Childhood Obesity Nursing CE Course

ling of fullness) can be affected by individual genes. For example, the hormone ghrelin is secreted by the stomach, and the small intestine secretes the hormone neuropeptide Y (NPY) in response to periods of fasting. These hormones are orexigenic, stimulating appetite through central nervous system (CNS) pathways that lead to the hypothalamus. The hypothalamus triggers additional neuronal pathways that lead to eating behaviors. Once eating occurs, the gastrointestinal (GI) tract secretes other hormones that signal satiety (i.e., insulin, somatostatin, cholecystokinin [CCK]). The release of CCK also slows gastric motility and emptying, stimulates gallbladder contraction, and triggers the release of bile and pancreatic enzymes for digestion. Somatostatin also slows gastric emptying; however, it decreases bile secretion in response to foods consumed and metabolic needs (Hinkle & Cheever, 2018). 

As adipose tissue increases, the secretion of leptin signals satiety to the hypothalamus. When patients with obesity lose weight, leptin levels decrease, which signals feelings of hunger. This decrease in leptin levels can persist long-term, contributing to rebound weight gain. The GI tract microbiota contains up to 100 trillion microbes that perform numerous digestive, metabolic, and immunologic functions. Researchers believe that the composition and diversity of these microbes may be connected to obesity. Patients with obesity tend to have less diverse microbes than those with a healthy weight. Less varied gut microbiota is also linked to dyslipidemia, impaired glucose metabolism, and low-grade generalized inflammatory disorders (Hinkle & Cheever, 2018).  

Risk Factors and Psychosocial Triggers 

Identifying the risk factors associated with childhood obesity can help to decrease the incidence. The risk factors for childhood obesity are multifactorial, including genetic (see pathophysiology section), physical, cultural, and environmental. Physical risk factors for obesity are related to a sedentary lifestyle. During the last decade, physical activity has declined due to increased screen time (i.e., smartphones, computers, televisions). Television watching or video game playing often replaces physical exercise. These behaviors can occur when the child is withdrawn or depressed and does not interact with peers. Researchers have found a connection between screen time and the overeating of non-nutritious foods. Advertised foods are often consumed more than unadvertised foods, leading to poor food choices. Most advertised foods are not healthy meal options. With feeding patterns being culturally driven, these factors can also be risk factors for obesity. Research has found that children develop their eating patterns at a young age, often determined by behaviors modeled by their parents or caregivers. Parental education about healthy food choices can positively influence healthy food choices in children. These poor food choices and overuse of screen time contribute significantly to the rise of obesity in children. During the COVID-19 pandemic, researchers found an increased risk of obesity due to the exponential increase in sedentary activities and screen time. Researchers have also found a connection between shortened sleep duration or irregular sleep patterns and the risk of obesity (Balasundaram & Krishna, 2022; Skelton & Klish, 2022; Tiwari & Balasundaram, 2022).  

According to Hemmingsson (2018), many environmental risk factors are known to impact the condition of childhood obesity. Researchers have found that obesity rates were higher in children living in low socioeconomic areas. Furthermore, lower socioeconomic status (SES) can negatively impact mental health, leading to depression, anxiety, and feelings of low self-worth, which are also linked to obesity in children. Emotional eating can lead to overeating and poor food choices. The most significant contributor to obesity in children with low SES is the lack of access to healthy foods and adequate exercise. This disparity is partly due to the lack of grocery stores with sufficient fresh vegetables and fruits and the lack of safe playgrounds (Balasundaram & Krishna, 2022; Hemmingsson, 2018). 

While low SES may be the most significant risk factor, Hemmingsson (2018) also discussed the presence of unhealthy family dynamics as another potential risk factor. In families where there is discord and dysfunction, children are found to be more at risk for obesity. This family dysfunction includes situations where there is neglect or emotional abuse. These situations can increase the risk of emotional eating, as previously mentioned. When a child is neglected, they are unlikely to be able to participate in activities that promote cardiovascular health. Children are also not primarily responsible for obtaining and preparing food. The parent or guardian controls this part of daily life, which can be negatively impacted in dysfunctional families (Hemmingsson, 2018).  

Hemmingsson (2018) identified the impact of stress on the child's eating habits and psychosocial development. Overusing junk food to ease the psychological burden is often seen in children of dysfunctional homes. Junk food, otherwise known as food with little nutritional value, is easily obtainable and often used to self-soothe when emotions are in turmoil. Once this habit is established, it becomes difficult to change. Therefore, living in a dysfunctional household increases the risk of junk food overconsumption. In addition to dysfunctional households, school-related stress can also affect the child's tendency to overeat or eat non-nutritious food. According to Nga et al. (2019), educational stress (deadlines, academic performance, and outside emotional situations) impacts students' healthy lifestyles from early childhood through adolescence. During a stressful episode, the body will excrete cortisol. Increased cortisol level causes an increase in appetite and cravings for foods higher in sugar and fat, which then results in food choices that are less nutritious, leading to more weight gain. This overeating affects girls much more frequently than boys (Hemmingsson, 2018; Nga et al., 2019). 

Hayes et al. (2018) identified a decrease in executive function in children who are obese. Executive functioning incorporates "inhibitory control, working memory, and cognitive flexibility" (Hayes et al., 2018, p. 11). When looking at control, the child with a high level of functioning can decline appealing food choices that are sugary or otherwise unhealthy. Working memory allows the child to synthesize the knowledge they have gained in education to make the best choice and understand how to develop a dietary or exercise plan that promotes health. Cognitive flexibility allows individuals to switch between unhealthy temptations and creatively substitute healthier options. Executive functioning has been well researched and leads to the ability to make healthy choices when confronted with unhealthy options. They also found that weight loss and physical exercise can improve one's executive functioning (Hayes et al., 2018).  

Additional biological factors can also increase the risk of childhood obesity. For example, research has found a connection between perinatal factors and the risk of obesity. These factors include high parental body mass index (BMI) in pregnancy, birth weight, child nutrition in the first 1,000 days of life, breastfeeding (protective) versus formula feeding, and weight gain in the first year. Certain medications can also cause weight gain in children, including antidepressants, antipsychotics, antiepileptics, glucocorticoids, progestins, antihistamines, alpha- and beta-blockers, and diabetic medications (e.g., sulfonylureas, insulin, thiazolidinediones; Balasundaram & Krishna, 2022; Hemmingsson, 2018). Corica et al. (2018) found that a familial correlation in childhood obesity does exist. This knowledge allows the provider to plan interventions more quickly when there is a strong suggestion of family history. Familial history is one aspect that is key to the onset of severe obesity, as well as endocrine disorders. Earlier onset of obesity suggests that the child will have significant lifelong weight issues (Corica et al., 2018). 

Defining and Measuring Obesity 

Obesity refers to excess fat; however, the methods used to measure body fat directly are not routinely available in clinical practice. Instead, HCPs assess obesity by evaluating the relationship between weight and height (i.e., anthropometrics). At well-child appointments, children are weighed and measured. Those measurements are then plotted on standardized growth charts individualized for males and females. The BMI is widely accepted as the standard measurement for determining overweight and obesity in children 2 years and older. BMI is calculated by dividing the weight in kilograms by the square of the height in meters. Although BMI does not measure body fat directly, it is correlated with direct measures of body fat, such as skinfold thickness measurements, dual-energy x-ray absorptiometry, bioelectrical impedance, and densitometry (i.e., underwater weighing). As children grow, the average BMI will vary with age and sex (CDC, 2021a; Skelton & Klish, 2022). In 2000, the National Center for Health Statistics and the CDC published reference BMI standards, using the CDC growth charts, for children ages 2 to 20 and were categorized as: 

• underweight: BMI <5th percentile for age and sex 

• average weight: BMI between the 5th and <85th percentile for age and sex 

• overweight: BMI between the >85th and 95th percentile for age and sex 

• obese: BMI ≥95th percentile for age and sex 

• severe obesity: BMI ≥120% of the 95th percentile value or a BMI ≥35 kg/m2 (whichever is lower; CDC, 2021a; Skelton & Klish, 2022) 

An expert panel that includes the American Medical Association (AMA), the CDC, and the Maternal and Child Health Bureau (MCHB) recommends that children with a BMI ≥95th percentile undergo an assessment for cardiovascular risk factors (National Heart, Lung, and Blood Institute [NHLBI], 2012). As children approach adulthood, the BMI thresholds for defining overweight and obesity will be the same as adults. The World Health Organization (WHO) has growth charts recommended for children younger than 2. The growth charts from the WHO are based on research regarding optimal growth in breastfed infants as opposed to historical data (Mukhopadhyay et al., 2019; WHO, n.d.). 

The validity and reliability of the BMI as a measurement of obesity have been called into question within the medical and fitness communities in recent years. Khanna and colleagues (2022) examined BMI to predict disease and health outcomes. They also reviewed how BMI correlates to other commonly used measures of obesity, such as waist circumference and waist-to-hip ratio. Amongst children, they found a positive association between elevated childhood BMI and cardiovascular death in adulthood based on a study of adolescents in Israel. Similar studies found a correlation between high childhood BMI and the incidence of type 2 diabetes and endometrial cancer in adulthood. They also point out significant limitations to using BMI to diagnose obesity: it cannot assess body fat percentage and may underestimate the variability in gender, age, and race. Those with higher muscle mass may be mistakenly categorized as overweight or obese due to an increased level of fat-free mass. They suggest the use of waist circumference along with BMI to increase its validity and accuracy (Khanna et al., 2022). A small study of just over 2,300 school-aged children in Switzerland found increased sensitivity when BMI and waist circumference were considered to predict the percentage of body fat versus either measure alone (Aeberli et al., 2013). 

History and Physical Examination 

Primary care providers play a vital role in screening for obesity in children. The USPSTF et al. (2017) found no evidence regarding the appropriate screening intervals for obesity in children. However, given that all children are at risk for obesity, screening is recommended for all children. When an HCP determines that a child meets the criteria for overweight or obese, a thorough history and physical are needed to determine etiology. HCPs should use a non-judgmental approach when talking with the child and family (Balasundaram & Krishna, 2022; Tiwari & Balasundaram, 2022). The evaluation of potential etiology and comorbidities should include: 

• behavior changes, such as extreme appetite or food-seeking behaviors 

• family history of obesity 

• family feeding patterns, meal composition, snacking, and screen time 

• a 24-hour diet recall, including the servings of vegetables, fruits, and high-carbohydrate foods 

• duration and type of physical activity 

• history of type II DM and hypertension; cardiovascular disease in the child and family 

• parental obesity 

• birth history, including intrauterine growth restriction (IUGR) and increased catch-up growth 

• head trauma (could suggest a hypothalamic cause) 

• easy bruising, fatigue, central obesity, and muscle weakness (could indicate Cushing syndrome) 

• cold intolerance, swelling of the neck, and dryness of the skin (could indicate hypothyroidism) 

• review current medications to look for drug-induced obesity 

• polyuria, polydipsia (could indicate DM) 

• anxiety and depression 

• worsening school performance or behavioral problems such as bullying 

• sleep disorders 

• irregular menses, hirsutism, and acne (indicating polycystic ovarian syndrome [PCOS]; Balasundaram & Krishna, 2022; Tiwari & Balasundaram, 2022) 

Physical examination should include an assessment of height, weight, and BMI. The HCP should complete a thorough head-to-toe physical examination looking for findings that could be causative of obesity or complications related to obesity (Balasundaram & Krishna, 2022; Tiwari & Balasundaram, 2022). In addition, laboratory tests may be indicated to evaluate for comorbidities associated with obesity, including: 

• dyslipidemia: low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol 

• metabolic syndrome, DM: fasting blood glucose and hemoglobin A1C (HbA1C) 

• nonalcoholic fatty liver disease (NAFLD): alanine aminotransferase (ALT) and aspartate transaminase (AST) 

• PCOS: luteinizing hormone (LH), stimulating follicle hormone (FSH), and free testosterone 

• hypothyroidism: stimulating thyroid hormone (TSH), free-T3, and free-T4 

• Cushing syndrome: serum cortisol (Balasundaram & Krishna, 2022; Tiwari & Balasundaram, 2022) 

Physical and Emotional Effects of Obesity 

Childhood obesity significantly impacts psychological and physical health. Certain diseases, such as type II DM and steatohepatitis, were historically considered adult diseases and are now regularly seen in children and adolescents with obesity. As obesity rates rise, the resulting comorbidities have physical, psychological, and economic implications across the US and worldwide. Obesity can impact every organ in the body, creating significant long-term effects (Balasundaram & Krishna, 2022; Skelton & Klish, 2021; Tiwari & Balasundaram, 2022). See Table 1 for common health conditions associated with obesity by body system.  

Prevention and Management Strategies for Obesity 

There is no single, simple solution to the obesity epidemic in the US. Instead, this complex problem requires a multifaceted approach that includes state and local organizations, policymakers, healthcare organizations, schools, and community leaders working together to create an environment that supports healthy living. The CDC recommends that obesity prevention be a community effort because children and adolescents are exposed to numerous care settings where healthy behaviors can be taught. Some community-based prevention strategies include (CDC, 2022c): 

• Improving early care and education (ECE) environments can directly impact healthy living. These environments can create a foundation of healthy habits by monitoring what children consume and how active they are.  

• Salad bar schools is a private-public partnership to engage stakeholders at various levels to sponsor and promote salad bars in schools.  

• Healthy food environments utilize policies and programs to create healthy environments in communities. Some of these programs include incentives to establish a healthy business in an underserved area, placing nutritional factors on restaurant menus, and implementing nutritional standards for childcare, schools, and worksites.  

• Healthy hospitals include obesity prevention efforts in these settings since they can impact large communities. 

• Physical activity community strategies include efforts to increase places where people can be active, such as walking trails, gyms, and parks. Additional approaches include community-wide education and enhanced school-based physical education programs.  

• Digital health interventions can increase healthy eating and physical activity.  

School systems and school nurses play an essential role in preventing childhood obesity. Children and adolescents spend significant time attending school; therefore, a comprehensive, school-based approach to addressing and preventing childhood obesity can impact healthy living. The CDC recommends that school systems adopt policies and practices to help children with healthy eating and increased physical activity. Research has shown that school-based obesity prevention programs are cost-effective and have successfully addressed childhood obesity, especially in elementary and middle school students. Schools can serve more fruits and vegetables, monitor portions, and limit foods and beverages high in added sugars or solid fats. These school-based programs can also have a meaningful impact on addressing weight-based stereotypes and creating a safe environment for students. The school nurse can address the complex physical, social, and health education needs of children who are overweight or obese. These nurses can create a health and wellness culture while partnering with families and HCPs (CDC, 2021b).   

General Approach to Weight Management 

The most successful prevention and management strategies for obesity in children focus on modifying behaviors that lead to excessive energy intake and insufficient energy expenditure. These behavioral strategies should focus on long-term behavioral change rather than short-term weight loss. Successful behavior change strategies for children and adolescents include:  

• Self-monitoring of target behaviors allows the child and family to identify behaviors contributing to weight gain using food and physical activity logs. HCP feedback throughout this process is essential.  

• Stimulus control includes reducing access to unhealthy behaviors, which helps to reduce environmental cues. 

• Goal-setting is a widely used strategy for behavior change. This approach involves setting measurable and realistic goals for healthy behaviors.  

• Contracting is an agreement to give a reward for achieving a specific goal (e.g., nutrition or activity). This approach provides structure to the goal-setting process.  

• Positive reinforcement involves giving a reward or praise for achieving a specific goal. The reward should be a small privilege or activity the child can frequently do instead of monetary incentives or toys.  

Additional strategies for weight management include patient- and family-centered approaches. The HCP should use a collaborative rather than prescriptive approach to behavior change. When the HCP allows the child and family to help choose the goals, they are more likely to be successful. The child should be directly involved in the decision-making process, as appropriate, based on their age. Sometimes this might include giving two healthy choices and allowing them to pick which one they prefer. Motivational interviewing is an effective counseling technique for obesity management. Motivational interviewing utilizes a non-judgmental, empathic, and encouraging approach to help patients identify their reasons for a behavior change. HCPs should encourage family involvement and avoid pressure or criticism whenever possible. In addition, the HCP should address potential economic and cultural factors that could limit the family's ability or willingness to change nutrition or physical activity. Discussions about childhood obesity can be difficult, and the HCP should avoid language that implies blame. Instead, consider initiating these discussions by acknowledging that some individuals gain weight more easily than others. This technique allows the HCP to recognize the role of non-modifiable factors such as genetics. Finally, HCPs should use terms like "weight" or "BMI" instead of "obese" or "fat" (Skelton, 2022).   

The USPSTF (2017) and the American Psychological Association (APA) clinical practice guideline panel (2018) recommend obesity screening for children and adolescents 6 years and older and offering prevention and treatment services. They recommend offering comprehensive, family-centered, intensive behavioral interventions to improve weight status. The USPSTF found that at least 26 contact hours over 12 months lead to weight loss in children and adolescents. Behavioral interventions totaling over 52 contact hours had more significant weight loss and improved metabolic and cardiac risk factors. The USPSTF defined intensive and comprehensive behavioral interventions as multi-component, including sessions with the parent and child alone and together, and information about safe exercising, healthy eating, reading labels, stimulus control, goal setting, and self-monitoring. They also found that supervised physical activity sessions are beneficial (USPSTF et al., 2017). 

Staged Approach to Weight Management 

The American Academy of Pediatrics (AAP) recommends a staged approach to weight management. With this approach, the initial stage of treatment is determined by the child's age, BMI percentile, and weight management history. The stages comprise varying degrees of supervision, counseling, and interventions. The PCP generally completes stages 1 and 2 of this approach. General obesity prevention should be performed on all children at each well-child visit and should include routine monitoring and brief counseling. Routine monitoring should consist of BMI measurements tracked over time (Skelton, 2022). In addition, HCPs should assess all children for obesity-related risk factors: 

• obesity in parents and other family members 

• dietary habits that promote weight gain 

• physical activity habits 

• sleep habits (Skelton, 2022) 

Routine obesity-related counseling for all children at well-child visits should include: 

• establishing healthy feeding environments, including family-based meals 

• encourage a diverse diet and meal-based eating; limit snacking, picky eating, and poor modeling by family members 

• encourage structured and unstructured physical activity and limit screen time 

• target recommended sleep time for each age group (Skelton, 2022; Tiwari & Balasundaram, 2022) 

Stage 1: Prevention Plus 

Stage 1 is for children over 2 years of age with excessive weight gain (i.e., BMI ≥85th percentile or rising sharply). Additional assessments in this stage include measuring and plotting BMI at each visit. HCPs should also assess the parents' weight status, indicating a genetic factor. HCPs should also evaluate for weight-related comorbidities with the review of systems, physical assessment, and laboratory monitoring described above. Stage 1 counseling education involves goal-setting and counseling focused on long-term changes. Goals should be selected collaboratively with the child and family, considering the family's finances, available caregivers, and schedule. HCPs should have educational materials and community resources available to share with the family. Stage 1 follow-up should occur between 1 and 3 months. Children 6 years and older with no improvement in BMI trend after 3 to 6 months should progress to Stage 2 (Skelton, 2022; Tiwari & Balasundaram, 2022). 

Stage 2: Structured Weight Management 

Stage 2 is for children 6 years and older with no improvement in BMI trend after 3 to 6 months. This stage involves more frequent visits, usually monthly, but can vary depending on the level of concern and availability. HCPs should be aware that greater intensity counseling is generally more efficacious. The HCP should work collaboratively with the child and family to set specific nutrition, physical activity, and weight goals. Nutritional goals are similar to stage 1, but counseling by the PCP or a dietician should include setting and tracking goals. Structured or restrictive dietary approaches are not used because these often lead to short-term weight loss and not long-term behavioral change. Physical activity goals in stage 2 should be more stringent, including limiting screen time to less than 1 hour per day and moderate or vigorous physical activity for more than 1 hour per day. Strategies for increasing physical activity should be individualized based on the child's age and ability. Specific weight loss goals are sometimes avoided because they can be misleading and vary as the child grows. If weight goals are set, they should be realistic for the child. Similar to stage 1, educational materials and community resources should be available to share with the family (Skelton, 2022; Tiwari & Balasundaram, 2022). 

Stage 3: Comprehensive Multidisciplinary Intervention 

Stage 3 of this approach is for children 6 years and older with severe or refractory obesity that requires management beyond the PCP office. This stage involves referrals to one or more services depending on the severity of the obesity, presence of mental health concerns, available resources, and affordability. Referrals in this stage can include a dietician, mental health providers (e.g., psychologist, school counselor, mental health therapist, or social worker), and subspecialists for management of comorbidities (e.g., cardiology, endocrinologist). A referral to a comprehensive weight management program may be beneficial because these programs provide nutritional and behavioral counseling while having expertise in pharmacotherapy and weight loss surgery options. Pharmacotherapy is used occasionally, but this option is limited by efficacy, tolerability, costs, and information on long-term safety in children (Skelton, 2022; Tiwari & Balasundaram, 2022). 

References 

Aeberli, I., Gut-Knabenhans, M., Kusche-Ammann, R. S., Molinari, L., & Zimmermann, M. B. (2013). A composite score combining waist circumference and body mass index more accurately predicts body fat percentage in 6- to 13-year-old children. European Journal of Nutrition, 52(1), 247–253. https://doi.org/10.1007/s00394-012-0317-5 

American Psychological Association Clinical Practice Guideline Panel. (2018). Clinical practice guideline for multicomponent behavioral treatment of obesity and overweight in children and adolescents: Current state of the evidence and research needs. https://www.apa.org/obesity-guideline 

Balasundaram, P., & Krishna, S. (2022). Obesity effects on child health. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK570613/#_NBK570613_pubdet_ 

Centers for Disease Control and Prevention. (2013). Genes and obesity. https://www.cdc.gov/genomics/resources/diseases/obesity/obesedit.htm 

Centers for Disease Control and Prevention. (2021a). Defining childhood weight status. https://www.cdc.gov/obesity/basics/childhood-defining.html 

Centers for Disease Control and Prevention. (2021b). School health services: Obesity. https://www.cdc.gov/healthyschools/obesity/index.htm 

Centers for Disease Control and Prevention. (2022a). Adult obesity facts. https://www.cdc.gov/obesity/data/adult.html 

Centers for Disease Control and Prevention. (2022b). Childhood obesity facts. https://www.cdc.gov/obesity/data/childhood.html 

Centers for Disease Control and Prevention. (2022c). Proven strategies: Community efforts. https://www.cdc.gov/obesity/strategies/community.html 

Corica, D., Aversa, T., Valenzise, M., Messina, M., De, L., Wasniewska, M., & Alibrandi, A. (2018). Does family history of obesity, cardiovascular, and metabolic diseases influence onset and severity of childhood obesity? Frontiers in Endocrinology, 9(May). https://doi.org/10.3389/fendo.2018.00187 

Hayes, J. F., Eichen, D. M., Barch, D. M., & Wilfley, D. E. (2018). Executive function in childhood obesity: Promising intervention strategies to optimize treatment outcomes. Appetite, 124, 10-23. https://doi.org/10.1016/j.appet.2017.05.040 

Hemmingsson, E. (2018). Early childhood obesity risk factors: Socioeconomic adversity, family dysfunction, offspring distress, and junk food self-medication. Current Obesity Reports, 7(2), 204-209. https://doi.org/10.1007/s13679-018-0310-2 

Hinkle, J. L., & Cheever, K. H. (2018). Textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.  

Khanna, D., Peltzer, C., Kahar, P., & Parmar, M. S. (2022). Body mass index (BMI): A screening tool analysis. Cureus, 14(2), e22119. https://doi.org/10.7759/cureus.22119 

Mukhopadhyay, S., Mondal, S., & Chatterjee, S. (2019). Strategies for prevention of childhood obesity. In Global Perspectives on Childhood Obesity (2nd ed., pp. 299-312). Academic Press. 

National Heart, Lung, and Blood Institute. (2012). Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. US Department of Health and Human Services. https://www.nhlbi.nih.gov/files/docs/guidelines/peds_guidelines_full.pdf 

National Heart, Lung, and Blood Institute. (2022). Childhood obesity. US Department of Health and Human Services. https://www.nhlbi.nih.gov/health/overweight-and-obesity/childhood-obesity 

Nga, V. T., Dung, V. N. T., Chu, D., Tien, N. L. B., Thanh, V. V., Ngoc, V. T. N., Hoan, L. N., Phuong, N. T., Pham, V., Tao, Y., Linh, N. P., Show, P. L., & Do, D. (2019). School education and childhood obesity: A systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 13(4), 2495-2501. https://doi.org/10.1016/j.dsx.2019.07.014 

Skelton, J. A. (2022). Prevention and management of childhood obesity in the primary care setting. UpToDate. Retrieved July 5, 2022, from https://www.uptodate.com/contents/prevention-and-management-of-childhood-obesity-in-the-primary-care-setting? 

Skelton, J. A., & Klish, W. J. (2021). Overview of the health consequences of obesity in children and adolescents. UpToDate. Retrieved July 5, 2022, from https://www.uptodate.com/contents/overview-of-the-health-consequences-of-obesity-in-children-and-adolescents? 

Skelton, J. A., & Klish, W. J. (2022). Definition, epidemiology, and etiology of obesity in children and adolescents. UpToDate. Retrieved July 5, 2022, from https://www.uptodate.com/contents/definition-epidemiology-and-etiology-of-obesity-in-children-and-adolescents? 

Tiwari, A., & Balasundaram, P. (2022). Obesity in pediatric patients. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK570626/ 

US Preventative Services Task Force, Grossman, D. C., Bibbins-Domingo, K., Curry, S. J., Barry, M. J., Davidson, K. W., Doubeni, C. A., Epling, J. W., Jr, Kemper, A. R., Krist, A. H., Kurth, A. E., Landefeld, C. S., Mangione, C. M., Phipps, M. G., Silverstein, M., Simon, M. A., & Tseng, C. W. (2017). Screening for obesity in children and adolescents: US Preventative Services Task Force recommendation statement. JAMA (Journal of the American Medical Association), 317(23), 2417-2426. https://doi.org/10.1001/jama.2017.6803 

World Health Organization. (n.d.). Child growth standards. Retrieved July 5, 2022, from https://www.who.int/tools/child-growth-standards