Making Sense of the Science: Results We Can Take to the Office

making sense of the science
Several snapshots of obesity research and interventions that have shown some success.

Julee Waldrop, MS, FNP, PNP | Clinical Associate Professor | Schools of Nursing and Medicine | The University of North Carolina

It has been widely publicized that children in developed countries worldwide are experiencing an epidemic of increasing weight. What is less clear is what exactly we can do about it. Although we do not completely understand what portion of overweight risk is genetic, the fact that the increase in weight has changed so rapidly over only the last 30 years argues against a significant genetic factor. Environmental factors are a much more likely cause. These include many potentially modifiable causes.

Research has demonstrated that if parents—especially the mother—are obese, the child has a significantly increased risk for overweight in adulthood. Other studies have shown that if the adult was breastfed, he/she has a decreased risk of obesity. Babies who are large at birth and those who gain weight rapidly in the first two years of life have an increased risk of obesity in childhood and adolescence. Preschoolers who are overweight or display an early adiposity rebound are at significantly increased risk of being obese as adults. Finally, we are seeing that self-regulation of feeding or eating by infants and young children may be the key to obesity prevention. 

The latest study results show that there are many things a healthcare provider can do to help encourage parents and children to avoid the trap of overeating, overweight, and the numerous health and social problems that accompany these maladies. In the first year of a child's life, the pediatric health care provider will usually interact with that child and his/her family an average of eight times just for well-child care. Each of these visits provides an opportunity to discuss energy-balance and related topics. Following are several snapshots of what the latest research has found, interventions that have shown some success, and some personal suggestions for increasing success in daily practice.

Epidemic of Increasing Weight

In the worldwide epidemic of increasing weight, the U.S. has many more overweight children than other countries. For example, the prevalence of overweight in 15-year-old boys is 13.9% in the U.S. The next closest prevalence rate is 10.8% in Greece. In females, the difference in overweight prevalence is even greater—15.1% prevalence for U.S. 15-year-old girls and only 6.7% prevalence in Portugal. 

In the U.S., children from 6-23 months had weights greater than the 95th percentile at a prevalence of 7.2% in 1976-1980. Now that prevalence is 11.4%. The number of children two-to-five years old who are overweight has increased from 5.0% (1971-1974) to 10.4% (1999-2000). The percentage of children who are 6-11 years old and overweight has risen from 4.0% (1963-1965) to 15.3% (1999-2000), while the increase in 12-19 year olds is from 4.6% (1966-1970) to 15.5% (1999-2000). Both of these categories have tripled.

In evaluating overweight by ethnicity, the NHANES (National Health and Nutrition Examination Study) recorded respondents as white (non-Hispanic white), black (non-Hispanic black) or Mexican American (Hispanic). There were no other ethnicities distinguished. In the Hispanic population there is a greater prevalence of overweight than in whites or African Americans; especially at risk are Hispanic males. The other higher risk group is African American teenagers.1

Medical Conditions Associated with Overweight
Being overweight as a child can cause many of the same problems that obese adults experience. The most worrisome are those that increase the risk of cardiovascular disease (CVD). As discussed elsewhere in this publication, the psychosocial issues are also serious.



Glucose metabolism4,5
- Glucose intolerance
- Increased circulating insulin levels
- Type II diabetes

Liver challenges6
- Hepatic steatosis
- Increased liver enzymes
- Cholelithiasis

Orthopedic problems
- Pain in feet, ankles, knees
- Blount's disease
- Slipped capital femoral epiphysis

Sleep apnea7

Early onset of puberty; subsequent skeletal maturation

Negative self-image, self esteem8-10

Lowered body esteem, lowered confidence in cognitive ability11

Risk Factors Associated with Childhood Obesity

Even with the limited research we have on the early risk factors associated with childhood obesity, there is enough evidence to support these associations. Overweight parents, breastfeeding, and heavy birth weight are apparently all factors that can affect childhood obesity. It also appears that if an infant gains weight quickly over the first two years of life, the risk for overweight is increased. 

Between the ages of three to six, a child who has an early adiposity rebound will be more likely to be overweight in adulthood. Children who watch more TV and participate in less physical activity are more likely to be overweight. There appears to be a lot more to learn about feeding and eating behaviors and how they can support self-regulation and healthy eating. It also appears that parents may be trying to control their children's diets too much and at the same time may be making poor choices about what foods to offer.

The positive take on these studies is that all of these risk factors can be modified. However, at this time there is minimal research on the best way to do this, especially in the youngest age groups.

Infant Feeding
The following studies support the idea that breastfeeding may have a protective effect against overweight.


  • In Scotland, researchers evaluated a sample of 32,200 three-to-four year olds for over- weight, then determined which children had been breastfed. Those who were breastfed had a significantly decreased prevalence of overweight (7.2% vs. 9.1%) or if severely overweight, 3.4% vs. 4.6%.13



  • A cohort of 9,257 German children who were five and six years old were assessed for risk of overweight based on exclusively breastfeeding versus all other combinations of infant feeding. The breastfed infants had an overweight prevalence of 2.3% at ages five to six versus the others with a prevalence of 3.8%. The authors concluded that breastfeeding was a significant protective factor against developing overweight (OR* = 0.75) and at risk for overweight (OR = 0.79). The risk of overweight decreased the longer the infant was breastfed, down to 0.8% in those infants who were breastfed for greater than 12 months.14



  • Similar results occurred in a group of adolescents (N = 15,341) whose mothers were involved in the Nurses Health Study II (N = 15,341). Infants who received more breast milk than formula and for more months of life (N = 9553) had a statistically significant lowered risk of overweight in older childhood and adolescence (OR = 0.78).15


    *Odds Ratio (OR)

    Overweight Parents
    Having obese parents more than doubles the risk of adult obesity in children under 10 years old whether the child is overweight yet or not.16 Adults whose mothers were obese had a 25% obesity rate while those with lean mothers had only a 5% rate. Having one obese parent increases the odds of being overweight as a 15-17 year old by 2.2. (p < 0.01) If both parents are obese than the odds are increased by 3.2 (p < 0.01).17


  • Strauss & Knight examined 2,913 children between the ages of infant-to-eight years and followed them for six years. The most significant factor associated with an increased risk of developing overweight during the study was maternal obesity (OR = 3.6).(18) Other risk factors identified but not as strongly associated with overweight included: lower income, single mother, children with non-working parents, children with non-professional parents, and children of mothers with a lower level of education.



  • In a smaller comparison of two groups of children over the first six years of life, the high-risk (N = 33) group had mothers who were overweight and the low risk group (N = 37) had mothers who were not overweight.(19) At age two the children showed no statistically significant differences in measurements of adiposity. By age four the BMI of the high-risk children was greater than the low risk children (p < 0.92). By age six, the fat mass in the high-risk group was even greater (p < 0.02) with approximately 30% classified as at risk for overweight or overweight as compared to only 0.04% of the low risk group. 

    Birth Size and Growth Velocity
    From the following studies we can begin to see a relationship between higher birth weight and faster growth in infancy, plus an increased risk for overweight later in childhood. 


  • In Brazil, a cross section of adolescents (N = 1,076) was identified as overweight. Birth and early growth and development records were analyzed and it was determined that birth weight was positively associated (p = 0.041) with overweight in adolescence. Males whose birth weight was 2,500-3,999 grams had a prevalence of at-risk for overweight of 20.2% and overweight of 8.2 %. If the birth weight was greater than or equal to 4,000 grams the prevalence was 30.9% and 16.4%, respectively. In females if the birth weight was between 2,500-3,999 grams then the risk for overweight was 19.5% and overweight was 6.0%. If the birth weight was greater than or equal to 4,000 grams then the prevalence was 38.5% and 15.4%, respectively.21 Rapid weight gain both between birth and 20 months and between 20 and 43 months was associated with overweight in adolescence.



  • In a study by Armstrong & Reilly, birth weight was significantly associated with overweight at three-to-four years of age. For example, children born at 3,000-3,999 grams had a prevalence rate of 7.4% for overweight. This doubled to 14.8% for children with a birth weight of greater than 4,000 grams.22



  • In 12 sites across the U.S., Stettler and colleagues (2002) evaluated 19,397 seven-year olds.23 The overweight prevalence was 5.4%. (This was for only seven-year olds, not an average of 6-11 year olds as stated previously.) An increased rate of weight gain in the first four months of life was also associated with an increased risk of overweight by age seven. For each 100 grams of weight gained per month the risk of overweight increased significantly by 30% (p < .001).


    Early Adiposity Rebound
    Early adiposity rebound is a good predictor of childhood, adolescent and adult overweight.24 Children who had an early adiposity rebound had higher adult obesity rates (25%) as compared with children with later adiposity rebound (5%). Adiposity rebound is when the BMI begins to rise again after reaching a nadir at four-to-six years of age. (See CDC growth charts.) 


  • If a child's BMI begins to climb before this time (four-to-six years), it is early and signifies a red flag and an opportunity for early intervention.



  • The Bogalusa study supports this with BMIs of two-to-five year olds moderately associated with adult adiposity (r = 0.33-0.41). Overweight two-to-five year olds were four times as likely to become overweight adults.25


    Eating and Feeding Behaviors
    The increased availability of energy-dense foods (those high in fat and sugars) has surely contributed to the epidemic of overweight in children. In addition, how parents manage feeding may require some rethinking. The following information supports some of the interventions recommended later.


  • Since 1977 there have been changes in the diet of preschoolers.26 The U.S. Department of Agriculture's Continuing Survey of Food Intake (N = 5,355) evaluates current eating habits of responders and their family members. The average energy intake (calories) per day has significantly increased from 1,389 calories in 1977 to 1,558 calories in 1994. Preschoolers now eat more saturated fat, juice and other added sugar drinks (p = 0.0014). 



  • In a study of two and three year olds (10,904), researchers found that children who were at risk of overweight or already overweight and consumed one-to-three sweet drinks a day were significantly (two times) more likely to become overweight.27



  • Parenting practices and the environment of the family may be facilitating obesity in our children.28 During infancy and early childhood, self-regulation of energy intake develops. In general, we know that children have a predisposition for sweet and salty flavors as opposed to bitter or sour tastes. Children tend to reject new foods/flavors initially. They can also learn associations between foods and the consequences that occur after eating them. Early childhood feeding practices can either facilitate this self-regulation or interfere with it. Strict parental control of feedings can foster preferences for high-fat, energy-dense foods as well as decrease the variety of flavors a child will accept. External regulation of food by parents can deter the child from responding to internal hunger and satiety cues. 



  • In 1987, the Framingham Children's Study began following 92 three-to-five-year-olds and their parents. Eating attitudes of the parents were evaluated and included dietary restraint and disinhibition. (Restraint is a measure of the control a parent exerts over her child's diet. Disinhibition is a measure of lability in eating behaviors and weight—for example, frequent dieting, restrictive and or binging behaviors as well as fluctuations in weight.) Over the six years these families were studied, children from the homes of parents who scored high on dietary restraint and inhibition had a greater change in BMI (4.0) than those whose parents had lower scores (2.0) (p = 0.003).29


    Television Viewing and Physical Activity
    As it is in adults, there appears to be a strong association between inactivity and overweight in children.


  • In children ages 8-16 years (4,063), those who watched more than four hours of TV daily had significantly higher BMIs (p < 0.001) than those who watched less than two hours per day.30 At increased risk are non-Hispanic black and Mexican-American girls.



  • In a prospective study of children for three years from ages three-to-four to ages six-to-seven years, only decreased physical activity and increased TV viewing were predictors (along with baseline BMI) of an increased BMI. The number of minutes of TV time was positively correlated with BMI (p < 0.05). The number of minutes of moderate to vigorous physical activity was negatively correlated with BMI (p < 0.05).31



    In a review of family-based interventions for childhood overweight, Berry et al. (2004) reported that of the 13 studies published on this topic, only three were large enough to have statistical power. Their results are described below.32 The age groups studied were varied, with a majority of Caucasian middle class participants. Most studies addressed interventions in older children (> 5 years old). Although the data is limited there seems to be support for behavioral interventions including behavior modification, problem-solving and behavior/family therapy. There is also support for involvement of parents and family in the endeavor of weight loss for the affected child. Of course, the behavioral interventions focus on issues related to nutrition and physical activity.

    Suggested Methods for Early Intervention
    At this time, we have very few studies on prevention or intervention, especially in the younger age group. Those we do have are plagued with methodological issues. Therefore, healthcare providers are left to a trial-and-error approach to the problem. 

    It is much easier to prevent a problem than to treat it, so the ideal interventions would begin early in a child's life. Watchful waiting is not a good option. One study from a pediatric endocrinologist's office demonstrated that by the time children were referred to them (9.5 years), the children had been overweight since preschool. The endocrinologists were also unsuccessful in addressing the problem at this stage.33

    Based on studies that have identified modifiable risk factors, the following recommendations for early intervention are worth pursuing.


  • Strongly encouraging breastfeeding may decrease the risk of later childhood overweight. 



  • Educating parents on paying careful attention to the infant's hunger and satiety cues helps develop self-regulation and decreases overfeeding. 



  • Infants naturally prefer the taste of sweet and salty foods—in order to foster healthy food preferences, fruits and vegetables must be offered multiple times. 



  • Avoid controlling food situations or using food as a reward. 



  • Parents are in charge of foods that children have available. Parents are also in charge of when the child will eat, for example distinct times for meals and snacks. Children are responsible for deciding if they will eat what is offered or not.34



  • Decreasing TV viewing time to less than two hours per day may conversely increase physical activity if opportunities are available. 



  • Families who are resistant to change may benefit from family counseling and working on areas that may be connected with eating behaviors.35

    Success So Far
    The fight is just beginning, but more doctors are discovering ways to offer real counseling to parents to help prevent and treat childhood overweight. There may be minimal results to report at this point, but as awareness increases, more programs will find success.


  • The first study is over 25 years old and involved 93 children. Researchers used a family based behavior modification intervention with overweight children 6-12 years old. The participants were divided into three groups—a parent-child group, a child group and a control group. All groups received education on calorie restriction, nutrition, exercise and behavioral management skills in a formal class setting. Participants also had contact with a therapist. Results showed no difference in percent of overweight in children but participating parents lost more weight than non-participating parents. Unfortunately this difference disappeared at 13 months. The only positive outcome was that those in the child-parent group were less overweight than the other groups, but this was not statistically significant.36



  • In 1998, Golan et al. asked one group of parents to take complete responsibility for weight loss of their child. In the other group the child was the change agent. 60 children ages 6-11 and their parents participated. Everyone received the same nutrition, physical activity and behavioral information. The group where the parent was the change agent lost significantly more weight than the other group.37



  • Floodmark et al. (1993) utilized family therapy as the intervention for 93 children and their parents. The groups were a conventional parent-child treatment group, a family therapy group and a usual care control group. Both treatment groups received dietary restriction counseling and exercise education. Those in the family treatment group received six family therapy sessions over one year. The children in the family therapy group had a significantly lower increase in BMI than the other groups (p < 0.04).38


    Julee Waldrop is a Clinical Associate Professor at The University of North Carolina in the Schools of Medicine and Nursing. She is currently working on her Doctorate in Education at North Carolina State University. She has worked in primary care pediatrics for 14 years and teaches nurse practitioner students, medical students and pediatric residents at UNC. 


    1. Speiser, P. W., Rudolf, M. C. J., Anhalt, H., Camacho-Hubner, C., Chiarelli, F., Eliakim, A. et al. on behalf of the Obesity Consensus Working Group. (2005). Consensus statement: Childhood obesity. The Journal of Clinical Endocrinology & Metabolism, 90(3), 1871-1887.
    2. Dietz, W. H. (1998). Health consequences of obesity in Youth: Childhood predictors of adult disease. Pediatrics, 101, 518-525.
    3. Freedman, D. S., Khan, L. D., Serdula, M. D., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (2005). The relation of childhood BMI to adult adiposity: The Bogalusa heart study. Pediatrics, 115, 22-27.
    4. Shinha, R., Fisch, G., Teague, B., Tamborlane, W. V., Banyas, B., Allen, K, et al. (2002). Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. NEJM 346(11), 802-810.
    5. Dietz, W. H. (1998). Health consequences of obesity in Youth: Childhood predictors of adult disease. Pediatrics, 101, 518-525.
    6. Ibid.
    7. Ibid.
    8. Strauss, R. (2000). Childhood obesity and self-esteem. Pediatrics, 105(1), 15.
    9. Falkner, N. H., Neumark-Sztainer, D., Story, M., Jerrery, R. W. Deuhring, T. & Resnick, M. D. (2001). Social, educational, and psychological correlates of weight status in adolescents. Obesity Research, 9, 32-42.
    10. Davison, K. K. & Birch, L. L. (2001). Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics, 107, 46-53.
    11. Ibid.
    12. Ogden, C. L., Flegal, K. M., Carroll, M. D. & Johnson, C. L. (2002). Prevalence and trends in overweight among U.S. children and adolescents, 1999-2000. JAMA, 288(14), 1728-1732.
    13. Armstrong, J., Reilly, J. J. & the Child Health Information Team. (2002). Breastfeeding and lowering the risk of childhood obesity. The Lancet, 359(9322), 2003-2004.
    14. Von Kries, R., Koletzko, B., Sauerwald, T., von Mutius, E., Barnert, D., Grunert, V. & von Voss, H. (1999). Breast feeding and obesity: cross sectional study, BMJ, 319(7203), 147-150.
    15. Gillman, M. W., Rifas-Shiman, S. L., Camargo, C. A., Berkey, C. S., Frazier, A. L., rocket, H. R. H. et al. (2001). Risk of overweight among adolescents who were breastfed as infants. JAMA, 285(19), 2461-2467.
    16. Whitaker, R. C., Wright, J. A., Pepe, M. S., Seidel, K. D. & Dietz, W. H. (1997). Predicting obesity in young adulthood from childhood and parental obesity. NEJM, 337(113), 869-873.
    17. Whitaker, R. C., Pepe, M. S., Wright, J. A. Seidel, K. D. & Dietz, W. H. (1998). Early adiposity rebound and the risk of adult obesity. Pediatrics, 101, 5-10.
    18. Strauss, R. & Knight, J. (1999). Influence of the home environment on the development of obesity in children. Pediatrics, 103(6),e85.
    19. Berkowitz, R. I., Stallings, V. A., Maislin, G. & Stunkard, A. J. (2005). Growth of children at high risk of obesity during the first 6 y of life: implications for prevention. American Journal of Clinical Nutrition, 31(1), 140-146.
    20. Speiser, P. W., Rudolf, M. C. J., Anhalt, H., Camacho-Hubner, C., Chiarelli, F., Eliakim, A. et al. on behalf of the Obesity Consensus Working Group. (2005). Consensus statement: Childhood obesity. The Journal of Clinical Endocrinology & Metabolism, 90(3), 1871-1887.
    21. Monteiro, P. O. A., Vicora, C. G. Barros, F. C. & Monteiro, L., M., A. (2003). Birth size, early childhood growth, and adolescent obesity in a Brazilian birth cohort. International Journal of Obesity, 27(10), 1274-1282.
    22. Armstrong, J., Reilly, J. J. & the Child Health Information Team. (2002). Breastfeeding and lowering the risk of childhood obesity. The Lancet, 359(9322), 2003-2004.
    23. Stettler, N., Zemel, B. S., Kumanyika, S., & Stallings, V. A. (2002). Infant weight gain and childhood overweight status in a multicenter, cohort study. Pediatrics, 109(2), 194-199.
    24. 17. Whitaker, R. C., Pepe, M. S., Wright, J. A. Seidel, K. D. & Dietz, W. H. (1998). Early adiposity rebound and the risk of adult obesity. Pediatrics, 101, 5-10.
    25. Freedman, D. S., Khan, L. D., Serdula, M. D., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (2005). The relation of childhood BMI to adult adiposity: The Bogalusa heart study. Pediatrics, 115, 22-27.
    26. Kranz, S., Siega-Riz, A. M. & Herring, A. H. (2004). Changes in diet quality of American preschoolers between 1977 and 1998. American Journal of Public Health, 94(9), 1525-1530. 
    27. Welsh, J. A., Cogswell, M. E, Rogers, S., Rockett, H., Mei, Z., Grummer-Strawn, L. M. (2005). Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999-2002. Pediatrics, 115(2), e223-e229.
    28. Birch, L. L. & Fisher, J. O. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101, 539-549.
    29. Hood, M. Y., Moore, L. L., Sundarajan-Ramamurti, A., Singer, M., Cupples, L. A. & Ellison, R. C. (2000). Parental eating attitudes and the development of obesity in children. The Framingham Children's Study. International Journal of Obesity Related Metabolism Disorders. 24(10), 1319-1325.
    30. Andersen, R. E., Crespo, C. J., Barlett, S. J., Cheskin, L. J. & Pratt, M. (1998). Relationship of physical activity and television watching with body weight and level of fatness among children. JAMA, 279(12), 938-942.
    31. Jago, R., Baranowski, T., Baranowski, J. C., Thompson, D. & Greaves, K. A. (2005). BMI from 3-6 y of age is predicted by TV viewing and physical activity, not diet. International Journal of Obesity, 29,557-564.
    32. Berry, D., Sheehan, R., Heschel, R., Knafl, K., Melkus, G. & Grey, M. (2004). Family-based interventions for childhood obesity: a review. Journal of Family Nursing, 10(4), 429-449. 
    33. Quattrin, T., Liu, E., Shaw, N., Shine, B. & Chiang, E. (2005). Obese children who are referred to the pediatric endocrinologist: characteristics and outcome. Pediatrics, 115, 38-351.
    34. Dietz, W. H. & Gortmaker, S. L. (2001). Preventing obesity in children and adolescents. Annual Reviews in Public Health, 22, 337-353.
    35. Jonides, L., Buschbacher, V. & Barlow, S. E. (2002). Management of child and adolescent obesity: physiological, emotional, and behavioral assessment. Pediatrics, 110, 215-221.
    36. Epstein, L. H., Wing, R. R., Koeske, R., Andrasik, F., & Ossip, D. J. (1981). Child and parent weight loss in family-based behavior modification programs. Journal of Consulting and Clinical Psychology, 49(5), 674-678.
    37. Golan, M., Weizman, A., Apter, A., & Fainaru, M. (1998). Parents as exclusive agents of change in the treatment of childhood obesity. American Journal of Clinical Nutrition, 67, 1130-1135.
    38. Flodmark, C. E., Ohlsson, T., Ryden, O., & Sveger, T. (1993). Prevention of progression to severe obesity in a group of obese school children treated with family therapy. Pediatrics, 91, 880-884.
    39. Freedman, D. S., Khan, L. D., Serdula, M. D., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (2005). The relation of childhood BMI to adult adiposity: The Bogalusa heart study. Pediatrics, 115, 22-27.
    40. Dietz, W. H. (1998). Health consequences of obesity in Youth: Childhood predictors of adult disease. Pediatrics, 101, 518-525.
    41. Rattay, K. T., Fulton, J. E. & Galuska, D. A. (2004). Weight counseling patterns of U.S. pediatricians. Obesity Research, 12(1), 161-169.
    42. Perrin, E. M., Flower, K. B., Garrett, J. & Ammerman, A. S. (2005). Preventing and treating obesity: pediatrician's self-efficacy, barriers, resources, and advocacy. Ambulatory Pediatrics, 5(3), 150-156.
    43. Ibid.
    44. Story, M. T., Neumark-Stzainer, D. R., Sherwood, K. H., Sofka, D., Trowbridge, F. L. & Barlow, S. E. (2002). Management of child and adolescent obesity: attitudes, barriers, skills and training needs among health care professionals. Pediatrics, 110(1), 210-214.
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