Care Coordination for the
Overweight and Obese Pediatric Patient - 4 Nursing CEs
Care Coordination for the Overweight and Obese
Pediatric Patient - 4 Nursing CEs Author: Patti Kelly RN BA CCNC
Course
Description
Overweight
and obese pediatric patients are at an increased risk for lower quality
of life, premature disability, and premature death. The epidemic of
overweight and obese children has resulted in a need to better
understand the physiological and psychological components of this
condition, along with treatment options. This course will begin with a
review of foundational knowledge, including the definitions of
overweight and obese, statistical prevalence, risk factors, and causes.
Physical and mental health implications will be highlighted. A
description of available resources will be reviewed, along with
discussion on determining the medical and nutritional soundness of
these resources. The course will conclude with a description of the
nurse’s role in providing care, education, and support to
children who are overweight or obese and their families.
Course
Objectives
Calculate Body Mass
Index (BMI)
Differentiate between
underweight, normal weight, overweight, and obese
Describe statistical
trends of the overweight and obese pediatric population
Identify risk factors
that predispose children to becoming overweight or obese
Identify causes of
childhood overweight and obesity
Describe short term
health implications of childhood overweight and obesity
Describe long term
health implications of childhood overweight and obesity
Describe psychosocial
implications of childhood overweight and obesity
List potential nursing
diagnosis for the overweight or obese pediatric patient
List and evaluate
community resource options for children and families
Describe potential
nutrition, activity and psychosocial lifestyle modifications
Identify medical
treatment options for the obese or overweight pediatric patient
Defining
overweight and obesity in the pediatric patient:
Body Mass Index (BMI)
is a screening tool that provides an indicator of the amount of body
fat an individual has. Height and weight are used to determine this
number.
BMI is an effective
screening method but is not a diagnostic tool. Accuracy is decreased in
individuals who have more or less than average amounts of muscle mass.
When there is a
question in BMI accuracy, other methods may be utilized. An example is
body composition analysis. This method estimates body fat through
measuring skin-fold thickness or determining mid upper arm area.
The formula used to
determine BMI using metric measurements is weight in kilograms divided
by height in meters squared.
Formula:
weight(kg)/[height(m)]2
The formula used to
determine BMI using English measurements is weight in pounds divided by
height in inches squared and then multiplied by a conversion factor of
703. Convert any fractions to decimals prior to calculation.
Formula:
weight(lb)/[height(in)]2 x 703
While BMI is calculated
the same for all age groups, the resulting number is interpreted
differently. Both sex and age are factors in determining a healthy BMI
for children and adolescents.
Growth charts,
available from the U.S. Center for Disease Control and Prevention
(CDC), are used to determine if a pediatric patient is underweight,
normal weight, overweight or obese.
Once BMI is calculated,
the number can be plotted according to age on the CDC growth chart.
Status
BMI Percentile
Underweight
<5%
Normal
5-85%
Overweight
85-95%
Obese
>95%
Trends
in Childhood Overweight and Obesity:
Childhood obesity is
one of the most serious public health challenges of the 21st century,
according to the World Health Organization (WHO). In 2005 the number of
overweight children under 5 years of age in the world was at least 20
million. In 2010 that figure is expected to more than double, reaching
42 million.
Overweight and obese
pediatric populations are no longer only a problem in high-income
countries, rates in low- and middle-income countries are also
increasing dramatically, especially in urban areas.
The prevalence of
childhood obesity in the United States has steadily increased over the
last thirty years. Data from National Health and Nutrition Examinations
Surveys (NHANES) demonstrates this increase in children with a BMI
>95%.
Ages
1976-1980
2007-2008
Increase
2 to 5 years
5%
10.4%
5.4%
6 to 11 years
6.5%
19.6%
13.1%
12 to 19 years
5%
18.1%
13.1%
According to 2007 data
from the U.S. National Survey of Children’s Health (NSCH),
over 30% of children age 10 to 17 were either overweight or obese.
Age
Underweight
Healthy weight
Overweight
Obese
10 to 17 years
5.2%
63.2%
15.3%
16.4%
Boys and girls age 10
to 17 years old have similar rates of overweight but boys have a higher
rate of obesity.
Underweight
Healthy weight
Overweight
Obese
Boys
5.8%
59.7%
15.3%
19.2%
Girls
4.5%
66.8%
15.2%
13.5%
Disparity among
racial/ethnic groups was noted in 2007 NSCH data.
Children 10 to 17 years
of age
Underweight
Healthy weight
Overweight
Obese
Hispanic
4.6%
54.5%
17.5%
23.4%
White
5.1%
68.1%
14.0%
12.9%
Black
4.7%
54.2%
17.3%
23.8%
Multi-racial
3.9%
62.1%
19.8%
14.2%
Other
10.7%
65.0%
12.0%
12.3%
Disparity among income
levels is statistically noted as well. Children living below
or slightly above the Federal Poverty Level (FPL) have a higher rate of
being overweight and obese than children living in more affluent homes.
Underweight
Healthy weight
Overweight
Obese
0-99% FPL
5.1
50.1
17.6
27.2
100-199% FPL
4.6
57.4
17.0
20.9
200-399% FPL
5.0
64.2
15.9
14.9
> 400% FPL
5.7
72.2
12.3
9.8
In
summary, both national and global data demonstrates that the number of
overweight and obese children in the world has increased substantially
in recent decades. National data indicates rate differences
related to gender, socioeconomic status, and race/ethnicity.
Risk
Factors for Childhood Overweight and Obesity
Behavioral,
environmental, parental, and genetic risk factors typically contribute
to a child being overweight or obese. It’s unlikely that one
particular risk factor is the only reason for obesity. Rather, a
combination of multiple risk factors contributes to weight gain and
retention.
Behavioral
Factors Excessive
intake of calories leads to obesity. Excessive intake is often the
result of:
Large portion sizes
Frequent snacking or
“grazing”
Consumption of calorie
dense foods
Consumption of
sugar-sweetened drinks
Fast food and eating
meals away from home
Unconscious eating
during “screen time”
Limited
physical activity and sedentary behavior result in decrease calorie use
and an overall lowering of the metabolic rate. Limited activity is the
result of:
Decreased participation
in physical education and athletic activities
Increased time spent
watching television, DVDs and videos
Increased time spent on
the computer and playing video games
Increased
overall screen time increases exposure to multiple food advertisements
which frequently encourage poor food choices.
Environmental
Factors
The size of portions
and the type of food offered to a child at home, childcare and school
influences both current food consumption and developing food
preferences.
Lack of opportunities
for physical activity at home, childcare or school decreases energy
output and can impact long term activity choices.
Socioeconomic
conditions in the home and community can influence children’s
access to healthy food and the availability of physical activities.
Lack of access to play
equipment, walking trails, and parks can increase the amount of time
spent indoors engaging in sedentary activities.
In communities where
there are safety issues, children’s activity levels may be
decreased because of an inability to walk to school and play outside.
Parental
Factors
Choosing to breastfeed
an infant provides a small but consistent amount of protection against
obesity, especially in early childhood.
Parental food
preferences directly influence those of their children. Parents who
have unhealthy diets generally have children with unhealthy diets.
Meal patterns, snacking
habits, and social eating behaviors are learned through observation of
other family members.
Lack of time due to
parental work schedules can often result in more consumption of fast
food and high calorie processed foods.
Parental work schedules
may also result in unsupervised children spending more time indoors and
less time engaged in active outdoor play
Children who are left
unsupervised may make unhealthy food choices and develop unhealthy
habits.
Inadequate sleep can
result in hormonal changes that lead to eventual weight gain.
Genetic
Factors
A
child’s BMI is directly linked to that of the biological
parents. A possible explanation for this is may lie in the belief that
the human body tends to store fat during times of surplus in order to
survive periods of scarcity. Individual variations of this evolutionary
factor could explain why some children are born with a genetic
predisposition to accumulate excess body weight and also why some
children lose weight at a slower rate than other children.
The
influence of heredity on basal metabolic rate (BMR) may result in up to
a 20% difference in the amount of calories utilized by an individual.
This can result in one child burning a significantly smaller number of
calories, both at rest and during exercise, than another child.
Causes
of Childhood Overweight and Obesity
~Energy Imbalance
caused by the existence of multiple risk factors is the most common
cause of childhood overweight and obesity. A thorough
assessment of an overweight or obese child should include a review of
risk factors to determine if excessive energy intake combined with
decreased energy output is resulting in fat storage, weight gain, and
weight retention.
~Eating Disorders
are another possible cause of overweight and obesity. While the exact
etiology of eating disorders is uncertain, they appear to be related to
a combination of biological, psychological, and environmental factors.
One common feature of eating disorders is that there is often an
underlying psychological or psychiatric factor such as anxiety,
depression, or low self esteem. There also tends to be significant
distress related to food behaviors and body appearance.
~Bulimia Nervosa
affects about 1.6% of adolescents. Bulimia Nervosa is manifested as
recurrent binge-purge behavior. Most of those affected are of normal
weight, but a minority are overweight or obese.
Binge –
Binges are often triggered by stress or emotional upset. Frequencies of
binges vary, escalating to multiple times daily. During a binge a large
amount of-generally high calorie-food is consumed in a very short
period of time. Thousands of calories may be consumed during one binge.
Patients report a sense of losing control and binges are usually
carried out in secret.
Purge –
Binges are immediately followed by purging behaviors. These include:
laxative and enema use, diuretic use, excessive exercising, fasting,
and induced vomiting.
~Binge Eating Disorder
(BED) presents with the same
persistent compulsive binges described above but lacks the purging
element. Large amounts of weight are gained and often obesity is
severe. ~Night-eating Syndrome
(NES) is demonstrated by a
persistent pattern of morning anorexia followed by hyperphagia in the
evening with insomnia. Food consumption is similar to a binge but is
over a longer duration of time. This disorder can also result in severe
obesity. ~Eating Disorder Not
Otherwise Specified (EDNOS)
is the diagnosis used for those eating disorders that do not meet all
of the specified diagnostic criteria required by the American
Psychiatric Association’s Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV). An example of an EDNOS would be when all
of the criteria for bulimia nervosa are met except that the recurring
binges occur less than twice weekly.
Psychological and
Psychiatric factors
frequently affect both food consumption and activity level. Emotional
upset can lead to an increased intake of high calorie
“comfort” foods. Distress may also result in
lethargy and withdrawing from physically active pastimes and turning to
more isolating, sedentary activities. The combination of these factors
can result in substantial weight gain. Consider the following when
assessing the overweight child or adolescent.
Anxiety disorders
Mood disorders
Depression
Family problems
Low self esteem
Poor coping skills
Peer problems
Stressful life events
like abuse, death, divorce and other losses
Medications
sometimes have an unwanted side effect of weight gain. A review of
medications can provide valuable insight. Certain categories of
medications are more prone to this effect.
Antipsychotics
Aripiprazole (Abilify)
Chrlorpromazine
(Thorazine)
Clozapine (Clozaril)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Mood
Stabilizers
Carbamazepine (Tegretol)
Lithium
Valproic Acid (Depakote)
Antidepressants
Carbamazepine (Tegretol)
Imipramine (Tofranil)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Steroids
Prednisolone (Pediapred)
Prednisone (Deltasone)
Dexamethasone (Decadron)
Medical conditions,
particularly some neurological and endocrine disorders, may result in
weight gain. Obesity is also a symptom in some genetic
syndromes. Assessment of the pediatric patient who is
overweight or obese should include an investigation for possible
medical causes.
Brain damage caused by
a tumor or an infection
Congenital Leptin
Deficiency
Hypercortisolism due to
Cushing’s syndrome
Hyperinsulinism due to
pancreatic tumors
Hypothyroidism
Prader-Willi Syndrome
(PWS)
Effects
of Childhood Overweight and Obesity
Approximately
300,000 preventable deaths may be attributed to obesity in the United
States each year. This makes obesity the second worse health hazard in
the country, preceded only by smoking. Health consequences once noted
only in adults are now seen with increasing frequency in the pediatric
population.
Short
Term Health Implications
Cardiovascular Disease
(CVD) risk factors are noted in obese children. In a population-based
sample, 70% of obese children had at least one CVD risk factor and 39%
had two or more risk factors. Risk factors included abnormal glucose
tolerance, high blood cholesterol levels and hypertension.
Diabetes Type 2 is
increasing among children and adolescents who are obese.
Metabolic Syndrome
occurs in 25-40% of children who are overweight, setting the stage for
heart disease and diabetes. The syndrome consists of insulin
resistance, elevated triglyceride levels, hypertension and access
abdominal fat.
Polycystic Ovarian
Syndrome (PCOS) is noted to have a higher incidence in girls who are
overweight and obese. CVD risk factors, abnormal menstrual cycles and
abnormal hormone levels are common manifestations of this syndrome.
Precocious puberty and
early menstruation is noted to have a higher incidence in girls who are
overweight and obese.
Sleep Apnea incidence
is an increasing complication of obesity in children and adolescents.
Oxygen levels fall dramatically during periods of sleep apnea.
Children
who are overweight or obese also have increased risks for
Pain in the knee, thigh
and hip (frequently related to slipped capital femoral epiphysis)
Pancreatitis
Severe headaches with
visual disturbances
Skin infections
(related to fungi trapped in skin folds)
Long
Term Health Implications
Overweight
adolescents have a 70% chance of being overweight or obese adults. If a
child has a parent who is overweight or obese, this chance increases to
80%. Overweight and obesity that continues into adulthood affects
multiple systems and increases the risks of many diseases and
conditions.
Arthritis (risk
increases by 9 to 13% for every 2 pound increase in weight)
Cancer (particularly
breast, colon, endometrial, gall bladder, kidney and prostate)
Pickwickian syndrome
(obesity, red face, hypoventilation and drowsiness)
Pulmonary Embolism
Reproductive disorders
(low plasma testosterone level in men; polycystic ovary syndrome,
infertility, and irregular menstrual cycles in women)
Skin infections
Increased
pregnancy specific complications include
Birth defects
(particularly neural tube defects such as spina bifida)
Difficult labor and
delivery
Gestational diabetes
High birth weight
infants
Overall maternal and
infant death rates are increased if a mother is obese during pregnancy
Childhood
overweight and obesity that continues throughout the lifespan can
result in the possibility of earlier manifestation of serious long term
health consequences. These may result in an increased incidence of
premature disability and death.
Psychosocial
and Metal Health Implications
The
risk of social and emotional problems increases when a child or
adolescent is overweight or obese. Children and adolescents who are
obese are often early targets of bullying and systematic social
discrimination. The most immediate result of being overweight reported
by children is social discrimination and low self-esteem.
The
resulting psychological stress can hinder a child’s academic
and psychosocial success. Underachievement and social discrimination
may persist into adulthood. The stress and resulting low self esteem
may serve as a precursor to eventual mood, anxiety and obsessive
compulsive disorders.
Quality of Life
(QOL) health related scores in obese children are as low as those of
young cancer patients on chemotherapy according a 2003 study published
in the Journal of the American Medical Association. A higher BMI also
correlated with parental reports of lower total QOL scores and also
lower QOL scores in the areas of physical functioning, social
functioning and psychosocial functioning.
Symptoms
like joint pain, fatigue and breathing problems affect not only how a
child feels but also the ability to play and participate in the same
activities as peers who have a healthy BMI. Also, necessary monitoring
and treatment of conditions like diabetes and hypertension create an
additional burden for kids already coping with challenging
developmental milestones. Gender specific conditions-such as precocious
puberty-present additional obstacles as children struggle to develop
identity and a positive body image.
Nursing
Diagnosis
Childhood
obesity is multifaceted, with numerous individual, family, cultural and
community aspects. These form an intricate belief system and behavior
pattern. Social discrimination, poor self esteem, denial, and feelings
of guilt can make discussions about weight difficult for children,
families and health care providers alike.
Acknowledging
the sensitivity of the subject and providing reassurance of self worth
regardless of weight may help nurses to encourage parents and children
to open up about the specific challenges that they are encountering.
A
thorough patient history, review of any concurrent medical and mental
health conditions, along with a physical assessment will culminate into
nursing diagnosis.
Activity Intolerance
Liver Function, risk
for impaired
Activity Planning,
ineffective
Fluid volume, excess
Diversional Activity,
deficient
Pain, chronic
Fatigue
Breathing Pattern,
ineffective
Insomnia
Health Maintenance,
ineffective
Lifestyle, sedentary
Health Maintenance,
impaired
Sleep Deprivation
Skin Integrity, risk
for impaired
Sleep Pattern, disturbed
Glucose, risk for
unstable blood
Cardiac Output,
decreased
Coping, ineffective
community
Anxiety
Coping, compromised
family
Body Image, disturbed
Loneliness, risk for
Coping, ineffective
Social Interaction,
impaired
Denial, ineffective
Social Isolation
Hopelessness
Development, risk for
delayed
Identity, disturbed
personal
Growth, risk for
disproportionate
Powerlessness, risk for
Health Behavior,
risk-prone
Self-Esteem, chronic low
Health Management,
ineffective self
Self-Esteem,
situational low
Knowledge, deficient
Spiritual Distress,
risk for
Noncompliance
Nutrition: more than
body requirements, imbalanced
Treatment
A
holistic treatment approach combined with extensive follow-up and
reevaluation increases the likelihood of successful long term weight
management.
Education
Individual
and family education can decrease anxiety, minimize guilt and provide
the foundation for behavior change. Reliable resources and discussions
regarding basic obesity facts and misconceptions can assist families in
discriminating legitimate, research-based information from expensive,
potentially dangerous fads with statistically unsupported claims.
Public
health officials, along with several other government and non-profit
agencies, have literature and websites devoted to health and nutrition
information for children and families.
Let’s Move
(www.letsmove.gov) is a nationwide initiative sponsored by the White
House to raise a healthier generation of children by improving
Information and tools
for parents
Food quality in schools
Access and
affordability of healthy foods
Amount of physical
activity
MyPyramid
(www.mypyramid.gov) is sponsored by the U.S. Department of Agriculture
and offers
Personalized food plans
Printable educational
materials
An online game and
activities
Food and physical
activity tracker
We Can!
(Ways to Enhance Children’s Activity and Nutrition)
(http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan) is a
national movement sponsored by the National Institutes of Health
designed to assist parents, caregivers and communities in helping
children stay at a healthy weight. The program provides parents,
caregivers, health professionals and communities with
Tools
Activities
Educational programs
Support materials
Training opportunities
American Academy of
Pediatrics
(http://www.aap.org/obesity) Prevention and Treatment of Childhood
Overweight and Obesity website offers the following online and
printable resource information for families, health care providers and
communities
Clinical tools
Audio files
Community funding
opportunities
Review
resources and have printed materials available for families and
children. Educational resources should provide clear guidelines and
opportunities for practice through games and activities. Resource
evaluation skills should be reviewed with patients, families, and
caregivers. Explain the increased pediatric health and mental health
risks of extreme diets, over the counter weight loss medications, and
the use of unregulated nutritional supplements. Encourage health care
provider involvement at all stages of weight management.
Nutrition
Education
The
overweight or obese pediatric patient with no medical conditions may
benefit significantly from dietary changes that promote healthier
eating. Key nutrition topics should be covered over the course of long
term education.
Consistent eating
patterns that include breakfast, small meals and selected snacks
Elimination of grazing
and unconscious “screen time” eating
Replacement of
processed, high calorie foods with healthy alternatives
Increased water intake
Decreased intake of
sweetened beverages (even those with fruit juice)
Increased
“sit down” family meals with decreased fast food
consumption
Utilization of the
basic food groups in meal planning:
Grains - at least half
of these should be whole grains
Vegetables –
encourage variety and vary preparation methods
Fruits –
fresh produce is preferred over those packed in syrup
Dairy –
cheese and yogurt are good alternatives for those who dislike milk
Meats – nuts
or beans may be substituted
Healthy portion size
with practice weighing and measuring food quantities
Healthy cooking methods
such as steaming, broiling, and decreasing the use of saturated fats
Benefits of writing
food choices in a food journal to raise consciousness about eating
choices and patterns
Reassure
patients and families that their current eating patterns did not
develop overnight and new habits will take awhile to establish as well.
A gradual move toward healthier habits is the goal, not instant
perfection. Feelings of shame and a history of repeated failed diet
attempts can result in hopelessness and a lack of follow-up. Emphasize
the importance of reporting challenges and repeated failed attempts to
a heath care provider so that additional evaluation, support, and
interventions can occur.
Registered Dieticians
(RD) can provide additional support, education, and nutritional
guidance. Patients who need to lose significant amounts of weight or
who are already manifesting medical or mental health complications-such
as diabetes or an eating disorder-need the insight of a healthcare
professional with specific training in pediatric nutritional
requirements.
Activity
Family
and patient education about physical activity can promote behavior
change and decrease risk factors. Physical activity counteracts many of
the negative health and mental health implications of obesity. Not only
does activity burn calories, it also increases overall BMR and may help
regulate appetite. In addition, activity increases feelings of well
being, decreases fatigue, and can decrease CVD risk factors. Increased
movement builds muscle mass and strengthens bones. Active children also
tend to sleep better at night.
Activity,
not exercise or athletics, may be the key element for attaining patient
cooperation. The obese or overweight child with low self esteem may
feel anxious about typical group sports, especially those that are
competitive. Routine active play time, spent bike riding or in a game
of hide and seek, can be just as beneficial as structured alternatives.
Discuss play options, challenges, and community resources- parks, YMCA,
or Boys and Girls Club-with children and families.
The
development of a progressive, child-based, activity plan may be
beneficial in decreasing the amount of time spent in sedentary
activities. Review activity interests and options with
children. Encourage creativity and include activities that are known to
decrease stress and promote relaxation like nature hikes, gardening,
dancing, yoga or martial arts. Once the list is developed, encourage
the child to work through the list, trying each activity several times.
A variety of activity options can eliminate boredom and reduce the
tendency to view activity as a chore.
In
the same way that a food journal increases awareness about consumption,
an activity journal can increase awareness about the amount of time
spent in sedentary activities like watching television and playing
video games. Once a baseline has been established, encourage the child
to set activity goals, gradually increasing the amount of time spent
being physically active. Ideally, children and adolescents should reach
the point of getting 60 minutes or more of moderate- to vigorous-
intensity physical activity every day.
Psychological
Support
Bullying,
social discrimination, isolation, and low self esteem are often a daily
reality in the lives of overweight and obese pediatric patients. Mental
health education topics should review options, warning signs, and
potential psychological complications.
Social support groups
Cognitive therapy
Psychotherapy
Stress management and
coping skill development
Depression signs and
symptoms
Eating disorder signs
and symptoms
Mood disorders
Anxiety disorders
Obsessive Compulsive
disorders
Emotional
support and treatment of the psychological complications of obesity can
help improve the child’s quality of life. Review local mental
health resources with the child and family.
Medical
Support
Medications
are not often utilized in children and adolescents as long term side
effects are currently unknown. However, there are medications that are
used in special circumstances.
Selective Serotonin
Reuptake Inhibitors (SSRIs) may be utilized in the treatment of some
depressive disorders and eating disorders
Sibutramine (Meridia)
is an appetite suppressant that has been approved in pediatric patients
16 years and older
Orlistat (Xenical)
prevents intestinal absorption of fats and has been approved for
pediatric patients 12 years and older
Bariatric
surgery is also uncommon in pediatric patients due to risk potential
and unknown long term effects. However, this may be considered if a
child’s weight poses a significant health threat.
Long
Term Outcomes
An
increase in the overweight and obese pediatric population has created a
need for broader nursing awareness of pediatric obesity assessment,
complications, and treatment options. The multifaceted nature of the
disease, along with socially integrated behavior patterns and belief
systems, necessitates an equally extensive intervention plan. Increased
understanding and thorough knowledge of available resources will help
nurses establish proactive policies, procedures, and plans for patient
care.
References
American Academy of
Child and Adolescent Psychiatry (2006). Facts for Families: Obesity in
Children and Teens. Retrieved on April 28, 2010 at: http://www.aacap.org/cs/root/facts_for_families/obesity_in_children_and_teens
American
Academy of Child and Adolescent Psychiatry (2008). Preventing and
Managing Medication-Related Weight. Retrieved on May 3, 2010 at: http://www.aacap.org/cs/root/facts_for_families/preventing_and_managing_medicationrelated_weight
American
Academy of Pediatrics (2010). Health Issues: Organic Causes of Weight
Gain and Obesity. Retrieved on May 4, 2010 at: http://www.healthychildren.org/English/health-issues/conditions/obesity/pages/Organic-Causes-of-Weight-Gain-and-Obesity.aspx
American
Academy of Pediatrics (2010). Health Issues: Your Overweight Child and
the Risk of Disease. Retrieved on May 4, 2010 at: http://www.healthychildren.org/English/health-issues/conditions/obesity/pages/Your-Overweight-Child-and-the-Risk-of-Disease.aspx
Battaglia,
C., De laco, P., Lughetti, L., Mancini, F., Perscio, N., Genazzani,
A.D., Volpe, A., de Aloysio, D. (2005). Ultrasound Obstet Gynecol,
26(6), 651-7. Retrieved on May 4, 2010 at: http://www.ncbi.nlm.nih.gov/pubmed/16254911
Child
and Adolescent Health Measurement Initiative (2007). 2007
National Survey of Children's Health, Data Resource Center for Child
and Adolescent Health website. Retrieved April 28, 2010 at: http://nschdata.org/DataQuery/DataQueryResults.aspx
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