This chapter will address the following American College of Graduate Medical Education competencies: patient care and interpersonal and communication skills.

Patient Care: This chapter will help the pediatric health care provider deliver patient care that is individualized, evidence based, compassionate, and family centered by helping them understand the implementation of evidence-based nutritional interventions within the context of family readiness. In addition, this chapter will also help the pediatric health care provider develop an understanding of the environment and resources available in order to deliver individualized care for their patients.

Interpersonal and Communication Skills: This chapter will help the pediatric health care provider understand nutritional interventions based on accurate and sensitive assessment of a family’s behaviors and beliefs about food and feeding and use this understanding to communicate compassionately and effectively with the family.

Although the rapid growth rates of infancy and the toddler years slow during the preschool period, adequate and varied nutritional intake continues to be essential for proper growth and prevention of obesity. The preschool and school-age years can be a window of opportunity to encourage food acceptance and increase dietary variety, following the neophobic toddler years. Adequate and thorough nutritional assessment and review of dietary history by the pediatric health care provider are critical components of evaluating a child’s overall health status. This assessment is key to the formation and provision of appropriate anticipatory guidance to parents or caregivers about healthy nutrition and informs the prevention or identification of pediatric overweight or obesity. In this chapter, nutritional guidelines and anticipatory guidance for nutrition including tips for management of overweight and obesity will be provided. Primary care providers will learn to manage overweight and obesity for children between 3 and 12 years of age through the use of nutritional assessment and counseling, motivational interview, and stepwise evaluation and treatment recommended by the Expert Committee.¹

Close monitoring of growth by continuing to plot BMI is important in order to prevent and/or respond to significant rapid weight accelerations often indicated by crossing BMI percentiles. Parents may also need reassurance during this period, that is, it is normal for growth to slow with a corresponding decrease in appetite and intake that may vary greatly day to day. Children who have overweight or obesity during the preschool- and school-age period have a greater likelihood of becoming adults with obesity. This risk is increased in girls and if the child is older,^2,3 and is less for children with overweight than obesity. Results from a study by Guo et al predict the probability of having a BMI of 30 kg/m² or greater (defined as obesity) at 35 years of age based on body mass indices for childhood, and are summarized in Table 5-1.³

Children in this age group should continue to be offered 3 meals and 1 to 2 snacks a day. Parents or caregivers should continue to observe the “division of responsibility” in feeding first described by Ellyn Satter⁴ (and most successfully established during the infancy and toddler years). In this paradigm, the caregiver determines “what and when” to eat, and the child determines “how much.” Guidance should be provided to caregivers on appropriate portion sizes for preschool- and school-aged children (Table 5-2).

A balanced approach to healthy eating and food choices is the best long-term strategy for obesity prevention and treatment. Appropriate caloric intake for children aged 3 to 12 years is based on gender and activity level and can be found in the Dietary Guidelines for Americans, 2010, page 78, available at http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf. It is important to remember that calorie intake is only an estimate and careful evaluation of nutritional quality, eating habits, and micronutrient intake is essential to ensure a healthy eating plan. Dietitians can help with this as well as help families having difficulty with shopping, menu planning, and/or cooking strategies.

The child’s BMI and BMI z-scores should be monitored and change in BMI z-scores can be used to assess response to treatment and need to advance from Stage 1 to Stage 2 intervention.¹ For example, a child whose BMI is well above the 99th percentile and who loses weight will still have a BMI above the 99th percentile; however, there should be a decrease in the child’s corresponding BMI z-score. For example, the z-score may decrease from 2.5 to 2.4 with weight loss. In children whose BMI is above the 95th percentile, the change in BMI z-score should be monitored for decreases to evaluate a response to treatment. If there is not a decline in the BMI z-score, then the child is not responding and should be advanced to the next stage of intervention. Table 5-3 provides examples of Web sites that may be helpful for the clinician assessing growth and estimating calorie or nutrient needs, as well as online resources for families.

During obesity prevention and treatment, it is important to ensure adequate micronutrient intake. Special attention should be given to nutrients that are already at risk for deficiencies given typically low intakes of fruit, vegetables, dairy products, and whole grains commonly seen in children with overweight or obesity.^5,6 These include calcium, vitamin D, iron, vitamins A and C, and fiber. See Table 5-4 for recommended intake for preschool- and school-aged children, and the link to the complete description of the 2010 Dietary Reference Intakes (DRIs) can be found at http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.

Calcium and vitamin D

The DRI is a system of nutrition recommendations from the Institute of Medicine (IOM) of the US National Academy of Sciences. The DRIs for calcium and vitamin D were both increased in 2010 and assume minimal sun exposure.⁷ The requirement for calcium in children is now approximately equivalent to 3 cups of milk per day for ages 4 to 8 years and 4 cups of milk per day for ages 9 to 13 years.⁷ With excessive intake of sugar-sweetened drinks (soda, sports drinks, and other sweetened beverages), milk intake is often inadequate for this population, causing a high risk of calcium and vitamin D deficiency, which may compromise bone health.⁸ Vitamin D deficiency has been associated with higher BMI levels, thought in part to be because of sequestration of this fat-soluble vitamin in adipose tissue.⁹ Additionally, some studies have suggested higher calcium intake (particularly from dairy products) and increased serum vitamin D may lead to greater weight loss.^10,11

There are few foods naturally rich in vitamin D, and sun exposure alone is not a reliable source in some geographic locations and/or with persons with darker skin tone. The main sources of vitamin D are from fortified foods or supplements. Fortified dairy products (cow’s milk, yogurt, etc) are the most common sources of both calcium and vitamin D. For individuals with lactose intolerance, low-lactose sources are available including fortified soy milk, lactose-free cow’s milk, aged cheeses (such as cheddar or Swiss), and yogurt. There is a higher risk of dietary calcium deficiency in those with milk allergy, and/or who completely avoid cow milk protein.¹² Nondairy sources of calcium should be reviewed, including kale, bok choy, fortified fruit juice, fortified soy, and fortified rice milk.

For children who do not consume adequate servings of milk or milk products per day, supplementation should be considered.¹³ See Dietary Guidelines for Americans, 2010, Appendices 14 and 15 (pp 89-90) for food sources of calcium and vitamin D (http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf).

Vitamins A, C, and fiber intake

To maintain overall health and increase chronic disease prevention, it is recommended to consume a minimum of 5 fruit and vegetable servings daily.⁵ Americans 4 years and older do not consume the recommended servings of fruit per day⁵ and those 2 years and older do not consume recommended servings of vegetables.⁵ Because of this, intake of vitamin A, vitamin C, as well as other nutrients is at risk. Because a Stage 1 obesity treatment recommendation is to increase fruits or vegetables to 5 servings or more per day, intake of vitamins A and C and fiber will also increase, and the DRIs should be met with this intake. Fruits and vegetables are nutrient dense and naturally low in calories, so increasing to recommended levels is an effective treatment to lower calorie intake if substituted for unhealthy foods. However, if fruit and vegetable intake continues to be less than recommended or if there is doubt that a child is not meeting requirements, a multivitamin supplement designed for the child’s age group can be considered.¹⁴ See the following links for specific foods high in vitamins A and C:

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  http://ods.od.nih.gov.easyaccess2.lib.cuhk.edu.hk/factsheets/vitaminC-healthprofessional/ (Table 2)

  
  
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  http://ods.od.nih.gov.easyaccess2.lib.cuhk.edu.hk/factsheets/vitaminA-healthprofessional/ (Table 2)

Fiber

In treatment of individuals with obesity, slowly increasing fiber to recommended levels may aid in the feeling of fullness and promote normal bowel function.¹⁵ Dietary fiber will increase naturally as fruit, vegetables, and whole grains are increased. By following the American Academy of Pediatrics (AAP) recommendation to limit or reduce fruit juice intake (4-6 oz per day for children 1-6 years of age, 8-12 oz for older children)¹⁶ and replace juice with whole fruits instead, fiber intake will increase. Counsel parents on how to incorporate beans and peas into the diet, because these are some of the best sources of dietary fiber. See the following link for sources of fiber:

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  http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf (Appendix 13, p 88)

Iron

Obesity is a nontraditional risk factor for iron deficiency and this is an area of active research. Obesity is associated with low serum iron concentrations.^17,18 Therefore, iron levels in children with obesity, especially menstruating preteen and teenage girls, need to be monitored.¹⁹ Intake of iron-rich foods is encouraged, especially foods high in heme iron, which is more easily absorbed by the body. Heme iron sources include lean beef, turkey, and chicken. Adding vitamin C–rich foods to meals will increase absorption of nonheme iron, which is not well-absorbed, as well as meat protein. Nonheme iron sources include ready-to-eat fortified cereal, fortified oatmeal, and dried beans and lentils. Despite these recommendations, after clinically assessing iron status and intake of a patient, iron therapy may be needed. See the following link for food sources of heme and nonheme iron:

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  http://ods.od.nih.gov.easyaccess2.lib.cuhk.edu.hk/factsheets/Iron-HealthProfessional

Nutrition guidance is important to offer to all patients, but will have additional health-related benefits when offered to patients who have overweight or obesity. Children with a BMI in the 85th to 94th percentile for age and gender with evidence of health risk and children with a BMI at 95th percentile or greater should begin Stage 1 of the Expert Committee Recommended Stages of Obesity Treatment.¹ Stage 1, Prevention Plus, provides families with general guidelines for meal planning, choosing beverages, screen time, and physical activity. In this stage, the clinician works to involve the entire family, but also promotes the autonomy of the child. The child should have their weight measured on a monthly basis with a goal of weight maintenance and decreasing BMI with ongoing linear growth over time. If no improvement is seen in weight or BMI after 3 to 6 months and the family is willing, the child should be advanced to Stage 2, Structured Weight Management. Stage 2 encompasses all the recommendations of Stage 1, but provides more structure and accountability (Table 5-5) than Stage 1. Tracking intake, physical activity, and screen time with the use of logs is one of the major differences with the advancement to Stage 2. Goals of Stage 2 are similar to Stage 1. Guidelines regarding acceptable weight loss should be based on age. Similar to Stage 1, if no improvement is seen in weight or BMI after 3 to 6 months and the family is willing, the child should be advanced to Stage 3, Comprehensive Multidisciplinary Intervention.