Ways to Enhance Children’s Activity and Fitness). juice drink ● Nap for 1 hour ● Dinner at 6:30 p. binge eating behaviors. nocturnal eating is a 7 because she feels she can provide yogurt and fruit for her daughter easily but not a 9. Teach children to eat when hungry and not to snack on food constantly. fast-food or other Meals: as a family yes/no. The provider should help families to recognize successes and to support and provide guidance for relapses in behavior. hiding/sneaking foods. Based on this 24-hour recall. rapid eating.CM E ● ● ● ● Lunch: yes/no from home/school/both or other. there are multiple areas for nutritional intervention to assist in implementing healthy eating behaviors. as she believes she can eat the yogurt and fruit on the way to school and not a 10 because she might forget. The level of conﬁdence (step 5) for the child is a 7.nih. and eliminating/decreasing high saturated fats and salt in diet. ● Reward behavioral changes in the child (trip to the park. community partnerships. increasing ﬁber/whole grains in the diet. slow foods (food that you can eat in moderation). The scores help the family to put into words their ability and likelihood of mak- Case Example Here is an example of a 24-hour recall and initial behavioral intervention for a 12-year-old girl with a BMI at the 97th percentile in a family that is motivated to make changes in behavior (step 2). Snack: Ramen noodles. overall energy restriction diets. Additionally.com | 151 3903Prout. Resources for parents. high-sugar snacks and drinks from the house. ● Monitor behavioral changes for younger children and encourage selfmonitoring in older children. low-fat chocolate milk ● Home from school at 3:00.gov. Follow-up (step 8) is essential to the success of behavioral management. bag of chips. or doing homework. and low glycemic load diets in children. who prepares the meals Feeding behaviors in child: presence of constant hunger. friend stay overnight). Allow the family to decide on areas they are willing to work on (step 3). ● Skipped breakfast ● Lunch: slice of cheese pizza. ● Schedule regular meal times with at least one parent eating with the child at the table. weightloss was equivalent in all groups.26 The family was given self-monitoring forms to record the days that the child met her goal of eating breakfast and was told to bring the forms with them to her follow-up appointment in 1 month (steps 6 and 7). juice ● 8 p. stewed chicken.indd 151 3/3/2010 3:26:56 PM . The child and her family decided on the behavior of skipping breakfast.: two scoops of ice cream ● Bedtime: 10 p. The level of conﬁdence for making the change for Mom parent(s) their following potential roles in their child’s weight management:28 ● Follow the same healthy eating plan as the child and model healthy eating behaviors.” We Can! categorizes foods as “whoa” foods (high sugar.PediatricSuperSite. family rates the importance of making the change to the child’s eating breakfast as a 7 (step 5). ● Discourage eating while doing other activities. fruit cup. it is helpful to discuss with the PEDIATRIC ANNALS 39:3 | MARCH 2010 www. high ﬁber low-calorie foods). She has speciﬁcally agreed to eat yogurt and fruit for breakfast 5 days a week (step 4). low glycemic index and low glycemic load diets resulted in more rapid weight loss during the ﬁrst 6 months.m. low glycemic index. which include eating breakfast. with low-carbohydrate diets.nhlbi. ● Buy healthy foods and remove highfat. It is not a 9 because she is rushed in the morning. cooked by grandmother: rice. ing the designated change now and give the provider the ability to help problem-solve ways to increase the family’s conﬁdence or suggest a simpliﬁed behavioral change.m. prepared at home or outside of the house. On a scale of 1-10. book/toy/comic. scores of 7 or more are a strong indication that the family is ready for action. although lowcarbohydrate. ● Teach children to eat when hungry and not to snack on food constantly. eliminating the juice drink. playing videogames.
removing the television from the bedroom. and television viewing.html has suggestions for buying vegetables and fruits within restricted budgets Emphasis on health and motivation interviewing Refer for food stamps.PediatricSuperSite. convenience drive food choices rather than health Cultural and family beliefs about obesity Food insecurity Media/inﬂuence of advertising OVERCOMING CHALLENGES FOR IMPLEMENTING NUTRITION RECOMMENDATIONS The following are recommendations for overcoming some of the main feeding behavior challenges in the child or adolescent. encouragement. or any caregiver resistant to plan Give simple.33 Causes of SSD include obstructive sleep apnea (OSA).fruitsandveggiesmatter. and support Refer to community cooking classes Limit. These recommendations are implemented with particular attention to supporting or establishing child and family behavior patterns that will avoid excess weight gain. Additional family challenges are highlighted in Table 2. mood and. include motivational interviewing Presence of multiple caregivers Frequent meals outside of the home Single -parent families and/or poor family support systems Limited cooking skills Hostile attitudes to healthy dietary patterns Cost. Nutrition therapy for the obese child involves all of the above. It is recommended that a dietitian or a clinician with specialized training in nutrition be consulted for reduced-calorie meal plans in children and adolescents. 152 | www.CM E TABLE 2. When children/ adolescents are “hungry” in between meals and snacks. include motivational interviewing www. and monitoring.31. if possible meet with all caregivers. if the child is still hungry.indd 152 3/3/2010 3:26:57 PM . Picky Eaters Encourage families to continue to introduce healthy foods and to recognize that children up to 10 years sometimes need up to 15 exposures of a food before accepting that new food. Nutrition guidance in overweight children involves a nutrition assessment of the family. and food pantries Discuss limiting screen time.32 Hunger Schedule three meals and one to two snacks (dependent on the age) and increase high-ﬁber foods. not eliminate.gov/publications/index. goal setting. provide vegetables. popsicles made with non-caloric beverages). NES is deﬁned by the consumption of more than 25% of the daily caloric intake after the evening meal and having nighttime awakenings for food at least twice a week for at least 3 months with feelings of distress. use distraction ﬁrst: direct them to an activity. The nutrition recommendations for the prevention of childhood overweight are the same recommendations for healthy growth of children and adolescents. plus a more structured meal plan. goals should be eliminating daytime napping.34 For adults.35 There is no consistent deﬁnition of NES for children. Family Challenges for Implementing Nutrition Recommendations Type of Challenge Many families do not eat together Overcoming the Challenges Agree that one adult will be present for one meal with child/adolescent daily Write down the plan and provide to all caregivers.com PEDIATRIC ANNALS 39:3 | MARCH 2010 3903Prout. quick recipes Simpliﬁed plans.36 Children with NES or BED should be referred to a psychologist. night eating syndrome (NES). energy dense foods. reinforcement of healthy nutrition.6 CONCLUSION Childhood obesity is epidemic.8 Shortened Sleep Duration Shortened sleep duration (SSD) is associated with childhood obesity. sugar-free gelatin. If they are still hungry. provide low-/zero-calorie foods (eg.8 Rapid Eater/Multiple Portions Give half of the regular portion on the plate at a time. NES is associated with binge eating disorder (BED) deﬁned by binge eating with feelings of loss of control and stress without any weight-reducing behaviors. WIC program. and negotiating an earlier bedtime.8. After medical causes for nocturnal eating have been considered.
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