Prevention and Treatment of Obesity From the Prenatal Period to Preschool
Data suggest that obesity affects emotional and physical health, quality of life, and mortality in all life stages. Obesity is particularly troublesome for young children because of both its health risks and the tendency of early weight issues to persist as the child ages. Almost one-third of school-aged children and adolescents are overweight or obese, and they have more than a 50% chance of continuing to struggle with weight issues into adulthood.1 Obesity rates among preschoolers are between 8% and 14%. If left untreated, these children are 5 times more likely to be overweight as preteens. Although there is some debate about whether these rates are stabilizing, the bottom line is that more than 4 million children aged 2 to 19 years have a disease for which there is no cure.2,3
Treatment options and interventions vary depending on a child’s age and stage of development. For preschoolers, many of the contributing factors to their weight are beyond their control. Treatment programs for this age group typically focus on feeding cues/self-regulation, mealtime environment, and physical activity. Many of the treatment programs for preschoolers aim to prevent obesity or minimize the risk of weight-related complications.
The best course of action is preventing a child from becoming obese in the first place. The American Academy of Pediatrics (AAP) believes that obesity prevention is as important a public health priority as treatment.4 The AAP asserts that prevention should begin prior to preschool age, with an emphasis on healthy maternal weight, breastfeeding, appropriate weight gain in infancy, and parental role modeling of healthy behaviors (Table).
PREVENTION
Prenatal. Choosing to breastfeed may be one of the first postnatal opportunities to prevent childhood obesity. The feeding practices of breastfeeding mothers may differ from those who use formula. Mothers who breastfeed may be more responsive to their child’s hunger cues, and they may be less likely to restrict feeding and diminish their child’s ability to self-regulate food intake. At age 3 years, body mass index (BMI) z-scores are lower in children who were exclusively breastfed for at least 6 months.5
However, children who are not exclusively breastfed may still benefit from breastfeeding. Analysis of data from the 2003 National Health and Nutrition Examination Surveys showed that duration of breastfeeding may be protective against obesity in children aged 2 to 5 years, even in those not exclusively breastfed.6 The mechanism for this protection is unknown.
In both of these studies, the mothers were typically college educated, living above the poverty line, and nonminority. It is difficult to generalize these findings to minority, urban-dwelling families, or to children of adolescent mothers. The protective effects of breastfeeding may only extend into preschool years, but by then the pediatrician may have a better idea of the feeding practices and weight perceptions of the parents/caregivers.
Preschool.Parents who have restrictive feeding practices or are obese are significantly more likely to have preschool children who are overweight or obese.7 Furthermore, mothers who use food as a reward or in response to emotions, as well as those who restrict intake based on weight or fat content of food, are more likely to have children with disordered eating (ie, overeating or emotional eating) and higher BMI z-scores.8
Anticipatory guidance directed toward feeding practices may help to change the food preference of preschoolers to include more fruits and to avoid “junk food.” Such guidance may also help to prevent other obesogenic behaviors such as emotional eating and poor hunger/satiety cues.9 New challenges also emerge as child care introduces more caregivers and more influences on the child’s nutrition and physical activity. In some instances, preschoolers consume more calories and fewer fruits/vegetables at home than they do in full time child care.10 Without adequate tools or support, caregivers and children are susceptible to behaviors that could lead to abnormal weight gain and obesity.11
TREATMENT
From birth to 24 months, families have frequent well visits and several chances to communicate with their pediatrician and receive anticipatory guidance. However, by age 3 the well visits are spaced out to every 12 months. For preschoolers whose weight continues to climb, the focus shifts from prevention to stabilizing weight and BMI trends, or finding treatment to facilitate weight loss.
Some treatment options exist within the primary care setting, and other treatment options take place in the community setting at home, school, or child care (Table). The challenges for the busy pediatrician are finding families who perceive their child’s weight as an issue, and then pairing those families with programs that reflect their readiness for and ability to change. As with prevention efforts, the treatment programs typically focus on eating behaviors, feeding practices, and physical activity. Multidisciplinary programs are available in some communities.
Multidisciplinary approaches. Bocca and colleagues conducted a study of overweight and obese children aged 3 to 5 years to determine the effect of multidisciplinary treatment.12 Seventy-five children were randomized to either multidisciplinary treatment (n = 40) or usual care (n = 35). Primary outcomes were weight reduction, change in BMI and BMI z-score, percent body fat, and visceral fat. Key secondary outcomes were waist and hip circumference and abdominal subcutaneous fat. Measurements were done at baseline, at the conclusion (16 weeks) of the intervention, and 12 months after the intervention. Patients were excluded if they had mental retardation, severe behavior problems, or developed obesity because of a medical condition or eating disorder. The multidisciplinary treatment group attended 25 sessions for 16 weeks (approximately 30 total hours) where they interacted with a registered dietitian, exercise specialist, and psychologist.
Dietary advice focused on eating breakfast and limiting snacking and sugary drinks. Supervised exercise sessions focused on enjoyable, age-appropriate activities. Parent-only group sessions included information on being a healthy role model, giving positive feedback, and learning more about food triggers and hunger cues. In contrast, the usual care group met with their pediatrician 3 times for 16 weeks (approximately 1.5 to 3 total hours). Parents were given information on healthy behaviors and counseled on allowing for active play at least 60 minutes per day. All participants received a pedometer and food diaries.
The highest attrition rate in both groups was seen during the initial 16 weeks and was approximately 18%. Parents cited time constraints and stress as the primary reasons for dropout. Compared with usual care, participants in the multidisciplinary treatment group demonstrated a significant decrease in their BMI, BMI z-score, and waist circumference z-score. They maintained these improvements 12 months after the intervention. Although both groups recorded lower energy intake after the intervention, there was no significant difference in energy intake between the groups.
In practice, the time constraints of the pediatrician and concern for insurance reimbursement could make it difficult to implement this type of intervention. Insurance reimbursement should be verified on an individual basis, but physician visits generally should be covered by insurance, especially if the chart documents weight-related comorbidities, diagnostic data reviewed, medical decision-making, and time spent during the encounter. Coverage of nutritional and psychological counseling varies by region and insurance carrier.
Text messages. In another approach to treatment, Mitilello and colleagues used cognitive behavior therapy to deliver face-to-face counseling and automated text messages to parents of overweight/obese preschoolers.13 Children included in the study were aged 3 to 5 years, had a BMI > 85th percentile, had an active mobile device, and had parents aged 18 to 45 years. A convenience sample of 15 dyads from 3 primary care offices received face-to-face counseling from a curriculum manual. Weekly text messages provided reminders, triggers for new behaviors, and tailored messages to reinforce goals set during counseling sessions. Parents had significant improvements in their personal- and family-centered beliefs toward healthy eating (P = 0.01), as well as improvements in child-related food and fitness knowledge (P = .001).
Motivational interviewing. Motivational interviewing offers another possibility for treatment. Resnicow and colleagues studied motivational interviewing and dietary counseling in children aged 2 to 8 years with BMIs between the 85th and 97th percentile.14 Although the age group in this randomized controlled trial extended beyond the preschool years, the intervention occurred in a medical home with a primary care provider and registered dietitian—a format that may be more appealing to pediatricians wanting to closely monitor behavior changes and BMI trends.
Patients from 42 practices (n = 645) within the AAP Pediatric Research in Office Settings Network were randomized to 1 of 3 groups: (1) usual care, including routine well care and informative handouts (n = 158), (2) provider only with 4 motivational interviewing sessions over 2 years (n = 145), and (3) Four provider motivational interviewing sessions and 6 registered dietician motivational interviewing sessions for 2 years (n = 154). Motivational interviewing sessions focused on specific behaviors such as sedentary/screen time, physical activity, snacking, consumption of fruits/vegetables, and consumption of sugary drinks. The primary outcome was BMI percentile at 2-year follow up.
Exclusion criteria were having diabetes, no working phone, medical/metabolic disorders that affect movement or growth, and enrollment in a weight management program within the past 12 months. The mean BMI within each group was around the 92nd percentile, which is considered overweight. The mean child age was 4.1 years, and the mean parent age was 29 years. Children and parents were predominantly female, white, and not college educated. More than 90% of the caregivers were mothers. More than two-thirds of the families had private insurance and household income greater than $40,000.
At 2-year follow up, the group that received a combination of provider and registered dietician counseling had a significantly lower BMI percentile than the usual care group, but their BMI was still between the 85th and 94th percentile, meaning they were overweight. Although the group receiving more counseling experienced improvements in BMI, it is important to note that patients within the usual care group also lowered their BMI.
CONCLUSION
Based on a review of the literature, clinicians have a variety of promising prevention and treatment options available to share with preschoolers and their parents. In the prenatal months, obstetricians are in a unique position to not only counsel pregnant mothers on minimizing excessive weight gain but to also discuss breastfeeding, infant feeding practices, and the roles of feeding practices in the health of the mother and infant. Communicating about prevention techniques with parents and caregivers as early as the prenatal period may help them to adopt healthy feeding practices and other behaviors that contribute to their child maintaining a healthy weight. If a child becomes obese, treatment focusing on feeding practices or physical activity may be helpful. Some providers and families may choose mobile health programs that use text messages to provide more convenient, feasible treatment options.
With all treatment and prevention options, families need continued support from their pediatrician with timely visits and anticipatory guidance. Addressing childhood obesity is not without challenges, but the evidence base suggests that it is not without hope either.n
Dominique R. Williams, MD, MPH, FAAP, is medical director at Children’s Hospital of the King’s Daughters Healthy You for Life program, and assistant professor of pediatrics at Eastern Virginia Medical School in Norfolk, Virginia.
REFERENCES
1. Rhee KE, DeLago CW, Arscott-Mills T, Mehta SD, Davis RK. Factors associated with parental readiness to make changes for overweight children. Pediatrics. 2005;116(1):e94-e101.
2. Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity in US children, 1999-2014. Obesity (Silver Spring). 2016;24(5):1116-1123.
3. Ferdman RA. A widely held belief about childhood obesity that simply isn’t true. The Washington Post. May 2, 2010. https://www.washingtonpost.com/news/wonk/wp/2016/05/02/we-all-thought-this-dangerous-trend-affecting-our-kids-had-stopped-but-it-didnt/. Accessed July 14, 2016.
4. Daniels SR, Hassink SG; Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275-e292.
5. Taveras EM, Rifas-Shiman SL, Scanlon KS, et al. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics. 2006;118(6):2341-2348.
6. Hansstein FV. The impact of breastfeeding on early childhood obesity: evidence from the National Survey of Children’s Health. Am J Health Promot. 2016;30(4):250-258.
7. Dev DA, McBride BA, Fiese BH, et al. Risk factors for overweight/obesity in preschool children: an ecological approach. Child Obes. 2013;9(5):399-408.
8. Rogers RF, Paxton SJ, Massey R, et al. Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: a prospective study. Int J Behav Nutr Phys Act. 2013;10:24.
9. Daniels LA, Mallan KM, Battistutta D, et al. Child eating behavior outcomes of an early feeding intervention to reduce risk indicators for child obesity: The NOURISH RCT. Obesity (Silver Spring). 2014;22(5):e104-e111.
10. Robson SM, Khoury JC, Kalkwarf HJ, Copeland K. Dietary intake of children attending full-time child care: what are they eating away from the child-care center? J Acad Nutr Diet. 2015;115(9):1472-1478.
11. Schroeder N, Rushovich B, Bartlett E, Sharma S, Gittelsohn J, Caballero B. Early obesity prevention: a randomized trial of a practice-based intervention in 0-24 month infants. J Obes. 2015;2015:795859.
12. Bocca G, Corpeleijn E, Stolk RP, Sauer PJ. Results of a multidisciplinary treatment program in 3-year-old to 5-year-old overweight or obese children: a randomized controlled clinical trial. Arch Pediatr Adolesc Med. 2012;166(12):1109-1115.
13. Militello L, Melnyk BM, Hekler EB, et al. Automated behavioral text messaging and face-to-face intervention for parents of overweight or obese preschool children: results from a pilot study. JMIR Mhealth Uhealth. 2016;4(1):e21.
14. Resnicow K, McMaster F, Bocian A, et al. Motivational interviewing and dietary counseling for obesity in primary care: an RCT. Pediatrics. 2015;135(4):649-657.