Pediatric Overweight Practice Guidelines--Implications for Extension Educators

Introduction

In the World Health Organization (2003) report, Diet, Nutrition and the Prevention of Chronic Disease , excess weight was cited as a health issue of global concern. The United States is not exempt (Mokdad et al., 1999; Ogden, Flegal, Carroll, & Johnson, 2002). The United States Department of Health and Human Services (2000) identified overweight and obesity, including pediatric overweight, as health issues in Healthy People 2010. Given the high profile of concern regarding overweight and obesity, it is not surprising that professional organizations have issued policy guidelines to help address prevention and treatment of these health concerns.

Extension educators incorporate practice guidelines and original research when developing exemplary science-based programming. The Cooperative State Research, Education, and Extension Service (CSREES, n.d.) identified Programs of Excellence, including the University of California program "Children and Weight: What Health Professionals Can Do About It."

Practice Guidelines

The American Dietetic Association (ADA) (1999a, 1999b, 2000, 2001, 2002, 2003) has several related position statements on child nutrition, child-care and school food environments, eating disorders, adult weight management, and child nutrition programs. The focus of dietary guidance for children has evolved from under-consumption of food and associated effects of nutrient deficiency to disease prevention and the development of healthful life-skills and behaviors. The professional organization for Registered Dietitians recognizes the importance of nutrition and nutrition education in safe, sanitary, supportive environments that promote health and the development of a lifelong commitment to healthful behaviors, including enjoyable eating practices and daily physical activity.

The American Academy of Pediatrics Committee on Nutrition (2003) released a policy statement and guidance on pediatric overweight. Prevention of pediatric overweight requires that physicians and other members of the health community recognize risk factors in order to identify those individuals who can benefit from early intervention. A survey (Barlow, Trowbridge, Klish, & Dietz, 2002) of health care providers, including pediatricians, pediatric nurse practitioners, and registered dietitians, identified interventions used to treat overweight children. Practitioners advised healthy eating and activity, and seldom endorsed highly restrictive diets or medications to control weight.

Similarly, the Society for Nutrition Education Weight Realities Division (2003) released guidelines for promoting healthy weight in children. The guidelines encourage a holistic health-centered approach. Interventions incorporating a "do-no-harm" approach may help prevent eating disorders, body hatred, size discrimination and inappropriate methods of weight management.

Integrating the prevention of obesity and eating disorders places disordered eating in a larger context (Irving & Neumark-Sztainer, 2002). Eating disorders occur across the body weight continuum and are the third most common chronic illness in adolescent teens (ADA, 2001). Children within highly restrictive eating environments where snacks or certain foods are prohibited may be more inclined to overeat in the absence of hunger (Birch, Fisher, & Davison, 2003). Eating without hunger is associated with binge eating disorder and increased body weight (Morgan, Yanovski, Nguyen, McDuffie, Sebring, Jorge, Keil, & Yanovski, 2002).

Children's Eating Environment

School food environments should enable choices consistent with the development of lifelong, healthy eating habits (ADA, 2002a). In addition to food policy, schools need a coordinated health curriculum that integrates nutrition education, professional training opportunities for faculty, program evaluation, and family/community involvement (Centers for Disease Control and Prevention, 1996). A recent report by the United States General Accounting Office (2003) recommends schools promote nutrition education.

Parents may need nutrition education intervention to better understand how children can be guided in the selection and enjoyment of healthy diets and lifestyles; the importance of modeling healthy food choices and physical activity; and the identification of personal and family behaviors that may be acting as barriers to change. Access and exposure to a wide range of healthful foods, such as fruits, vegetables, low-fat dairy products, whole grains, and lentils, are important for the development of a preference for these foods (Birch & Fisher, 1998).

Certain behaviors may increase the likelihood children will become overweight. Sedentary behavior, such as television viewing, is associated with increased risk for overweight (Proctor, Moore, Gao, Cupples, Bradlee, Hood, & Ellison, 2003). Children served large portions tend to eat more food than children served smaller age-appropriate servings (Fisher, Rolls, & Birch, 2003; McConahy, Smiciklas-Wright, Birch, Mitchell, & Picciano, 2002).

Components of successful pediatric overweight treatment interventions have been reported by the American Heart Association, Committee on Atherosclerosis, Hypertension, and Obesity in the Young (2002). They are:

1. Initiation of treatment prior to adolescence;
2. Willing participation by both child and family;
3. Family education about the medical complications of overweight;
4. Involvement of the entire family in treatment;
5. Emphasis on long- term permanent behavior change;
6. Establishment of small gradual goals;
7. Monitoring eating and physical activity behavior ; and
8. Empathy and encouragement.

Implications

What could be a response of the Extension educator?

• Network and collaborate with other state Extension specialists and agents. The CSREES (2002) collaborative project, "Reversing Childhood Obesity Trends: Helping Children Achieve Healthy Weights," provides resources and contacts.

• Because research into the prevention and treatment of overweight and obesity has accelerated, monitor position statements and health guidance from respected associations and health policy if you are unable to keep up with original research.

• Because weight loss by children and adolescents is seldom recommended, help to increase awareness that pediatric overweight is a health concern requiring medical diagnosis and intervention.

• Develop education materials that focus on health goals, not weight goals.

Long-term healthful behavior change may be achieved, in part, by education and skill-building that reinforces:

• Providing nurturing environments where healthful meals and snacks consisting of appropriate portions are enjoyed and modeled;

• Respecting a child's need to respond to hunger and satiety;

• Guiding children in the self-selection of foods by providing access to a variety of fruits, vegetables, whole grains and low-fat dairy foods;

• Promoting age-appropriate play that incorporates physical activity that engages family members, peers, and pets; and

• Encouraging the demonstration of love, affection, and nurture with the use of non-food items.

References

American Academy of Pediatrics, Committee on Nutrition. (2003). Prevention of pediatric overweight and obesity. Pediatrics, 112(2), 424-430.

American Dietetic Association (ADA). (1999a). Position of the American Dietetic Association: Dietary guidance for healthy children aged 2 to 11 years. Journal of the American Dietetic Association, 99(1), 93-101.

American Dietetic Association (ADA). (1999b). Position of the American Dietetic Association: Nutrition standards for child-care programs. Journal of the American Dietetic Association, 99(8), 981- 988.

American Dietetic Association (ADA). (2000). Position of the American Dietetic Association: Local support for nutrition integrity in schools. Journal of the American Dietetic Association, 100(1), 108- 111.

American Dietetic Association (ADA). (2001). Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified. Journal of the American Dietetic Association, 101(7), 810-819.

American Dietetic Association (ADA). (2002). Position of the American Dietetic Association: Weight management. Journal of the American Dietetic Association, 102(8), 1145-1155.

American Dietetic Association (ADA). (2003). Position of the American Dietetic Association: Child and adolescent food and nutrition programs. Journal of the American Dietetic Association, 103(7), 887-893.

American Heart Association, Committee on Atherosclerosis, Hypertension, and Obesity in the Young. (2002). AHA scientific statement: Cardiovascular health in childhood. Circulation , 106(1), 143-160.

Barlow, S. E., Trowbridge, F. L., Klish, W. J., & Dietz, W. H. (2002). Treatment of child and adolescent obesity: Reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics, 110(1), 229-235.

Birch, L. L., & Fisher, J. O. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101:539-549.

Birch, L. L., Fisher, J. O., & Davison, K. K. (2003). Learning to overeat: Maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. American Journal of Clinical Nutrition, 78(2), 215-220.

Centers for Disease Control and Prevention (CDC). (1996). Guidelines for school health programs to promote lifelong healthy eating. Morbidity and Mortality Weekly Report, 45(9).

Cooperative State Research, Education, and Extension Service. (n.d.). Children and Weight: What Health Professionals Can Do About It. Retrieved October 6, 2003 from http://www.reeusda.gov/f4hn/nutrition/PgmExcellence/
Health/children_and_weight.htm#childrenweight

Cooperative State Research, Education, and Extension Service. (2002). Reversing childhood obesity trends: Helping children achieve healthy weights. Retrieved October 16, 2003 from http://www.reeusda.gov/f4hn/nutrition/childhood-obesity/
july2002.htm

Fisher, J. O., Rolls, B. J., & Birch, L. L. (2003). Children's bite size and intake of an entree are greater with large portions than with age- appropriate or self-selected portions. American Journal of Clinical Nutrition, 77(5), 1164-1170.

Irving, L .M., & Neumark-Sztainer, D. (2002). Integrating the prevention of eating disorders and obesity: Feasible or futile? Preventive Medicine, 34, 229-309.

McConahy, K. L., Smiciklas-Wright, H., Birch, L. L., Mitchell, D. C., & Picciano, M.F. (2002). Food portions are positively related to energy intake and body weight in early childhood. Journal of Pediatrics, 140(3), 340-347.

Mokdad, A. H., Serdula, M. K., Dietz, W. H., Bowman, B. A., Marks, J. S., & Koplan, J. P. (1999). The spread of the obesity epidemic in the United States, 1991-1998. Journal of the American Medical Association, 282(16), 1519-1522.

Morgan, C. M., Yanovski, S. Z., Nguyen, T. T., McDuffie, J., Sebring, N. C., Jorge, M. R., Keil, M., & Yanovski, J. A. (2002). Loss of control over eating, adiposity, and psychopathology in overweight children. International Journal of Eating Disorders, 31, 430-441.

Ogden, C. L., Flegal, K. M, Carroll, M. D., & Johnson, C. L. (2002). Prevalence and trends in overweight among us children and adolescents, 1999-2000. Journal of the American Medical Association, 228(14), 1728-1732.

Proctor, M. H., Moore, L. L., Gao, D., Cupples, L. A., Bradlee, M. L., Hood, M. Y., & Ellison, R. C. (2003). Television viewing and change in body fat from preschool to early adolescence: The Framingham Children's Study. International Journal of Obesity, 27, 827-833.

Society for Nutrition Education, Weight Realities Division. (2003). Guidelines for childhood obesity prevention programs: Promoting healthy weight in children. Journal of Nutrition Education and Behavior, 35(1), 1-4.

United States Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health, (2nd ed.). Washington, DC: U.S. Government Printing Office.

United States General Accounting Office. (2003). School Lunch Program: Efforts needed to improve nutrition and encourage healthy eating. GAO-03-506.

World Health Organization (WHO). (2003). Diet, nutrition and the prevention of chronic disease: Report of a joint WHO/FAO expert consultation. WHO Technical Report Series, No. 916.