Abstract
Obesity is a public health crisis and continues to affect youth of increasingly younger ages. With significant medical and psychosocial comorbidities, it is critical that front-line providers feel confident in their abilities to assess, and appropriately refer, children and families to subspecialties to aid in weight management treatment. This article describes the development and utility of a 1-page screening tool for pediatricians and other providers. Utilizing research, clinical experience, and consensus opinion, a brief tool was developed that could be incorporated into medical visits to facilitate medical care decisions and management of pediatric obesity.
Introduction
About 8% of children aged 2 to 5 years are obese. 1 The prevalence of obesity rises to 17% for 6 to 11 year olds and 20% for 12 to 19 year olds, indicating that early childhood is a critical period of time for the establishment of long-term healthy lifestyle behaviors. Unhealthy lifestyle behaviors and inappropriate weight gain, which begin in early years, often persist into adolescence and adulthood. Furthermore, serious medical complications, previously seen only in adults, such as type 2 diabetes, sleep apnea, and hypertension, now occur increasingly in overweight children.2,3 Psychosocial difficulties often persist such as low self-esteem, depressed mood, and teasing/bullying.
It is critical that pediatricians and other providers in primary care offices can identify and develop treatment plans for children with obesity. However, limited resources, knowledge, or time may make it difficult for pediatricians to engage families in discussion about weight. In addition, obese children under the age of 5 have unique needs and thus treatment must be tailored for this developmental stage.
The purpose of this article is to discuss the development and utility of a 1-page handout that can be used in the pediatrician’s office to help clinicians triage and refer youth under the age of 5 who are obese to the appropriate resources. By examining previous research, clinical experience, and consensus opinion, key topics and referral sources were identified into a brief tool that can be incorporated into office visits.
Handout Development
The handout began as a series of questions for physicians to review with caregivers to better determine additional services for the young child and/or caregiver in order to increase effectiveness of treating obesity. The initial questions were developed to cover a wide range of topic areas including growth/development, parenting skills and knowledge, feeding practices, and child behavior, with the answers to the questions triggering a referral to another subspecialty if concerns were identified.
The initial questions were developed based on Bright Futures Tool and Resource Kit visit forms for primary care providers and the clinical experience of the subgroup working on this project. 4 The questions and recommended referrals were then reviewed and edited by the larger interprofessional treatment work group of the Children’s Hospital Association FOCUS on a Fitter Future. Through this process of collective clinical and research experience in the larger interprofessional group, a consensus of the topic areas with questions was determined with appropriate referrals identified.
To assist physicians in swift decision making, a condensed version of the consensus was developed. The condensed version was reviewed and edited through the same process of the treatment work group’s collective clinical and research experience. The condensed version (see Figure 1) removes the series of questions but maintains the topic areas to assess. This provides the physician with both guidance in assessment and treatment of pediatric obesity in the young child. During the medical examination the physician is encouraged to asses these areas and use the handout to determine appropriate referrals.
Provider Handout
Use of the Handout
A summary is provided below of the literature that provides the foundation for this handout.
Caregivers of obese youth often have limited knowledge about key concepts in the etiology and treatment of obesity. 5 American Academy of Pediatrics guidelines recommend the treatment of obesity be family centered, developmentally appropriate, and include a physical activity specialist, dietician, and parent classes or parent training provided by a pediatric psychologist. 6
Physical Activity
Many youth who are obese do not meet physical activity guidelines and are engaged in sedentary pursuits such as TV and screen-based games. 7 The engagement of children and adolescents in physical activity and sport and limitation of sedentary activities is important in the treatment of obesity. Energy expenditure is important for weight management but also has a positive impact on physiological functioning. Most children in this age range need structured and unstructured play as their physical activity. 8 Many young children attend preschool for the majority of their day, and many have insufficient levels of free play and physical activity and high levels of sedentary behavior. 9 Clear communication about physical activity concepts is helpful. 5 Family-based, individualized treatment plans by a physical activity specialist (physical therapist, exercise physiologist, or other specialist) to reduce sedentary behavior and increase vigorous physical activity to 1 hour per day or more is helpful. Neighborhood safety, financial cost, facility accessibility, and insurance coverage of physical therapy may all be barriers to treatment.10,11
Food/Nutrition
Nutritional intake is a health-related goal separate from weight loss or weight maintenance and is critical for proper brain and physical development in early childhood. 12 Key nutritional concepts are often misunderstood and require significant family education. 5 A review of dietary history (number of and timing of meals and snacks, quality of nutritional content of meals and snacks, portion sizes, types of beverages consumed, diversity of food eaten, buying/preparing activities, family member eating behaviors, etc) can be helpful. An individualized treatment plan to balance carbohydrate, protein, dietary fat needs and address low-cost healthy meals/snacks and healthy cooking strategies is often recommended. Dietitians can also provide meal plans targeting salt, fiber, cholesterol, balancing insulin levels, as needed. 13
Parenting Classes or Trainer
When designing lifestyle interventions targeting children, all caregivers should be involved. 14 A focus on general parenting skills can be helpful in many ways, but for the child who is obese it can be additionally helpful in assisting the family in changing family eating patterns and family activity patterns. 15 A meta-analysis of parenting and parent–child relationships in families with a child who is obese suggests that overall parental consistency may be an important target of intervention. 16 In fact, parent–child engagement has been found to be associated with pediatric obesity. 17 Poor general parenting skills in parents of infants and preschoolers is associated with certain obesogenic childcare behaviors (ie, using the TV as a babysitter), modifiable to help reduce childhood obesity in young children. 18 Often a referral for general parenting classes or working in a group with a parent trainer can be helpful.
More individualized behavioral modification programs may be needed (beyond a parenting class or general parenting skills training) for children who have more difficulty adjusting to lifestyle changes. The literature suggests that the following may be helpful targets for behavioral management training in treating pediatric obesity: parental feeding practices, 19 parental eating behaviors, 20 consistent family mealtimes, 21 and monitoring of nutritional intake, 22 and physical activity. 23 Parenting skills and behaviors are thus central to the behavioral change process in early childhood and a referral to a pediatric psychologist who can help shape parenting skills can be helpful.
There are several specific maladaptive child behaviors that can be barriers to successful lifestyle intervention. These include poor hunger/satiety cues, picky eating, and poor emotion regulation.
Poor Hunger/Satiety Cues
As noted above, caregiver feeding practices can have an impact on child eating. In some cases, caregiver feeding practices are not responsive to whether the child is hungry or full, leading the child to develop poor awareness of hunger and satiety. 24 A large-scale study on feeding practices in the United States suggests that caregiver behaviors, including attending to hunger/satiety cues (responsive feeding rather than feeding to soothe them or on a schedule that is not consistent with hunger/satiety in the youngster), are critical for obesity prevention and intervention. 25 A dietitian can be helpful in designing a dietary plan that is appropriate in content and feeding frequency for the child’s age. Content may be particularly important given that sugar and carbohydrates are associated with short-lived satiety, whereas protein 26 and fiber 27 are associated with longer periods of satiety.
Another factor that decreases a child’s hunger and satiety awareness is sleep deprivation, which affects hunger and satiety hormones. 28 Sleep deprivation has been identified as a risk factor for weight issues in young children. 29 Incorporating a structured sleep schedule to ensure adequate sleep and reducing screen time before bed can improve sleep onset, 30 and good sleep hygiene can assist in reducing sleep deprivation.
Food Aversion, Oral Aversion, Picky Eating
Atypical eating problems are common in early childhood, 31 including picky eating, avoiding certain foods, and avoidance of certain oral sensations. For children who are obese, this behavior is problematic as children who eat only a few foods often choose those that are high in calories, carbohydrates, and/or fat. These food preferences affect healthy eating 32 and are a clear risk factor for obesity and malnutrition. Intervention programs that target more diversity in food intake and appropriate parental responses to selectivity behaviors, especially those that increased intake of fruits and vegetables, are linked with lowered obesity rates. 19 Often, a combined approach from a dietitian (addressing the types of food being eaten) and a pediatric psychologist (addressing the behavioral aspects of eating) can be helpful.
Multiple exposures to unfamiliar or nonfavorite foods, not restricting foods that are favorite, and removal of caregiver pressure to eat can all be helpful 32 along with assessment of family eating environments and parental eating behaviors. Food chaining, a systematic method of expanding food repertoire by emphasizing similar features between accepted and targeted food items, is a helpful component. 33 Interestingly, parents who are concerned with their own weight may adopt controlling child-feeding practices that actually promote rather than prevent obesity in offspring. 34 In severe cases of food selectivity or in the cases of swallowing or oral/motor concerns, an interprofessional feeding clinic including a dietitian (nutritional intake), occupational therapist (sensory sensitivities), physical therapist (oral motor skill development), speech/language therapist (swallowing and chewing), and psychologist (behavioral planning) is warranted.
Emotion Regulation
Toddler self-regulation may predict risk for pediatric obesity, 35 creating a link between emotion/behavior and food. 36 Early self-regulation difficulties (behavioral and emotional) represent significant individual risk factors for the development of pediatric obesity. 35 Children with behavioral difficulties and low levels of prosocial behaviors consume fewer fruits/vegetables 37 and are at greater risk of obesity. 38 This relationship may be bidirectional such that behavioral problems and mood issues may increase the risk for obesity and obesity may increase the risk for behavioral problems and mood issues. 38 There is mounting evidence that degree of obesity is associated with diminishing psychosocial functioning and quality of life. 39 Insufficient sleep may magnify this effect, with greater obesity associated with short sleep duration even after adjusting for behavioral problems and demographic risk factors. 40 Referral to a pediatric psychologist who can treat child behavioral and emotional difficulties in the context of a young child who is obese can be helpful.
An important factor to consider with young children is the presence of developmental delays. Children with developmental delays have a higher incidence of obesity than typically developing children. 41 By age 3, children with developmental delay are significantly more likely to be obese than typically developing peers and this risk increases between ages 3 and 5. 42 Children diagnosed with autism 43 or Prader–Willi 44 seem to be at particularly high risk for obesity. Children with disabilities have a much higher rate of physical inactivity than children without disabilities. 45
Young children who have developmental delays and obesity have unique needs. The first critical question is whether they are receiving the full extent of services for their developmental needs. Referral for a comprehensive developmental evaluation might require a developmental evaluation center, early intervention program, or early childhood special education referral.
Second, it is important to identify what factors related to their developmental condition may be influencing their weight gain. Prader–Willi syndrome is a genetic disorder characterized by a hypothalamic–pituitary dysfunction suggesting underlying physiological factors related to hyperphagia. 44 Food selectivity, food aversions, and oral sensory issues are higher in youth with developmental delays. 46 Behavioral problems are also greater in youth with developmental delays including potentially self-injurious behaviors. 47
Preliminary evidence suggests there is hope for lifestyle intervention effectiveness with children and youth with intellectual disability or autism. 48 Disordered sleep, genetic factors, appetite regulation hormones, atypical eating patterns, psychopharmacological side effects, sensory issues, and muscle development and tone can all be challenges for engaging sufficient lifestyle changes.49,50 Referrals to a pediatric psychologist and dietitian are critical, in addition to referrals to a speech/language pathologist, occupational therapist, and physical therapist, when/if appropriate.
As can be seen in the developmental delay section, there are numerous factors that can affect a delayed child’s physiological weight regulation processes. This is no less true for the normally developing child. Investigation of additional contributors for excessive weight gain for all children should be undertaken as well as a review of family history. While a comprehensive review of all of them is beyond the scope of this article, health care providers should be aware of key variables in endocrinology (abnormal glucose homeostasis, acanthosis nigricans, intense hunger, thyroid, etc), genetics (related to hormonal production, muscle tone, etc), cardiology (hypertension, cholesterol, etc), gastrointestinal (reflux, constipation, etc), pulmonology (asthma, sleep apnea, etc), and orthopedics (musculoskeletal deformities, flat feet, joint pain, fractures, lower extremity malalignment, Blount’s disease, etc), and other subspecialties. 8
Discussion
Most randomized clinical trials testing interventions for obesity have focused on the school-aged child, and relatively little is known about how to treat the young child (0-5) with obesity 51 ; however, rates of obesity in young children are alarming with almost 10% of 2 to 5 year olds having a body mass index at or above the 95th percentile for their age and sex. 1 This developmental stage is ripe for intervention given the more direct influence that parents have on nutrition and physical activity behaviors. Moreover, the higher frequency of pediatrician visits in a child’s early years provides an important opportunity for providers to detect obesity and facilitate further intervention.
Thus, it is important to equip pediatricians with resources to not only screen and educate related to obesity but also understand the various factors to consider for the young child with obesity, and the appropriate providers to whom they should refer patients. Increasing knowledge with respect to physical activity, nutrition, and general behavior management skills is warranted for most caregivers of young children with obesity. If the child’s behavior is particularly challenging and difficulty managing that behavior poses a barrier to implementing change, an additional referral to a pediatric psychologist would provide more individualized intervention and parent coaching. Additional factors to consider are the child’s ability to detect hunger and satiety, aversion to foods and/or textures, and ability to regulate emotions, all of which may be mediated by parent behaviors. Children with developmental delays are at higher risk for obesity and will benefit from an interprofessional team that has expertise in weight management in addition to the other aspects of the developmental delay. Finally, providers should be mindful of other possible factors contributing to excessive weight gain in early childhood and refer to subspecialty services as appropriate.
Author Contributions
All authors participated in the conceptualization of the manuscript, a first draft, critically reviewed the final manuscript and approved the final mansucript as submitted.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was completed through the author’s participation in FOCUS on a Fitter Future through the Children’s Hospital Association (CHA). A CHA illustrator designed the flow of the handout.