January 2011 Issue

Small People, Big Problem — Address Infant Weight to Help Kids Avoid Future Health Problems
By Christin L. Seher, MS, RD, LD
Today’s Dietitian
Vol. 13 No. 1 P. 26

By attending to early growth patterns and intervening appropriately, the health community can help ensure better outcomes.

Over the last 10 years, childhood obesity has become a nationwide epidemic, with efforts to conquer it becoming a major focus of preventive public health initiatives such as Michelle Obama’s Let’s Move! campaign and the NFL Play 60 program. Obesity is showing up earlier in life, with 10.5% of children aged 2 to 5 now classified as obese (having a body mass index [BMI] greater than the 95th percentile for age and sex, according to Centers for Disease Control and Prevention [CDC] growth charts) and rates of type 2 diabetes in young children skyrocketing.1

Yet from the medical community to parent groups, initiating a discussion about infant or toddler weight can be considered almost taboo. Society, it seems, has a particular fondness for “plump” babies. Aside from the constant advertisements showing chubby, pink cherubs and Grandma’s comments about Mom and Dad needing to “fatten that baby up,” research conducted at Penn State University by Laraway and colleagues, published recently in Clinical Pediatrics, lends support to the theory that parents overwhelmingly perceive heavy babies as healthy babies. Their study also demonstrated that parents prefer infants who weigh in the highest quartile of the CDC growth charts.

The Research
The most recent data available (2007 to 2008) from the National Health and Nutrition Examination Survey indicate a fairly high prevalence rate (approximately 9.5%) of obesity in infants from birth through the age of 2.2 As a result, the medical community is starting to pay more attention to this issue, despite not being advised to routinely screen children under the age of 6 by the most current U.S. Preventive Services Task Force recommendations for screening for obesity in children and adolescents.3 However, medical professionals have become more proactive in the last two years as a plethora of research on this controversial topic has been released, with several large-scale studies and meta-analyses published in the most prominent research journals.

One such analysis, a retrospective nested case-control study that began with a review of the electronic medical records of more than 8,400 children, demonstrated that infants who were obese at the age of 24 months (measured as greater than the 95th percentile weight-for-length for age and sex) were more likely to have been obese at the age of 6 months.4 In fact, 35% of obese 24-month-old toddlers in this sample were obese at the age of 6 months, with another 39% having been classified as overweight (85th to 94th percentile) at that time.4

This study, published in the July 2010 issue of The Journal of Pediatrics, raises some critical questions regarding the prevention, screening, diagnosis, and treatment of infant obesity, a topic that, traditionally, many practitioners have been hesitant to engage. The title of the article, “Infant Obesity: Are We Ready to Make This Diagnosis?” captures the controversy and has sparked debate among researchers and parents alike.

According to David McCormick, MD, lead author of the study, “It’s time to call it what it is. Whether you choose to use the term ‘overweight’ or ‘obese,’ these children, who are over the 95th percentile weight-for-length at age 2, were more likely to be obese at age 6 months and are at risk for obesity later in life. Children continue to track along these lines, and when followed from age 2, they are highly likely to continue to be overweight as both children and adolescents.”

In fact, study after study verifies that although children often alter their growth patterns to achieve a healthy weight as they develop, many remain overweight or obese throughout childhood and into adolescence and adulthood if weight issues are not addressed.

In the only prospective study to date (published in 2009 in Pediatrics), researchers at Harvard Medical School found that weight status at 6 months of age was a good predictor of the risk of obesity at the age of 3; their study demonstrated a 40% predicted obesity risk for children who were in the highest quartile of weight-for-length at the age of 6 months.5 Additionally, data from a large, retrospective epidemiological analysis linked growth during the first few months of infancy to obesity later in life and to cardiometabolic risk factors such as high blood pressure.6

Studies have also shown that even the prenatal environment can play a huge role in an infant’s health and future weight status. Maternal weight gain is associated with neonatal adiposity at birth and an increased risk of insulin resistance later in life, which may predispose a child to chronic diseases.7 Additional risk factors for increased weight gain during infancy include being formula fed, overfeeding, the early introduction of solid foods or calorie-containing beverages such as juices and sodas, sleeping for less than 12 hours per day, and sedentary behavior.8

RDs Weigh in on the Controversy
RDs mirror the hesitation seen in the larger medical community on this topic, noting that diagnosing obesity at such a young age is fraught with complications.

“Though this is such a new area of research, what little information that is out there does suggest that infants who are obese at 6 months will be obese at 24 months, which we know is linked to long-term obesity in life if not treated. Therefore, I believe diagnosis is important at an early age, and educating parents is key. The word ‘obese’ has such a negative stigma. … Taking time to explain to parents the possible negative long-term health consequences of overfeeding and excess weight gain early on is key,” says Dana Vieselmeyer, MPH, RD, LD, chair of the American Dietetic Association’s (ADA) Pediatric Diabetes With Wellness and Weight Management Special Interest Group.

But Linda Steakley, MS, RD, LD, chairperson of the Pediatric Obesity Ad Hoc Committee for the ADA, says, “I think it would be very difficult to diagnose infant obesity at 6 to 24 months. There are too many factors involved.”

Beverly Henry, PhD, RD, an associate professor of nutrition, dietetics, and hospitality administration at Northern Illinois University, seconds Steakley’s concern about diagnosing obesity so young. “I think it is more appropriate to evaluate feeding,” she says, stating that children often grow normally unless something gets in the way.

Regardless of whether a true diagnosis of obesity is made, dietitians agree that pediatricians and medical professionals need to do more to monitor weight status during infancy and the toddler years and take necessary steps to alter growth patterns if appropriate. “The pediatrician has an opportunity to see the infant’s pattern of weight gain between 6 and 24 months and offer suggestions for slowing down the weight gain if appropriate,” Steakley says.

Henry agrees that accurate, long-term monitoring of weight status plays an important role at this age. “Children may ‘belong’ at either end of the growth chart and keep making progress in that range,” she says. “Tracking z scores of weight gain can help identify when shifts are occurring and help to compare the child against himself or herself.”

Vieselmeyer adds that it is important to “pay close attention to weight trends in all infants being followed to avoid excess weight gain and possibly screen out ‘overweight’ and ‘obese’ infants for early intervention rather than just screening those 2 years of age and older,” as is routinely done.

Moving Forward
Regarding what the pediatric community can do, McCormick says, “We’ve gotten better. More practitioners are addressing this issue with parents and more parents are becoming interested in doing something about it, whereas previously you really were not seeing much of an effect.

“From the very beginning, the first appointment, [pediatricians] talk about car seats. Now we need to talk about nutrition in that sense,” he continues. “We have to make sure when a mother is having a baby, as early as the prenatal visit, we tell them we are concerned about their babies being a healthy weight, and we are concerned because we want to prevent diabetes. That’s the message to give to parents—that we can prevent diabetes, if it’s type 2, but we need to do it with your help by keeping your baby very healthy with nutrition and activity. That’s a message that needs to reach every mother and father.”

Experts agree that there are several evidence-based, age-appropriate interventions for infants who are obese; however, the goal of these interventions should never be weight loss. Sarah Krieger, MPH, RD, LD/N, an ADA national spokesperson, notes that “even if a child is above the 95th percentile on the growth curve for the first two years of life, it is best to avoid putting the child on a diet or restricting their intake of nutrient-rich foods. The goal is to help infants and toddlers regulate their own food intake based on internal cues of hunger and fullness. This helps them eat what they need for healthy growth and development.”

Instead, the goal should focus on slowing the rate of weight gain while simultaneously evaluating and improving feeding practices when possible. “Obviously, weight loss at such a young age is not recommended, but decreasing the rate of weight gain over time (to be determined based on current weight and goal weight percentile over time) is appropriate” notes Vieselmeyer.

Nutrition interventions, therefore, should center on educating parents and caregivers of young children about appropriate feeding practices (including those that align with authoritative parenting) and the importance of allowing infants and toddlers to learn how to feed based on their own internal hunger cues. Focusing on weight, weight-for-length, or BMI in infants could lead parents to unnecessarily change feeding behaviors and could negatively impact their child’s eating patterns or distort their child’s expected growth pattern, Henry says. “If a parent responds to comments about [their child’s] growth by altering feeding composition, timing, or duration, those decisions may influence the infant's eating patterns and 'normal' consumption based on internal cues of hunger and satiety,” she says.

Specific Interventions to Focus On
McCormick notes three things in particular that can help fight infant obesity: increasing the number of women who breast-feed and for longer durations, introducing solids at an appropriate age (4 to 6 months) and not via the bottle (but by spoon) to help satiate while simultaneously decreasing liquid calories to account for solid foods, and limiting the volume of milk or formula and other calorie-containing beverages such as juice to age-appropriate portions.

Steakley agrees: “Offering advice to the mom, such as decreasing the number of feedings or the amount of milk given at a feeding, or the caretakers talking with an RD to help them understand what healthy weight gain is and an appropriate meal pattern for infants may be helpful.” She notes that “often caregivers give solid food too early in an attempt to make the child sleep through the night” and that parents need to understand their child’s developmental cues, recognizing that “stuffing a bottle in an infant’s mouth every time they cry is inappropriate.”

Krieger says, “If a family is unaware of how much formula or milk and foods a child needs for the first two years, they should consult a registered dietitian via EatRight.org. KidsEatRight.org also has great information for children in infancy through the teen years. Parents are in control of what the child eats, and this is the time in the child’s life when (s)he is exposed to a variety of new foods. If the child is offered a variety of fruits, vegetables, whole grains, and protein foods in early life, that child will continue to eat those nutritious foods for life. If a child is offered sweetened drinks, fried snacks, and candies instead of nutritious foods, that is what the child will grow up eating, which can lead to weight problems if consumed in large amounts.”

Vieselmeyer adds that any intervention should include an assessment of cultural practices and parental beliefs, in addition to feeding practices, and be grounded in “a motivational interviewing-based [approach] with support and close follow-up with the family. It is always important to help the family rather than place blame, which is often the case.”

Preventing Infant Obesity
According to Ann Weidenbenner, MS, RD, LD, manager of the Primary Prevention Section and Creating Healthy Communities Program at the Ohio Department of Health Bureau of Health Promotion & Risk Reduction, “Prevention of childhood obesity is easier and more economical than treatment of excessive weight in adults. This is a prime opportunity to venture into the world of public health, as registered dietitians can help immensely with the birth to 24-month-old population.”

Weidenbenner and her colleagues in Ohio have been at the forefront of this effort, developing and implementing a public health initiative geared toward preventing childhood obesity from birth. Their program, An Ounce of Prevention Is Worth a Pound (see sidebar), provides physicians and healthcare providers with the necessary tools to monitor weight and provide anticipatory age-appropriate information about nutrition and physical activity when children are seen by their pediatrician, in a WIC clinic, in a Head Start program, or at some other healthcare appointment. 

“My dream has always been to expand the intense RD education and interventions provided in the WIC program to the entire population via physician offices, outreach clinics, private practices, etc. In my experience, every parent, regardless of income, needs this information because no one else is providing it. This is the main reason why the Ounce of Prevention Is Worth a Pound tool kit was developed,” notes Weidenbenner.

The Ounce of Prevention tool kit has shown great success according to outcome surveys conducted by the Ohio Department of Health in conjunction with The Ohio State University’s College of Public Health. According to Weidenbenner, the following outcomes are among the many accomplishments the program boasts:

• Sixty-four percent of physicians have increased the number of children for whom they calculate and plot the BMI percentile.

• Eighty percent of physicians have increased providing anticipatory information on nutrition to parents.

• Eighty-one percent of physicians reported that parents were receptive to and interested in the physical activity and nutrition advice.

• Eighty-two percent of physicians have increased providing anticipatory information on physical activity to parents.

• Eighty-four percent of physicians reported that parents understood the tool kit messages.

• Ninety-three percent of physicians reported that they would continue to use the tool kit.

Additionally, the Ounce of Prevention initiative has been evaluated for prospective outcomes with the help of a National Institutes of Health grant; thus far, the study has evaluated more than 300 mothers and babies and has shown positive outcomes related to nutrition and physical activity indicators at both 6 and 12 months of age.  

Ways to Get More Involved
The Ounce of Prevention tool kit (and other tools like it) can be a great starting point for collaboration between RDs and area physicians, especially given that roughly 20% to 25% of pediatricians report not feeling competent or comfortable enough to address issues of obesity with their patients9 and that most pediatricians also report feeling ineffective in their ability to treat obesity.10 “When [practitioners] provide specific nutrition and physical activity information, encourage and support breast-feeding, and discuss the infant’s growth chart with the caregiver, the information is taken seriously,” notes Weidenbenner.

According to Krieger, “There are many ways registered dietitians can educate parents and caregivers. The first step is to be available on EatRight.org so a parent can connect with an RD in their area. Another is to partner or consult with pediatricians, health departments, preschools, and mommy play groups for individual or group sessions targeting this age population. By listing yourself on a hospital or community speaker’s bureau, it is easier for schools or play groups to find an RD.”

Regardless of how an RD chooses to view the diagnosis, infant obesity is a concern that is not going away. Strong evidence suggests it is unwise to ignore these early growth patterns, especially when these patterns are rooted in feeding practices that are likely to remain unchanged and subject a child to future weight problems and chronic health concerns. When considering nutrition interventions for this population, RDs should be at the forefront of preventive initiatives, working within their existing roles to counsel families with infants and toddlers on best practices related to feeding and forging new collaborations with pediatricians.

— Christin L. Seher, MS, RD, LD, is founder of Strategic Health Solutions, LLC, serving northeastern Ohio.

 

Help Online
The Ounce of Prevention Is Worth a Pound tool kit is a preventive public health initiative developed via a collaboration among the Ohio Department of Health/Healthy Ohio; the American Academy of Pediatrics’ Ohio Chapter; Nationwide Children’s Hospital; the American Dairy Association Mideast; and the Ohio Dietetic Association. To access updated materials for children aged birth to 17 (in both English and Spanish) free of charge, visit http://healthyohioprogram.org/healthylife/nutri2/nutrikids2/ounce.aspx.

 

References
1. Ogden CL, Carroll MD. Prevalence of obesity among children and adolescents: United States, trends 1963-1965 through 2007-2008. Available at: http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf

2. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303(3):242-249.

3. U.S. Preventive Services Task Force. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2010;125(2):361-367.

4. McCormick DP, Sarpong K, Jordan L, Ray LA, Jain S. Infant obesity: Are we ready to make this diagnosis? J Pediatr. 2010;157(1):15-19.

5. Tavaras EM, Rifas-Shiman SI, Belfort MB, et al. Weight status in the first 6 months of life and obesity at 3 years of age. Pediatrics. 2009;123(4):1177-1183.

6. Tzoulaki I, Sovio U, Pillas D, et al. Relation of immediate postnatal growth with obesity and related metabolic risk factors in adulthood: the Northern Finland birth cohort 1966 study. Am J Epidemiol. 2010;171(9):989-998.

7. Nelson SM, Matthews P, Poston L. Maternal metabolism and obesity: Modifiable determinants of pregnancy outcome. Hum Reprod Updates. 2010;16(3):255-275.

8. Monasta L, Batty GD, Cattaneo A, et al. Early-life determinants of overweight and obesity: A review of systematic reviews. Obes Rev. 2010;11(10):695-708.

9. Jelalian E, Boergers J, Alday CS, Frank R. Survey of physician attitudes and practices related to pediatric obesity. Clin Pediatr. 2003;42(3):235-245.

10. Perrin EM, Flower KB, Garrett J, Ammerman AS. Preventing and treating obesity: Pediatricians’ self-efficacy, barriers, resources, and advocacy. Ambul Pediatr. 2005;5(3):150-156.

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