1. Windows of Opportunity Obesity Prevention in Childhood Alan M. Lake, M.D. Alan M. Lake, M.D. Taskforce on Obesity Prevention in Childhood Maryland Chapter, American Academy of Pediatrics

2. Prevention vs. Treatment Why Prevention? Appeal, indeed mantra, in Pediatrics Appeal, indeed mantra, in Pediatrics Opportunities begin in-utero or before Opportunities begin in-utero or before Greatest and Quickest impact Greatest and Quickest impact Low risk Low risk Poor ability to recognize increased risk in time to make a difference Poor ability to recognize increased risk in time to make a difference

3. Why bother? David Katz: Yale David Katz: Yale “ Today’s kids may become the first generation in the history of man to have a life expectancy projected to be less than that of their parents.”

4. Definition of Obesity 0 -2 years: Wt/Ht > 95%ile 0 -2 years: Wt/Ht > 95%ile 2 – 18 years: BMI > 95%ile 2 – 18 years: BMI > 95%ile – At Risk: BMI 85 – 95%ile AdultOverweight: BMI > 25 – 30 AdultOverweight: BMI > 25 – 30 –Obesity Class 1:BMI 30 – 34.9 (30#) –Obesity Class 2:BMI 35 – 39.9 (50#) –Obesity Class 3:BMI > 40 (100#)

5. Physiology of Fat Excess energy intake relative to energy consumed Excess energy intake relative to energy consumed Excess 3500 kcal yields one pound of fat Excess 3500 kcal yields one pound of fat Excess 50 kcal a day yields 5# fat gain in one year. Excess 50 kcal a day yields 5# fat gain in one year.

6. Where we are now Childhood Obesity: Past 40 Years Percent with BMI > 95%ile AGE 6 – 11 12 - 19 1963 – 1970 4 % 5 % 1963 – 1970 4 % 5 % 1971 – 1974 4 6 1971 – 1974 4 6 1976 – 1980 7 5 1976 – 1980 7 5 1988 – 1994 11 11 1988 – 1994 11 11 1999 – 2000 15 15 1999 – 2000 15 15

7. Teen Obesity YRBS survey:2005 28.8% have BMI above the 85%ile 28.8% have BMI above the 85%ile –“at risk or already obese” Hospital Costs for Obesity Related complications: Hospital Costs for Obesity Related complications: 1979 – 1981$35 million/year 1979 – 1981$35 million/year 1997 – 1999 $127 million/year 1997 – 1999 $127 million/year

8. Where we are now Maryland WIC age 2 – 5 June, 2006 Total Children 33,154 BMI: < 5%ile3% BMI: 5 – 85%ile64% BMI: 85 – 95%ile17% BMI: > 95%ile16% ( one in three at risk or obese)

9. Where we are now Adult Obesity Increase % With BMI > 35 (Class 2) Age19911998 %Inc Age19911998 %Inc 18 – 29 7.1 %12.1%69.9 18 – 29 7.1 %12.1%69.9 30 – 3911.316.949.5 30 – 3911.316.949.5 40 – 4915.821.234.3 40 – 4915.821.234.3 50 – 5916.123.847.9 50 – 5916.123.847.9 60 – 6914.721.344.9 60 – 6914.721.344.9 > 7011.414.628.6 > 7011.414.628.6

10. Distribution of Adult Obesity:2004 Adult Females:57% have BMI> 25 Adult Females:57% have BMI> 25 Adult Males: Adult Males: –BMI > 2567% –BMI > 3032% –BMI > 408% Represents a 350% increase in 15 yrs Represents a 350% increase in 15 yrs

11. Adult Obesity Prevention Strategies: Surgeon General Increase Physical activity to 30 – 60 minutes a day Increase Physical activity to 30 – 60 minutes a day Reduce portion sizes of meals Reduce portion sizes of meals Reduce soda, fruit drinks, and desserts Reduce soda, fruit drinks, and desserts Eat 5 – 9 servings of fruits and vegetables a day. Eat 5 – 9 servings of fruits and vegetables a day. Reduce t.v. and video time to no more than one hour a day Reduce t.v. and video time to no more than one hour a day

12. Relevance of Early Obesity If >95% wt/ht at one year, 3 fold greater risk of >95% BMI at 3 years If >95% wt/ht at one year, 3 fold greater risk of >95% BMI at 3 years If > 95%ile BMI at 3 – 6 years, 50% remain obese as adults If > 95%ile BMI at 3 – 6 years, 50% remain obese as adults If > 99%ile at age 9, 100% risk of adult obesity and early complications of obesity If > 99%ile at age 9, 100% risk of adult obesity and early complications of obesity If > 95%ile BMI at 16 years, >80% remain obese as adults. If > 95%ile BMI at 16 years, >80% remain obese as adults. The <20% of teens who lose weight do not reduce increased cardiovascular risk The <20% of teens who lose weight do not reduce increased cardiovascular risk

13. Windows of Opportunity Prevention in Childhood Prenatal and pre-prenatal Prenatal and pre-prenatal Peri-natal “catch-up growth” Peri-natal “catch-up growth” Infancy, via breast feeding Infancy, via breast feeding Toddler self-regulation Toddler self-regulation Preschool habit intake Preschool habit intake Elementary “wellness education” Elementary “wellness education” Adolescent diet and exercise Adolescent diet and exercise

14. Intrauterine: “Thrift Gene” More than 250 obesity-associated genes More than 250 obesity-associated genes We all have at least one We all have at least one Only 2 lean-associated genes Only 2 lean-associated genes 15 single gene mutations predict obesity 15 single gene mutations predict obesity If one parent obese, increase risk 3 fold If one parent obese, increase risk 3 fold If both parents obese, increase risk 13 fold If both parents obese, increase risk 13 fold Gene marker: MC4R causes >5% of obesity Gene marker: MC4R causes >5% of obesity Genes set threshold of receptor response Genes set threshold of receptor response

15. Intrauterine “Programming” Barker Hypothesis Alterations in fetal nutrition and endocrine status result in permanent developmental adaptations in structure, physiology, and metabolism thereby predisposing the fetus to cardiovascular, metabolic, and endocrine disease in adult life. Alterations in fetal nutrition and endocrine status result in permanent developmental adaptations in structure, physiology, and metabolism thereby predisposing the fetus to cardiovascular, metabolic, and endocrine disease in adult life.

16. Intrauterine: Proof of Barker Hypothesis 16,000 subjects born 1911 – 1930 16,000 subjects born 1911 – 1930 For birth weights below 8#, lower the weight, the higher the risk of cardiovascular disease and mortality For birth weights below 8#, lower the weight, the higher the risk of cardiovascular disease and mortality Birth weights above 9#, higher the weight, greater the risk Birth weights above 9#, higher the weight, greater the risk If weight gain in first year too great or too slow, risk is increased If weight gain in first year too great or too slow, risk is increased

17. Intrauterine: Role of caloric deprivation Holland, World War 2 Holland, World War 2 Babies born IUGR, greatest risk of obesity, diabetes, hypertension. Babies born IUGR, greatest risk of obesity, diabetes, hypertension. Greatest risk if maternal malnutrition is in the first trimester in lower socio-economic classes. Greatest risk if maternal malnutrition is in the first trimester in lower socio-economic classes. Lower risk with caloric deprivation in last trimester when fetal body fat normally increases from 5% to 16% of body weight. Lower risk with caloric deprivation in last trimester when fetal body fat normally increases from 5% to 16% of body weight.

18. Intrauterine: Other Factors Over the past ten years, increased birth weights noted, primarily due to increased pre-pregnancy maternal wt. Over the past ten years, increased birth weights noted, primarily due to increased pre-pregnancy maternal wt. Maternal smoking reduces birth weight, increases risk of adult obesity Maternal smoking reduces birth weight, increases risk of adult obesity Highest risk for early Type 2 diabetes: birth weight in lowest 30%, weight at age 8 in highest 50%. Highest risk for early Type 2 diabetes: birth weight in lowest 30%, weight at age 8 in highest 50%.

19. Intrauterine: Other factors Maternal obesity and birth weight above 8# 8oz increases 5 fold the risk for subsequent leukemia in the child. Maternal obesity and birth weight above 8# 8oz increases 5 fold the risk for subsequent leukemia in the child. Attributed to increased IGF 1 stimulation of stem cells to predispose to leukemia. Attributed to increased IGF 1 stimulation of stem cells to predispose to leukemia.

20. Intrauterine: Nutrigenomics The science of interaction of nutrition and gene expression in utero The science of interaction of nutrition and gene expression in utero Role of “priming” of metabolic responses that persists into adulthood Role of “priming” of metabolic responses that persists into adulthood Goal of optimal maternal nutrition prior to and during pregnancy Goal of optimal maternal nutrition prior to and during pregnancy

21. Intrauterine: Options for Intervention Reduce pre-pregnancy obesity Reduce pre-pregnancy obesity Address maternal diet and exercise especially in first trimester Address maternal diet and exercise especially in first trimester Reduce glycemic index of intake to reduce intrauterine insulin and IGF1 levels Reduce glycemic index of intake to reduce intrauterine insulin and IGF1 levels Establish new nutrition and weight gain goals for pregnancy Establish new nutrition and weight gain goals for pregnancy

22. The Glycemic Index Determined by rate of glucose metabolism Determined by rate of glucose metabolism Glycemic load = index x intake Glycemic load = index x intake High glycemic = glucose, sucrose High glycemic = glucose, sucrose Lower glycemic = complex starches Lower glycemic = complex starches High glycemic intake induces hyperglycemia at 4 – 6 hours, increases insulin, epinephrine, and thus increases appetite High glycemic intake induces hyperglycemia at 4 – 6 hours, increases insulin, epinephrine, and thus increases appetite In past 20 years, maternal diet stable in protein, reduced in fat, increased in carbs by 65 grams a day. Calories up 270 kcal/d In past 20 years, maternal diet stable in protein, reduced in fat, increased in carbs by 65 grams a day. Calories up 270 kcal/d

23. Perinatal Factors Obesity risk correlates with weight gain in first week of life Obesity risk correlates with weight gain in first week of life In IUGR, rapid weight gain in first year increases risk of obesity, diabetes and cardiovascular disease, especially if outpaces height gain. Need to adjust caloric intake to optimize growth not weight gain. In IUGR, rapid weight gain in first year increases risk of obesity, diabetes and cardiovascular disease, especially if outpaces height gain. Need to adjust caloric intake to optimize growth not weight gain.

24. Infancy: Opportunities Encourage breast feeding to allow infant to self-regulate intake and increase flavor preference Encourage breast feeding to allow infant to self-regulate intake and increase flavor preference Delay introduction of solid foods until after 4 – 6 months Delay introduction of solid foods until after 4 – 6 months Wean from bottle use by 18 months of age Wean from bottle use by 18 months of age Improve WIC wellness education Improve WIC wellness education

25. Role of Breast Feeding 8 of 11 studies of > 100 breast fed babies followed more than 3 years revealed lower rates of childhood obesity 8 of 11 studies of > 100 breast fed babies followed more than 3 years revealed lower rates of childhood obesity If “ever” breast fed, reduction of 15% If “ever” breast fed, reduction of 15% Recent retrospective study at Harvard, no sustained benefit into adulthood Recent retrospective study at Harvard, no sustained benefit into adulthood

26. Value of Breast feeding Slower weight gain in first weeks Slower weight gain in first weeks Self regulated caloric intake Self regulated caloric intake Lower insulin levels in first year Lower insulin levels in first year Wider food preferences after 2 years of age, lower sugar, lower salt. Wider food preferences after 2 years of age, lower sugar, lower salt. Reduced or delayed development of Type 2 diabetes in Pima Indians Reduced or delayed development of Type 2 diabetes in Pima Indians

27. FITS study, 3000 infants Gerber and ADA Daily caloric intake relative to estimated need Daily caloric intake relative to estimated need 3 day diet histories, prospective, at 3 month intervals 3 day diet histories, prospective, at 3 month intervals AgeEst NeedActual Intake%excess AgeEst NeedActual Intake%excess 4 – 6 mo 629 690 +10% 4 – 6 mo 629 690 +10% 7 – 11 mo 739 924 +23% 7 – 11 mo 739 924 +23% 1 – 2 yrs 950 1249 +31% 1 – 2 yrs 950 1249 +31% 27% of infants in WIC, at 11 mos +32%, at 2 years, + 40% 27% of infants in WIC, at 11 mos +32%, at 2 years, + 40%

28. FITS data on solid foods 29% of infants fed solids before 4 mo 29% of infants fed solids before 4 mo By age 2, 30% ate no fruit, 20% no veges in the three days documented By age 2, 30% ate no fruit, 20% no veges in the three days documented By age 2, 37% drinking juice daily, 27% eating potato chips daily By age 2, 37% drinking juice daily, 27% eating potato chips daily

29. Role of extended bottles 20% of 2 year olds, 10% of 3 year olds, 2.5% of 4 year olds use bottle daily. 20% of 2 year olds, 10% of 3 year olds, 2.5% of 4 year olds use bottle daily. From NHANES III data, for every month past 18 months, that a child uses a bottle, there is a 3% increase in risk of having BMI > 95%ile at 10. From NHANES III data, for every month past 18 months, that a child uses a bottle, there is a 3% increase in risk of having BMI > 95%ile at 10.

30. Toddler: Self regulation From 18 months to 3 – 4 years, a toddler will self regulate their intake. If food of higher caloric density is served, they eat less. If food of reduced caloric density is served, they eat more. From 18 months to 3 – 4 years, a toddler will self regulate their intake. If food of higher caloric density is served, they eat less. If food of reduced caloric density is served, they eat more. Parent chooses food to offer, child regulates intake Parent chooses food to offer, child regulates intake

31. Toddler: Food choices A toddler, on average, must be offered a new food 10 – 12 times before they will eat it. Most parents offer it no more than 3 times and give up. A toddler, on average, must be offered a new food 10 – 12 times before they will eat it. Most parents offer it no more than 3 times and give up. Do not mix new food with existing preferred food, the toddler will stop eating both. Do not mix new food with existing preferred food, the toddler will stop eating both.

32. Toddler activity 75% of 3 year olds still in strollers, with 39% of 4 year olds still in strollers while “at the park” 75% of 3 year olds still in strollers, with 39% of 4 year olds still in strollers while “at the park” If a toddler is bored and fussy, take them out to play, do not turn on a video. If a toddler is bored and fussy, take them out to play, do not turn on a video. Minimize video or screen time Minimize video or screen time

33. Preschool Opportunities Community access to improve wellness education and role modeling through Head Start and licensed day care programs Community access to improve wellness education and role modeling through Head Start and licensed day care programs Preschool children at play devote only 11% of free time to moderate exercise Preschool children at play devote only 11% of free time to moderate exercise

34. Routine BMI Screening American Academy of Pediatrics and American Academy of Family Practice favor screening all children American Academy of Pediatrics and American Academy of Family Practice favor screening all children U.S.P.S.T.F.: Evidence insufficient to recommend for or against. U.S.P.S.T.F.: Evidence insufficient to recommend for or against. Bill Dietz: You can’t have evidence- based practice until you have practice- based evidence. Screen on!!!!! Bill Dietz: You can’t have evidence- based practice until you have practice- based evidence. Screen on!!!!!

36. The Adiposity “Rebound” The nadir of the BMI Normal BMI declines at 2 years to nadir at 3 to 5 years, then climbs through puberty (and beyond) Normal BMI declines at 2 years to nadir at 3 to 5 years, then climbs through puberty (and beyond) If child enters high on the curve or rebound begins early, greater risk of adult obesity and Type 2 diabetes If child enters high on the curve or rebound begins early, greater risk of adult obesity and Type 2 diabetes Occurs in transition from “self- regulated” intake to “habit intake” Occurs in transition from “self- regulated” intake to “habit intake”

37. Physiology of the Adiposity Rebound From age 1 to 3 years, child’s length increases and fat cell size declines with a stable number of fat cells From age 1 to 3 years, child’s length increases and fat cell size declines with a stable number of fat cells From age 4 to 6 years, there is an increase of fat cell number and size that may be predictive of future obesity From age 4 to 6 years, there is an increase of fat cell number and size that may be predictive of future obesity

38. The “window” in preschool Community access via existing programs Community access via existing programs First real value for role models First real value for role models Sustain self-regulated intake Sustain self-regulated intake Establish habit of daily exercise, 60 to 90 minutes a day, half unstructured Establish habit of daily exercise, 60 to 90 minutes a day, half unstructured Enter adiposity rebound on the lower end Enter adiposity rebound on the lower end

39. Elementary School Diet influenced by media and parent role model Diet influenced by media and parent role model Average USA child spends 75% of waking time inactive, 12 minutes a day in vigorous activity Average USA child spends 75% of waking time inactive, 12 minutes a day in vigorous activity In average elementary school gym class, child is active for only 3 minutes In average elementary school gym class, child is active for only 3 minutes

40. Elementary School Obesity risk can be reduced by 10% for every hour less watching television Obesity risk can be reduced by 10% for every hour less watching television Obesity risk can be reduced by 10% for every hour more in moderate exercise Obesity risk can be reduced by 10% for every hour more in moderate exercise By age 5 – 10 years, 50% of obese children have a positive risk factor for early cardiovascular disease By age 5 – 10 years, 50% of obese children have a positive risk factor for early cardiovascular disease

41. Elementary School Physical education goal of 30 min/day or 150 min/wk with 50% of time in moderate to vigorous activity Physical education goal of 30 min/day or 150 min/wk with 50% of time in moderate to vigorous activity Only one county in Maryland provides this time Only one county in Maryland provides this time Providing time for physical activity does not lead to reduced school performance or test results in NCLB Providing time for physical activity does not lead to reduced school performance or test results in NCLB

42. The “window” in elementary school Reduce screen time to less than 2 hours a day Reduce screen time to less than 2 hours a day Reducing t.v. time alone of no value Reducing t.v. time alone of no value Increase physical activity to 30 – 60 minutes a day Increase physical activity to 30 – 60 minutes a day Establish wellness agenda of improved nutrition and physical activity Establish wellness agenda of improved nutrition and physical activity Family and School-based role models Family and School-based role models

43. Secondary School Concerns 30% of obese teens have 2 or more features of metabolic syndrome present 30% of obese teens have 2 or more features of metabolic syndrome present High LDL-C at age 15 – 18 years associated with 5 fold increase in adult obesity, hyperlipidemia, and hypertension High LDL-C at age 15 – 18 years associated with 5 fold increase in adult obesity, hyperlipidemia, and hypertension

44. Secondary School Concerns 30% of teens and 40% of adults eat fast food on a daily basis. Fast food adds 187 kcal/day to intake. (22#/yr) 30% of teens and 40% of adults eat fast food on a daily basis. Fast food adds 187 kcal/day to intake. (22#/yr) Average teen consumes 870 cans of soft drink a year. Average teen consumes 870 cans of soft drink a year. Only 65% of teens have any vigorous activity more than 3 days a week and only 27% more than 5 days a week Only 65% of teens have any vigorous activity more than 3 days a week and only 27% more than 5 days a week

45. Secondary School Physical Activity Daily gym class: 6.4% of middle schools, 5.8% of high schools in U.S. Daily gym class: 6.4% of middle schools, 5.8% of high schools in U.S. Only 17% of students walk to school Only 17% of students walk to school Every half mile walked by teen reduces obesity risk by 5% Every half mile walked by teen reduces obesity risk by 5% Girls age 9 to 19, 83% decline in habitual physical activity Girls age 9 to 19, 83% decline in habitual physical activity

46. The “window” for teens Increase responsibility for food choices and food preparation Increase responsibility for food choices and food preparation Healthy breakfast, 3 balanced meals Healthy breakfast, 3 balanced meals Avoid after school “chicken box” Avoid after school “chicken box” Support exercise, dance, and family activities in evenings and weekends Support exercise, dance, and family activities in evenings and weekends Support school phys ed 225 min/wk Support school phys ed 225 min/wk

47. Office Monitoring for Complications Determine and plot BMI %ile and share with student and family Determine and plot BMI %ile and share with student and family Discuss pace of change, not blame Discuss pace of change, not blame Document blood pressure and waist circumference Document blood pressure and waist circumference Lab screening if >85%ile to document status and risk Lab screening if >85%ile to document status and risk

48. Lab screening Urine analysis for glucose and protein Urine analysis for glucose and protein Fasting lipid profile Fasting lipid profile Chemistry profile, Vitamin B-12 Chemistry profile, Vitamin B-12 Fasting glucose, insulin, HgbA1C Fasting glucose, insulin, HgbA1C Androgen levels if concern for PCOS Androgen levels if concern for PCOS Hepatic sonogram for steatohepatosis Hepatic sonogram for steatohepatosis

49. Psychological Screening Monitor school performance Monitor school performance Discuss bullying Discuss bullying Reduced self-esteem/depression Reduced self-esteem/depression –34% of teens with BMI >95%ile are depressed –8% of teens with normal BMI %ile

50. Treatment in Childhood Age 2 – 7 years, emphasis on maintaining weight unless established complication Age 2 – 7 years, emphasis on maintaining weight unless established complication Age 7 – 18, weight loss if >95%ile or >85%ile with complication Age 7 – 18, weight loss if >95%ile or >85%ile with complication Seek goal of 1 pound loss a month. Seek goal of 1 pound loss a month. Combined diet and exercise program Combined diet and exercise program

51. Bariatric surgery: Gastric banding Failure of > 6 months of supervised weight loss program Failure of > 6 months of supervised weight loss program Age greater than 13 years Age greater than 13 years BMI > 40 in presence of significant obesity-related co-morbidity BMI > 40 in presence of significant obesity-related co-morbidity BMI > 50 with any obesity-related complications BMI > 50 with any obesity-related complications

52. Goals in Adult: Identification of Risk Genetic risk profiles now studied Genetic risk profiles now studied Biologic age vs Chronologic Age Biologic age vs Chronologic Age Coronary inflammation: CRP, cardiac calcification on CT scan Coronary inflammation: CRP, cardiac calcification on CT scan 75% of asymptomatic adults under 45 with first MI have lipid profile not qualifying for statin therapy 75% of asymptomatic adults under 45 with first MI have lipid profile not qualifying for statin therapy

53. References American Academy of Pediatrics: Policy Statement: Prevention of Pediatric Overweight and Obesity: Pediatrics 2003: 112; 424 – 430. American Academy of Pediatrics: Policy Statement: Prevention of Pediatric Overweight and Obesity: Pediatrics 2003: 112; 424 – 430. Dietz, W.H. and Robinson, T.N. Overweight Children and Adolescents: NEJM 2005;352: 2100 – 2109. Dietz, W.H. and Robinson, T.N. Overweight Children and Adolescents: NEJM 2005;352: 2100 – 2109.

54. References: AAP Endorsed Policy Statement with AHA: Dietary Recommendations for Children and Adolescents: A Guide for Practitioners. Pediatrics 2006: 117, 544 – 559. AAP Endorsed Policy Statement with AHA: Dietary Recommendations for Children and Adolescents: A Guide for Practitioners. Pediatrics 2006: 117, 544 – 559. AAP Policy Statement: Active Healthy Living: Prevention of Childhood Obesity Through Increased Physical Activity. Pediatrics 2006: 117, 1834 – 1841. AAP Policy Statement: Active Healthy Living: Prevention of Childhood Obesity Through Increased Physical Activity. Pediatrics 2006: 117, 1834 – 1841.

55. References: U.S. Preventive Services Task Force: Screening and Interventions for Overweight in Children and Adolescents: Recommendation Statement. American Family Physician 2006: 73; 115 – 119. U.S. Preventive Services Task Force: Screening and Interventions for Overweight in Children and Adolescents: Recommendation Statement. American Family Physician 2006: 73; 115 – 119. Hassink, S.G., Klish, W.J., Robinson, T.N. and Freedman, M. Take a comprehensive approach to obesity control and prevention. Contemporary Pediatrics 2006: 23; 101 – 110. Hassink, S.G., Klish, W.J., Robinson, T.N. and Freedman, M. Take a comprehensive approach to obesity control and prevention. Contemporary Pediatrics 2006: 23; 101 – 110.

56. References: AHA Scientific Statement: Overweight in Children and Adolescents, Circulation 2005; lll: 1999 – 2012. AHA Scientific Statement: Overweight in Children and Adolescents, Circulation 2005; lll: 1999 – 2012. AHA Scientific Statement: Promoting Physical Activity in Children and Youth. A Leadership Role for Schools. Circulation 2006; 114: 1 -11. AHA Scientific Statement: Promoting Physical Activity in Children and Youth. A Leadership Role for Schools. Circulation 2006; 114: 1 -11.

57. References American Medical Association American Medical Association –Roadmaps for Clinical Practice –Assessment and Management of Adult Obesity: A Primer for Physicians 9 Booklets, downloaded from AMA website 9 Booklets, downloaded from AMA website –www.ama-assn.org Adapted from Serdula et al, Weightloss counseling revisited: JAMA 289:1747-1750. 2003. Adapted from Serdula et al, Weightloss counseling revisited: JAMA 289:1747-1750. 2003.

58. Web Sites for Information www.aap.org/obesity www.aap.org/obesity www.aap.org/obesity www.mdaap.org/obesityresources www.mdaap.org/obesityresources www.mdaap.org/obesity www.cdc.gov/nccdphp/dnpa www.cdc.gov/nccdphp/dnpa www.cdc.gov/nccdphp/dnpa www.VERBparents.com www.VERBparents.com www.VERBparents.com www.shapingamericasyouth.org www.shapingamericasyouth.org www.shapingamericasyouth.org www.kidshealth.org www.kidshealth.org www.kidshealth.org www.shapeup.org www.shapeup.org www.shapeup.org www.brightfutures.org www.brightfutures.org www.brightfutures.org www.eatright.org www.eatright.org www.eatright.org