To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child’s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient’s age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts.

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Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report

Ten per cent of the world’s school-aged children are estimated to be carrying excess body fat (Fig. 1), with an increased risk for developing chronic disease. Of these overweight children, a quarter are obese, with a significant likelihood of some having multiple risk factors for type 2 diabetes, heart disease and a variety of other co-morbidities before or during early adulthood. The prevalence of overweight is dramatically higher in economically developed regions, but is rising significantly in most parts of the world. In many countries the problem of childhood obesity is worsening at a dramatic rate. Surveys during the 1990s show that in Brazil and the USA, an additional 0.5% of the entire child population became overweight each year. In Canada, Australia and parts of Europe the rates were higher, with an additional 1% of all children becoming overweight each year. The burden upon the health services cannot yet be estimated. Although childhood obesity brings a number of additional problems in its train – hyperinsulinaemia, poor glucose tolerance and a raised risk of type 2 diabetes, hypertension, sleep apnoea, social exclusion and depression – the greatest health problems will be seen in the next generation of adults as the present childhood obesity epidemic passes through to adulthood. Greatly increased rates of heart disease, diabetes, certain cancers, gall bladder disease, osteoarthritis, endocrine disorders and other obesityrelated conditions will be found in young adult populations, and their need for medical treatment may last for their remaining life-times. The costs to the health services, the losses to society and the burdens carried by the individuals involved will be great. The present report has been written to focus attention on the issue and to urge policy-makers to consider taking action before it is too late. Specifically, the report:

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1467-789X.2004.00133.x

Obesity in children and young people: a crisis in public health.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(02)09678-2.pdf

Childhood obesity: public-health crisis, common sense cure

Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis

The current evidence suggests that many diet and exercise interventions to prevent obesity in children are not effective in preventing weight gain, but can be effective in promoting a healthy diet and increased physical activity levels.Being very overweight (obese) can cause health, psychological and social problems for children. Children who are obese are more likely to have weight and health problems as adults. Programmes designed to prevent obesity focus on modifying one or more of the factors considered to promote obesity.This review included 22 studies that tested a variety of intervention programmes, which involved increased physical activity and dietary changes, singly or in combination. Participants were under 18 and living in Asia, South America, Europe or North America. There is not enough evidence from trials to prove that any one particular programme can prevent obesity in children, although comprehensive strategies to address dietary and physical activity change, together with psycho-social support and environmental change may help. There was a trend for newer interventions to involve their respective communities and to include evaluations.Future research might usefully assess changes made on behalf of entire populations, such as improvements in the types of foods available at schools and in the availability of safe places to run and play, and should assess health effects and costs over several years.The programmes in this review used different strategies to prevent obesity so direct comparisons were difficult. Also, the duration of the studies ranged from 12 weeks to three years, but most lasted less than a year.

/pdf/interventions-for-preventing-obesity-in-children-4arhbcud58.pdf

Interventions for preventing obesity in children

Intervention: Students participated in a school-based interdisciplinary intervention over 2 school years. Planet Health sessions were included within existing curricula using classroom teachers in 4 major subjects and physical education. Sessions focused on decreasing television viewing, decreasing consumption of high-fat foods, increasing fruit and vegetable intake, and increasing moderate and vigorous physical activity.

Reducing Obesity via a School-Based Interdisciplinary Intervention Among Youth

Objective To evaluate the impact of a school-based health behavior intervention known as Planet Health on obesity among boys and girls in grades 6 to 8. Design Randomized, controlled field trial with 5 intervention and 5 control schools. Outcomes were assessed using preintervention (fall 1995) and follow-up measures (spring 1997), including prevalence, incidence, and remission of obesity. Participants A group of 1295 ethnically diverse grade 6 and 7 students from public schools in 4 Massachusetts communities. Intervention Students participated in a school-based interdisciplinary intervention over 2 school years. Planet Health sessions were included within existing curricula using classroom teachers in 4 major subjects and physical education. Sessions focused on decreasing television viewing, decreasing consumption of high-fat foods, increasing fruit and vegetable intake, and increasing moderate and vigorous physical activity. Main Outcome Measures Obesity was defined as a composite indicator based on both a body mass index and a triceps skinfold value greater than or equal to age- and sex-specific 85th percentiles. Because schools were randomized, rather than students, the generalized estimating equation method was used to adjust for individual-level covariates under cluster randomization. Results The prevalence of obesity among girls in intervention schools was reduced compared with controls, controlling for baseline obesity (odds ratio, 0.47; 95% confidence interval, 0.24-0.93; P = .03), with no differences found among boys. There was greater remission of obesity among intervention girls vs control girls (odds ratio, 2.16; 95% confidence interval, 1.07-4.35; P = .04). The intervention reduced television hours among both girls and boys, and increased fruit and vegetable consumption and resulted in a smaller increment in total energy intake among girls. Reductions in television viewing predicted obesity change and mediated the intervention effect. Among girls, each hour of reduction in television viewing predicted reduced obesity prevalence (odds ratio, 0.85; 95% confidence interval, 0.75-0.97; P = .02). Conclusion Planet Health decreased obesity among female students, indicating a promising school-based approach to reducing obesity among youth.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/346206/pnu8334.pdf

Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health

To determine the contribution of breakfast-eating behavior to dietary adequacy among low-income African-American children, 1151 children attending grades two through five at four elementary schools in East Orange, New Jersey were studied. Results of a 4-day eating behavior survey and a 24-hour dietary recall reveal that on any given day, 12% to 26% of children attend school without having eaten anything. Thirty-six percent of the children were obese, which did not vary with breakfast-eating behavior. A significantly greater proportion of the children who skipped breakfast compared to those who ate breakfast failed to achieve dietary adequacy for nearly every nutrient studied. More than one third of breakfast skippers consumed < 50% of the recommended dietary allowance for vitamins A, E, B6, and folacin, and nearly one fourth consumed < 50% of the recommended dietary allowance for calories, vitamin C, calcium, and iron. Not eating breakfast results in substantial deficits in dietary intake of a variety of essential nutrients among low-income African-American school children. Efforts to improve the nutritional status of children should include nutrition education to promote breakfast.

The nutritional impact of breakfast consumption on the diets of inner-city African-American elementary school children.

Objectives.  Parents may be deterred from obtaining commercial oral rehydration solutions (ORS) for their young children with acute diarrheal disease because of its availability and/or cost, especially if they are poor. We conducted a randomized clinical trial to determine 1) whether low-income parents could safely mix and administer cereal-based ORS (CBORS) both from ingredients commonly found in the home and from a premixed packet; 2) whether these CBORS were as effective in maintaining hydration as commercial glucose-based ORS; and 3) whether CBORS were more effective in reducing severity and duration of illness.

Methods.  Children 4 to 36 months of age discharged from emergency departments and health centers with acute diarrheal disease were randomized to receive either homemade CBORS, reconstituted packet CBORS, or Pedialyte. A study nurse saw the child at home each day until the illness resolved, and obtained capillary blood for serum sodium at enrollment and at 24 to 48 hours; a sample of CBORS for sodium concentration; stool for pathogen analysis; and daily fluid intake, stool frequency, and weight.

Results.  A total of 232 children were enrolled, of whom 203 (88%) completed the study. Two parents (3%) in the homemade CBORS group and one parent (1%) in the packet CBORS group made mixing errors resulting in a high sodium concentration (>100 mEq/L); their children refused the solution and had normal serum sodium values. Mean CBORS sodium concentration for the remainder of the homemade CBORS group was 60 ± 10 mEq/L, and for the packet CBORS group, 54 ± 13. Eighteen children (11%) had abnormal serum sodium values at presentation, which returned to normal in all groups in most cases. Three children (4.5%) in the homemade CBORS group, 4 (6%) in the packet CBORS group, and 1 child (1.4%) in the Pedialyte group failed therapy.

Children refused to take homemade CBORS and packet CBORS (43% and 32%, respectively) more often than Pedialyte (9%), and those in the CBORS groups tended to take less ORS and total fluids. There were no significant differences among the three groups in incidence of daily vomiting or stooling, duration of diarrhea, or weight gain.

Conclusions.  CBORS do not offer a clinically significant advantage over glucose-based ORS. Homemade CBORS represent a treatment option in carefully selected cases, but it is not the safest alternative for regular clinical use.

https://pediatrics.aappublications.org/content/pediatrics/100/5/e3.full.pdf

Safety and Effectiveness of Homemade and Reconstituted Packet Cereal-based Oral Rehydration Solutions: A Randomized Clinical Trial

Objectives. Parents may be deterred from obtaining commercial oral rehydration solutions (ORS) for their young children with acute diarrheal disease because of its availability and/or cost, especially if they are poor. We conducted a randomized clinical trial to determine 1) whether low-income parents could safely mix and administer cereal-based ORS (CBORS) both from ingredients commonly found in the home and from a premixed packet; 2) whether these CBORS were as effective in maintaining hydration as commercial glucose-based ORS; and 3) whether CBORS were more effective in reducing severity and duration of illness. Methods. Children 4 to 36 months of age discharged from emergency departments and health centers with acute diarrheal disease were randomized to receive either homemade CBORS, reconstituted packet CBORS, or Pedialyte. A study nurse saw the child at home each day until the illness resolved, and obtained capillary blood for serum sodium at enrollment and at 24 to 48 hours; a sample of CBORS for sodium concentration; stool for pathogen analysis; and daily fluid intake, stool frequency, and weight. Results. A total of 232 children were enrolled, of whom 203 (88%) completed the study. Two parents (3%) in the homemade CBORS group and one parent (1%) in the packet CBORS group made mixing errors resulting in a high sodium concentration (>100 mEq/L); their children refused the solution and had normal serum sodium values. Mean CBORS sodium concentration for the remainder of the homemade CBORS group was 60 6 10 mEq/L, and for the packet CBORS group, 54 6 13. Eighteen children (11%) had abnormal serum sodium values at presentation, which returned to normal in all groups in most cases. Three children (4.5%) in the homemade CBORS group, 4 (6%) in the packet CBORS group, and 1 child (1.4%) in the Pedialyte group failed therapy. Children refused to take homemade CBORS and packet CBORS (43% and 32%, respectively) more often than Pedialyte (9%), and those in the CBORS groups tended to take less ORS and total fluids. There were no significant differences among the three groups in incidence of daily vomiting or stooling, duration of diarrhea, or weight gain. Conclusions. CBORS do not offer a clinically significant advantage over glucose-based ORS. Homemade CBORS represent a treatment option in carefully selected cases, but it is not the safest alternative for regular clinical use. Pediatrics 1997;100(5). URL: http://www. pediatrics.org/cgi/content/full/100/5/e3; diarrhea, dehydration, oral rehydration, cereal. ABBREVIATIONS. ORT, oral rehydration therapy; ORS, oral rehydration solutions; CBORS, cereal-based oral rehydration solutions; CI, confidence interval. Acute infectious diarrhea is a common illness in young children worldwide and in the United States, where children average between 1.3 and 2.3 episodes per child per year for the first 5 years of life.1 Each year, approximately 1 of 5 children ,5 years of age sees a physician for diarrhea, and 1.4% are hospitalized, resulting in .200 000 hospital admissions, or 10.6% of all admissions in this age group.1 It has been estimated that the annual national cost of hospitalization for rotavirus-associated gastroenteritis was $352 million in 1988.2 Some 300 children ,5 years of age die in the United States each year because of diarrhea, a rate that has not declined since 1985. These deaths occur primarily in infants and disproportionately among those who are African-American, premature, and living in Southern states and in metropolitan areas.3 Oral rehydration therapy (ORT) is safe, effective, less invasive, and less expensive than intravenous rehydration for the treatment of diarrheal dehydration, and its use in the home early in the course of illness can prevent the development of dehydration.4–8 ORT has been promoted in practice guidelines published by the American Academy of Pediatrics (AAP)9,10 and the Centers for Disease Control and Prevention.11 However, there are economic barriers to the use of ORT for low-income families,12 who may have to pay .$6 per liter in their neighborhood pharmacy for commercial oral rehydration solutions (ORS). Coverage of commercial ORS varies among the state Medicaid programs,13 and one fourth of children in low-income families in the United States have no health insurance coverage at all.14 A possible approach to this problem is the promoFrom the *Division of General Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; ‡Division of Emergency Medicine, Children’s Hospital, Harvard Medical School, Boston, Massachusetts; and §Department of Maternal and Child Health, Harvard School of Public Health, Boston, Massachusetts. This work was presented, in part, at the Ambulatory Pediatric Association Annual Meeting, Washington, DC, May 9, 1996. Dr Sampson is currently at the Perinatal Epidemiology Unit, Department of Epidemiology and Public Health, Yale University School of Medicine, New

Sujata Dixit

Papers

Reducing Obesity via a School-Based Interdisciplinary Intervention Among Youth

Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health

The nutritional impact of breakfast consumption on the diets of inner-city African-American elementary school children.

Safety and Effectiveness of Homemade and Reconstituted Packet Cereal-based Oral Rehydration Solutions: A Randomized Clinical Trial

Oral Rehydration Solutions: A Randomized Clinical Trial Safety and Effectiveness of Homemade and Reconstituted Packet Cereal-based