EXPERT MONOGRAPH ISSUE 9 The Identification and Prevention … · 2020. 6. 17. · intake recommendations. Along these lines, recommendations for newborn feeds have been reduced from

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DR ROBYN LITTLEWOOD BSc, PGDipNut&D, MMedSc, PhD, GCEL

Dr Robyn Littlewood is the Director of Dietetics and Food Services at the Lady Cilento Children’s Hospital, Children’s Health Queensland and Co-Chair of the Queensland Child and Youth Clinical Network within the Clinical Excellence Division,

Department of Health. She owns a small private practice in Brisbane called Child Health in Life and Disease Dietetics (ChildD).

DR JACQUELINE WALKER B App Sc. (Ex and Sport Sc), B. Sc (Nutrition and Dietetics) (Hons), PhD

Dr Jacqueline Walker is a Research Fellow in Nutrition and Exercise at the School of Human Movement and Nutrition Sciences, The University of Queensland. She has been a paediatric clinical dietitian for eight years, and

worked in a variety of settings, including acute care (in major tertiary children’s hospitals), community settings and private practice.

This article discusses the proper identification and management of overweight and obese children in general practice.


Introduction

Nearly two-thirds (63.4%) of Australian adults and more than a quarter (27.4%) of all Australian children and adolescents are overweight or obese.1 In Queensland, the average adult has gained 4kgs in weight over the

past decade; young men gain on average 1.1kg and young women gain 0.7kg each year.2 Overweight Queensland adults generally need to lose approximately 7kgs to reach a healthy weight range and obese Queenslanders need to shed approximately 28kgs to reach the same healthy weight range.2 Nationally, all states and territories report very high overweight/obesity rates, ranging from between 61.6% (NSW) to 66.1% (SA).3

Internationally, obesity has more than doubled since 1980. The World Health Organisation (WHO) reports that 52% of adults aged eighteen years and over, and approximately forty-one million children under the age of five, were overweight or obese globally in 2014.4

EXPERT MONOGRAPH ISSUE 9

The Identification and Prevention of Obesity in Children

Take Home Messages

` Many of us have changed our perception and have become much more tolerant of people ‘at risk’ of obesity, including ourselves.

` Clinically, as per 2013 NHMRC recommendations, the WHO growth charts should be used to track children from birth to two years of age.7

` Linear growth will generally follow a similar pattern for all infants, regardless of feeding method.

` As health professionals, we need to make a personal effort to be a part of the solution in order to support our patients. The factors contributing to obesity require further awareness and they can and should be addressed by everyone

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Hormonal Contraception Trouble-shooting Part One: The Overweight Woman



Furthermore, this problem is affecting the regular health challenges faced by many developing countries (such as infectious diseases and malnutrition), particularly in more urban environments. ‘It is not uncommon to find under-nutrition and obesity existing side-by-side within the same country, the same community and the same household.’4 The WHO terms this the ‘double burden’ of disease.

In Australia, we are living in an obesogenic environment. This is defined as ‘an environment that promotes gaining weight and one that is not conducive to weight loss‘ within the home or workplace.5 As a nation, there are a multitude of factors that affect our obesity rates and an improvement in these statistics will only be achieved with multi-faceted, cross-government policies.

As health professionals, we need to make a personal effort to be a part of the solution in order to support our patients. The factors contributing to obesity require further awareness and they can and should be addressed by everyone.

Defining Growth and Obesity and Using the Right Growth Charts

Definitions

There are several definitions for overweight and obesity in paediatrics in Australia, all of which are traditionally accepted.

a. Cole and Lobstein,6 as part of the International Obesity Task Force, developed recommended cut-off points for body mass index (BMI) for children and these are aligned to the corresponding adult BMI cut-off points. A table has been created to allow health professionals to easily define overweight or obese children. The cut-offs also include categories relating to the severity of obesity (e.g. a BMI of ≥35 for morbid obesity).

b. In 2013, the National Health and Medical Research Council (NHMRC) recommended that being overweight or obese in childhood and adolescence should be defined through the use of growth charts. Specifically, it recommended that the WHO growth charts should be used from birth to two years of age, and WHO or Centres for Disease Control (CDC) growth charts should to be used for those aged two to eighteen years (but the same chart is to be used for serial measurements).7 It should be noted that at this time, the WHO and CDC have not defined morbid obesity in children.

i From birth to two years, using WHO growth charts, being overweight can be defined as a BMI at or above the 85th and under the 97th percentile. Obesity is defined as a BMI at or above 97th percentile.7

ii. From age two to eighteen years, using WHO growth charts, being overweight is defined as having a BMI at or above the 85th percentile and under the 97th percentile. Obesity

is defined as a BMI at or above 97th percentile. From age two to eighteen years, using CDC growth charts, being overweight is defined as having a BMI at or above the 85th and under the 95th percentile, and obesity is defined as having a BMI at or above 95th percentile.7

The BMI growth charts are published in the various types of personal health records and are also available online: www.who.int/childgrowth/standards/en/ (WHO)8 and www.cdc.gov/growthcharts/cdc_charts.htm (CDC).9

It is not uncommon to find under-nutrition and

obesity existing side-by-side within the same country, the

same community and the same household.4

Growth Charts

The CDC growth charts have been used routinely across Australia. These charts were released in 2000 and the data was based on the growth of children in the United States between 1963 and 1994 (via five national surveys).9 The CDC growth charts are known as a ‘growth reference’, as they describe how these children grew at a particular place and point in time.9

The WHO growth charts are currently being implemented throughout Australia. These charts (often called the ‘Breastfeeding Charts’) were released in 2006 and are based on significant data (longitudinal data for the age range of birth to two years, n=1743, and cross-sectional data for the age group twenty-four to forty-nine months, n=6669, from six sites, including Brazil, Ghana, India, Norway, Oman and California).8 The WHO charts are known as a ‘growth standard’ as they represent how children should grow, as subjects were chosen according to specific health behaviours that favoured full growth potential. They establish the breastfed infant as the normative model, and provide a single international standard that represents the best description of growth and development.8

Clinically, as per 2013 NHMRC recommendations, the WHO growth charts should be used to track children from birth to two years of age.7 As stated by the WHO, these charts ‘can be applied to all children everywhere, regardless of ethnicity, socioeconomic status and type of feeding’8. Breastfed infants tend to have a different growth pattern to that of a formula-fed infant. The average weight gain over the first year of life for a breastfed infant is lower than



that of a formula-fed infant, and formula-fed infants typically gain weight at a faster rate after about 3 months of age. Linear growth will generally follow a similar pattern for all infants, regardless of feeding method. GPs need to understand these differences when measuring infants, plotting their growth and applying clinical judgement. By measuring all children using the WHO growth chart, which establishes the breastfed infant as the normative model against which all other infants are compared, we can establish and ensure a better long-term growth pattern for all children. The use of the WHO charts will decrease the long-term risk of overweight and obesity for all children10, which is most critical in Australia, where obesity is a growing problem. The WHO growth charts are now included in the personal health records.

From two to eighteen years of age, it is recommended either chart can be used, but the same chart should be used to monitor growth over time to allow for the identification of trends and obesity.7

Breastfeeding in Australia

At least 92% of Australian new mothers were initiating breastfeeding at birth, however, dropout rates are very high. According to the Longitudinal Study of Australian Children (LSAC) 2008 Annual Report,11 an average of 88% of babies are breastfed at one month of age, 70% at three months and an average of 53% are continuing to breastfeed at six months, and only 14% of babies are still fully breastfed at this age. In comparison, in Norway 95% to 97% of babies are breastfed at one month of age and 80% are continuing to breastfeed at six months.12

The links between breastfeeding and the development of obesity has been of interest for some time. In addition to the significant health benefits that breastfeeding holds for the mother, the benefits for the baby include optimal growth and protection from diarrhoea and respiratory infections.13 It is well-known that children and adolescents who were breastfed as babies are less likely to be overweight or obese, and perform better in intelligence tests.13

In Australia, our focus when it comes to breastfeeding needs to be on targeting and improving the dropout rates. GPs need to be able to support mothers to overcome the challenges that they may face when breastfeeding. Nipple and breast pain, and milk supply adequacy are two common concerns that women will raise with their GP.14 It is essential for doctors to be able to provide mothers with helpful tips and information, or to direct them to other sources of information and support. Services such as the Australian Breastfeeding Association or the support of a lactation consultant, if available, can offer women the practical advice they need to continue breastfeeding.

Infant Formulas

The steady growth of infants along the same centiles is always the goal. For formula-fed infants, it appears that lower protein

intakes are associated with slower, more consistent and safer weight gain.15-17 As a result, many infant formula companies have made some significant changes to both their formula composition (decreasing protein content by 10% to 13%) and to the daily intake recommendations. Along these lines, recommendations for newborn feeds have been reduced from seven to nine feeds per day to seven feeds per day. Babies over six months have had their feeds reduced from four to five feeds to specifically four feeds per day. These suggestions are displayed on product websites and the product packaging. These are very positive changes towards obesity prevention in Australia and have resulted from a number of well-known studies investigating the protein content of formula and weight gain. Specifically, in these studies, babies were assigned to low protein and high protein groups and there was a comparison breastfeeding group. The resulting weights were then examined. Clear outcomes indicated that infant length was not significantly changed, however, weight increased significantly in the higher protein groups. Furthermore, slower, more consistent weight gain was seen in breastfed groups, and this was very similar to babies who had lower formula protein intakes.15-17

It is preferable to use an infant formula with a lower protein

concentration if the decision has been made not to breastfeed

The NHMRC Infant Feeding Guidelines recommend that it is preferable to use an infant formula containing a lower protein concentration for healthy term infants if a decision has been made not to breastfeed. Knowing that 1.3g/100ml is the lowest permissible level of protein as set by the FSANZ, GPs can instruct parents on how to find this information on the product label. This would apply to looking for this level across all infant formula including starter infant formula and follow on infant formula. Alternatively, if this is too difficult for the parents to cope with, a list of the different brands may be offered.

A recent systematic review18 investigating children from birth to two years reported that the strongest associations for childhood obesity include the mother being overweight pre-pregnancy, a high infant birth weight and rapid weight gain in the first twelve months of life. They also found that there was a 15% decreased risk of a child becoming overweight when breastfed as an infant, compared to not being breastfed.18 Although the evidence is not yet conclusive about the length of breastfeeding that confers the greatest benefit, these risk factors are identifiable, and can be addressed at the primary healthcare level to help protect against the development of children being overweight or obese.

Screen Time and Activity Recommendations

Overall, increased electronic screen time is associated with feelings of loneliness and withdrawal, a greater intake of unhealthy foods, increased rates of obesity, less sleep and higher cholesterol levels.19 Furthermore, in 2016, NSW Health reported that 92% of students aged twelve to seventeen years watched television, used the Internet or played computer games more than the recommended two hours a day.20 Screen time limits are recommended to be two hours per day (for entertainment purposes) for children and adolescents.21 Too much screen time has been shown to impact aspects of child development and to result in poorer social behaviours, poorer academic results and a slower overall development of the brain.18, 22

Australia’s Physical Activity and Sedentary Behaviour Guidelines (released in 2014) detail the appropriate amount of daily physical activity and screen time according to age.21 We know that the majority of Australian children and adolescents are not meeting these Guidelines.23 The difficulty remains: How do we get families and children to be more physically active and decrease their sedentary behaviours? More often than not, screen time is displacing opportunities for physical activity, and parents are facing an uphill battle, not only with the increased range of electronic media devices available, but also the use of these devices in teaching and learning.

GPs need to support these recommendations, and to discuss with children, adolescents and families what activities should be done every day, and how screen time can be limited. Some suggestions are detailed below:

a. Empower families to limit screen time (for leisure) to two hours per day.

In order to initiate change and to improve habits within the home environment, parents need to be role models and set an example. For families to reach the goal of two hours or less of screen time per day, parents will need to limit their own screen time. Families should be encouraged to plan ahead and set goals, such as reviewing favourite TV shows and setting up a TV viewing schedule for the week. Certain rules should be initiated, such as no electronic media in bedrooms, all phones and tablets to be returned to a central charging station by a certain time each night and no meals to be eaten in front of the TV. Parents to may need to purchase a bedside alarm for their offspring so no child or adolescent needs to have their phone in their room.

b. Set an activity target to burn 100kcals/day or do twenty minutes of activity.

Children and adolescents between the ages of five and seventeen should be physically active for at least sixty minutes per day, at a moderate to vigorous intensity.21 This exercise time can be accumulated across the day, and simply encouraging a family to set activity targets can be a good way to start. Have

an easy to understand chart to share containing what activities expend energy.

Introduce new ideas and goals slowly, as it takes time for habits to be incorporated into everyday life. Small, sustainable changes in behaviour are critical to achieving long-term outcomes.

Health Claims, Industry and Marketing

There is a lot of discussion in the media about fad diets, super foods, supplement drinks, new food products and the marketing of health claims. There is a continuation of popular trends such as low carbohydrate diets, coconut products, juice bars, yoghurt bars, salad bars and confusing food labels (such as ‘cholesterol-free avocados’). Many of our patients want to be healthier and, given all this marketing, may become confused about what they should be doing. It is critical to empower your patients to make informed decisions by:

a. Advising limits on what a regular meal should provide.

This will depend on the gender, age, weight, activity level and medical history of the patient. For example, a ten-year-old boy, weighing 32kg and 1.4m tall, who is quite sedentary, and consuming approximately 1700kcal per day, might be recommended to have 300-400kcal meals three times daily and 150-200kcal for snacks, three times daily. This should encourage informed decision-making about products.

b. Understanding food content and talking about this with your patients.

For example, commercial muffins can contain 23g fat, a glass of juice contains eight teaspoons of sugar, a low-fat juice bar drink can provide over 450kcals (more than a meal) and an average size skim milk cappuccino provides over 100kcals. This information is not, and should not be, restricted to the educated individual, but is something that everyone should understand.

c. Recommending smartphone apps to count calories regarding meals and physical activity.

Patients need to understand the science behind nutrition and activity to achieve and maintain a healthy weight. These apps can also be used as motivational tools that may be particularly useful as an accountability measure or to encourage adolescents to move more.

Talking to Patients about Overweight and Obesity

Do we avoid the subject of obesity with our patients, or do we not recognise obesity when we see it? Could it be possible that our norms have changed?



Refer to the photographs below. Would you define this child as underweight, normal weight, overweight or obese?

©Copyright 2016 ChildD – reproduced with permission

This child is of normal weight and is fourteen years old; he weighs 53kg and is 165cm tall. He is close to the 50th percentile for weight, height and BMI. This is what a child of a healthy weight looks like. It has been said that ‘few medical conditions can be diagnosed as confidently by untrained individuals as gross obesity’.24 Identifying overweight children may be made more difficult by the age-related physiological variations.24 See below for examples of where the definition of healthy or normal weight, overweight and obese can be challenging25:

© Copyright 2016 Centers for Disease Control and Prevention – reproduced with permission

The child in the photograph on the left is classified as overweight, the child in the photograph in the middle is classified as healthy or normal weight, and the child in the photograph on the right is classified as obese25.

A child’s growth should ideally be measured whenever possible by health professionals. GPs must promote and support the acceptance of weight monitoring as normal in community healthcare delivery.2 Consider weighing the child routinely at each appointment. This is to reduce associated anxiety from the presenting patient and their family, and normalise the procedure.

It is recommended that when performing anthropometric measurements, plotting these measurements to gain an accurate description of the weight and height is critical. We need to be aware that our perceptions of what is now a healthy weight may

no longer be reliable, as society norms have changed. It is essential to use the above evidence-based tools (WHO/CDC growth charts) and definitions accurately, in combination with appropriate clinical judgement. Once we have this objective information, health professionals should provide the following support and leadership, ensuring all families have access to the appropriate information. GPs need to educate parents and help them to understand that changes in family lifestyle factors is the best way forward. Even so, everyone needs to acknowledge that there is a level of personal and parental responsibility about this issue.

It is often difficult to comprehend, but many parents report that they were never aware that their child was overweight or obese. Health professionals need to have the hard conversation and keep an open dialogue about weight. Overall it should be a positive experience, both for the family and the professional. For example, ‘Let’s plot John’s weight together. John’s weight is in the very, very overweight range, in fact, medically we call this the ‘obese range’. Did you want to talk a bit more about this today?’ or ‘It’s great that you have identified this as an issue as this is the right time to get on top of it. The nice part about this problem is that it is fully reversible/fixable, and that all family members can work together to make changes to benefit everyone. Well done to you and your family for addressing this now’. Talk about John’s weight, height and BMI as modifiable factors, rather than talking about John himself is recommended. This is a discussion around measurements and facts, being objective rather than subjective and emotional. Often a sensitive approach works well, ensuring that no parties are blamed for the situation. This conversation may happen over a number of appointments, or sometimes can be addressed in a single appointment – every family is going to be different. Each encounter should always be concluded with an action plan and it is wise to ask the family and child how they feel about what has been discussed.

In summary, we are at crisis point regarding the average weight of Australians. Most of us are overweight or obese. Health professionals play a key role in paediatric obesity prevention and management, but only if they act on this. The authors propose that many of us have changed our perception and have become much more tolerant of people ‘at risk’ of obesity, including ourselves. Specifically, as health professionals, it is our duty of care to prevent and manage obesity prevention whenever possible.

To summarise, the authors propose the following recommendations be considered for implementation within each clinical setting including primary, secondary and tertiary healthcare when reasonable. These include:

1. That health professionals understand the definition of obesity and use the correct growth charts to identify overweight and obese patients in paediatrics.

2. Discuss being overweight or obese with patients. This should be a very sensitive, supportive and hopefully positive experience.

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3. Promote and support breastfeeding, particularly the continuation of breastfeeding throughout the first six months of life. Target potentially manageable reasons for failure and understand why these occur.

4. If a decision has been made to use infant formula for feeding, support and encourage the choice of lower protein formulae.

5. Empower families to understand and acknowledge that it is ok to limit screen time. Give some activity targets, but encourage that this be shared with the family.

6. Have a good understanding of health industry claims and be ready to talk through these with your patients. Provide the facts around these claims and explain errors.

Most importantly, personally feel empowered to tackle obesity.

The final words of Dr David Rosengren (Chair of the Queensland Clinical Senate) and Mark Tucker-Evans (Chair of Health Consumers Queensland) in the 2015 Queensland Clinical Senate Meeting Report entitled, ‘Every k over is not okay – Putting the brakes on obesity’ are significant and fitting:

‘By raising awareness of the problem, identifying strategies that can have an impact and demonstrating leadership, we can drive a prevention and intervention agenda for our future generation. We must all step up and take responsibility’ (page iv)2.

Declaration

Dr Robyn Littlewood was commissioned by Healthed for this article. The ideas, opinions and information presented are solely those of the author. The advertiser does not necessarily endorse or support the views expressed in this article.

Dr Robyn Littlewood and Dr Jacqueline Walker do not endorse any of the advertising surrounding this article, and do not receive any funding or incentives from the advertisers.

The authors’ competing interests statements can be viewed at www.healthed.com.au/monographs.

References

A list of references is included in the website version of this article.Go to www.healthed.com.au/monographs

1. National Health Survey Australian Bureau of Statistics. National Health Survey First Results Australia 2014-2015. Canberra; 2015. 51 p. ABS Cat. No. 4364.0.55.001.

2. Queensland Clinical Senate. Every k over is not okay – Putting the brakes on obesity. Queensland Health; September 2015. 18 p. Available online at: https://www.health.qld.gov.au/publications/clinical-practice/engagement/qcs-meeting-report-201507.pdf

3. Department of Health. Measured obesity in Queensland 2011-12. Brisbane: Queensland Health; September 2013. 8 p. Available online at: https://www.health.qld.gov.au/__data/assets/pdf_file/0015/442140/measured-obesity.pdf

4. World Health Organization. Obesity and Overweight: Fact Sheet [internet]. WHO; June 2016 [cited 2016 Oct 22]. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/

5. Swinburn B, Egger G, Raza F. Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Preventative Medicine. 1999 Dec; 29(6 Pt 1): 563-570

6. Cole TJ, Lobstein T. Extended international (IOTF) body mass index cut-offs for thinness, overweight and obesity. Pediatr Obes. 2012 Aug; 7(4): 284-294

7. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: National Health and Medical Research Council; October 2013. 202 p. Available online at: https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57_obesity_guidelines_140630.pdf

8. World Health Organization. The WHO Child Growth Standards [internet]. Geneva: WHO. [cited 2016 Oct 22]. Available from: http://www.who.int/childgrowth/standards/en/



Video Resources

Reducing Obesity and Diabetes Risk by A/Prof Adrienne Gordon

Watch the full lecture on the Healthed website. Visit www.healthed.com.au/video

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Hormonal Contraception Trouble-shooting Part One: The Overweight Woman



9. Centers for Disease Control and Prevention. CDC Growth Charts [internet]. December 2016. [cited 2016 Oct 22]. Available from: http://www.cdc.gov/growthcharts/cdc_charts.htm

10. Grummer-Strawn LM, Reinold C, Krebs NF, Centers for Disease Control and Prevention. Use of the World Health Organisation and CDC growth charts for children aged 0-59 months in the United States. MMWM Recomm Rep. 2010 Sep; 59(RR-9): 1-15. Available online at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm

11. Australian Institute of Family Studies. Growing up in Australia: the longitudinal study of Australian children: 2006-07 annual report. Commonwealth of Australia; 2008. 44 p. Available online at: http://www.growingupinaustralia.gov.au/pubs/ar/ar200607/annualreport2006-07.pdf

12. Department of Health. Norway – The WHO code and breastfeeding: An international comparative overview [internet]. Department of Health; May 2012 [cited 2016 Oct 22]. Available from: http://www.health.gov.au/internet/publications/publishing.nsf/Content/int-comp-whocode-bf-init~int-comp-whocode-bf-init-ico~int-comp-whocode-bf-init-ico-norway

13. Victora CG, Bahl R, Barros AJD, Franca GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016 Jan; 387(10017): 475–479.

14. Amir LH, Bearzatto A. Overcoming challenges faced by breastfeeding mothers. Aust Fam Physician. 2016 Aug; 45(8): 552-556. Available online at: http://www.racgp.org.au/afp/2016/august/overcoming-challenges-faced-by-breastfeeding-mothers/

15. Ong KK, Loos RJ. Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions. Acta Paediatr. 2006 Aug; 95(8): 904-908

16. Koletzko B, von Kries R, Monasterolo RC, Subias JE, Scaglioni S, Giovannini M, et al. Infant feeding and later obesity risk. Adv Exp Med Biol. 2009; 646: 15-29

17. Trabulsi J, Capeding R, Lebumfacil J, Ramanujam K, Feng P, McSweeney S, et al. Effect of an lactalbumin-enriched infant formula with lower protein on growth. Eur J Clin Nutr. 2011 Feb; 65(2): 167-74

18. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child. 2012 Dec; 97(12): 1019-26

19. Martin K. Electronic overload: The impact of excessive screen use on child and adolescent health and wellbeing. Perth: Department of Sport and Recreation; August 2011. 13 p.

20. Healthy Kids. Switch off the screen [internet]. NSW Ministry of Health, NSW Department of Education, Office of Sport and the Heart Foundation; 2016 [cited 2016 Oct 22]. Available from: https://www.healthykids.nsw.gov.au/kids-teens/switch-off-the-screen.aspx

21. Department of Health. Australia’s physical activity and sedentary behaviour guidelines [internet]. Department of Health; July 2014 [cited 2016 Oct 22]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines

22. Ko CH, Liu GC, Hsiao S, Yen JY, Yang MJ, Lin WC, et al. Brain activities associated with gaming urge of online gaming addiction. J Psychiatr Res. 2009 Apr; 43(7): 739-747

23. Active Healthy Kids Australia. Is sport enough? The 2014 Active Healthy Kids Australia report card on physical activity for children and young people. Adelaide: Active Healthy Kids Australia; 2014. 49 p. Available online at: https://www.heartfoundation.org.au/images/uploads/publications/ahka_reportcard_longform.pdf

24. Poskitt EME. Defining childhood obesity: the relative body mass index (BMI). Acta Paediatrica. 1995 Aug; 84(8): 961-963

25. Centers for Disease Control and Prevention. Using the BMI-for-age growth charts [internet]. CDC [cited 2016 Oct 22]. Available from: http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/module1print.pdf

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EXPERT MONOGRAPH ISSUE 9 The Identification and Prevention … · 2020. 6. 17. · intake recommendations. Along these lines, recommendations for newborn feeds have been reduced from