Screening and Interventions for Childhood Overweight: A Systematic Review for the US Preventive Services Task Force

DOI: 10.1542/peds.2005-0242 2005;116;e125-e144 PediatricsShipman

Evelyn P. Whitlock, Selvi B. Williams, Rachel Gold, Paula R. Smith and Scott A. for the US Preventive Services Task Force

Screening and Interventions for Childhood Overweight: A Summary of Evidence

http://www.pediatrics.org/cgi/content/full/116/1/e125located on the World Wide Web at:

The online version of this article, along with updated information and services, is

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

. Provided by Univ Of Arizona on May 17, 2010 www.pediatrics.orgDownloaded from

http://www.pediatrics.org/cgi/content/full/116/1/e125

http://www.pediatrics.org

SPECIAL ARTICLE

Screening and Interventions for Childhood Overweight: A Summary ofEvidence for the US Preventive Services Task Force

Evelyn P. Whitlock, MD, MPH*‡; Selvi B. Williams, MD*‡§; Rachel Gold, PhD, MPH*‡§;Paula R. Smith, RN, BSN*‡; and Scott A. Shipman, MD, MPH‡§

ABSTRACT. Background. Childhood and adolescentoverweight and obesity are related to health risks, med-ical conditions, and increased risk of adult obesity, withits attendant effects on morbidity and mortality rates.The prevalence of childhood overweight and obesity hasmore than doubled in the past 25 years.

Purpose. This evidence synthesis examines the evi-dence for the benefits and harms of screening and earlytreatment of overweight among children and adolescentsin clinical settings.

Methods. We developed an analytic framework and 7key questions representing the logical evidence connect-ing screening and weight control interventions withchanges in overweight and behavioral, physiologic, andhealth outcomes in childhood or adulthood. We searchedthe Cochrane Library from 1996 to April 2004. Wesearched Medline, PsycINFO, DARE, and CINAHL from1966 to April 2004. One reviewer abstracted relevant in-formation from each included article into standardizedevidence tables, and a second reviewer checked key ele-ments. Two reviewers quality-graded each article withUS Preventive Services Task Force criteria.

Results. Although BMI is a measure of relativeweight rather than adiposity, it is recommended widelyfor use among children and adolescents to determineoverweight and is the currently preferred measure. Therisk of adult overweight from childhood overweight pro-vides the best available evidence to judge the clinicalvalidity of BMI as an overweight criterion for childrenand adolescents. BMI measures in childhood track toadulthood moderately or very well, with stronger track-ing seen for children with >1 obese parent and childrenwho are more overweight or older. The probability ofadult obesity (BMI of >30 kg/m2) is >50% among chil-dren >13 years of age whose BMI percentiles meet orexceed the 95th percentile for age and gender. BMI-basedoverweight categorization for individuals, particularlyfor racial/ethnic minorities with differences in body com-position, may have limited validity because BMI mea-sures cannot differentiate between increased weight forheight attributable to relatively greater fat-free mass

(muscle, bone, and fluids) and that attributable to greaterfat. No trials of screening programs to identify and totreat childhood overweight have been reported. Limitedresearch is available on effective, generalizable interven-tions for overweight children and adolescents that can beconducted in primary care settings or through primarycare referrals.

Conclusions. BMI measurements of overweight amongolder adolescents identify those at increased risk of de-veloping adult obesity. Interventions to treat overweightadolescents in clinical settings have not been shown tohave clinically significant benefits, and they are notwidely available. Screening to categorize overweightamong children under age 12 or 13 who are not clearlyoverweight may not provide reliable risk categorizationfor adult obesity. Screening in this age group is compro-mised by the fact that there is little generalizable evi-dence for primary care interventions. Because existingtrials report modest short- to medium-term improve-ments (�10–20% decrease in percentage of overweightor a few units of change in BMI), however, overweightimprovements among children and adolescents seempossible. Pediatrics 2005;116:e125–e144. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2005-0242; adoles-cents, children, obesity, intervention, overweight, screen-ing.

ABBREVIATIONS. USPSTF, US Preventive Services Task Force;NHANES, National Health and Nutrition Examination Survey;CDC, Centers for Disease Control and Prevention.

Obesity/overweight has been declared an epi-demic1–3 and a “public health crisis” amongchildren worldwide4 due to an alarming in-

crease in its prevalence. Overweight among children(defined by experts as a BMI of �95th percentile forage and gender)5,6 �2 years of age has at least dou-bled in the past 25 years (Fig 1). The age- and gender-specific mean BMIs and the proportion of childrenwith BMIs of �95th percentile increased markedlyamong children from the mid-1970s to the 1990s,with almost all of this increase occurring amongchildren in the upper half of the BMI distribution.7Therefore, �50% of children appear to have “obesitysusceptibility genes” on which environmentalchanges have acted in the past 25 years.8

Because increases in mean BMI have occurred pri-marily because of increases in the upper half of theBMI distribution,7,9 weight-related health conse-quences will become increasingly common amongchildren. The health consequences of childhoodoverweight and obesity include pulmonary, ortho-pedic, gastroenterologic, neurologic, and endocrine

From the *Center for Health Research, Kaiser Permanente, Portland, Ore-gon; ‡Oregon Evidence-Based Practice Center, Portland, Oregon; and §Or-egon Health and Science University, Portland, Oregon.Accepted for publication Feb 4, 2005.doi:10.1542/peds.2005-0242The authors of this article are responsible for its contents, including anyclinical or treatment recommendations. No statement in this article shouldbe construed as an official position of the US Agency for Healthcare Re-search and Quality or the US Department of Health and Human Services.No conflict of interest declared.Address correspondence to Evelyn P. Whitlock, MD, MPH, Center forHealth Research, Kaiser Permanente, 3800 N Interstate Ave, Portland, OR97227. E-mail: [email protected] (ISSN 0031 4005). Published in the public domain by theAmerican Academy of Pediatrics.

www.pediatrics.org/cgi/doi/10.1542/peds.2005-0242 PEDIATRICS Vol. 116 No. 1 July 2005 e125. Provided by Univ Of Arizona on May 17, 2010 www.pediatrics.orgDownloaded from


conditions and cardiovascular risk factors.4,10–15

Tables 1 and 2 contain the limited prevalence data forkey morbidities and risk factors available from recentsummaries. Rarely, severe childhood obesity is asso-ciated with immediate morbidity resulting from con-ditions such as slipped capital femoral epiphysis,16

whereas steatohepatitis and sleep apnea are morecommon.17–21 Medical conditions new to this agegroup, such as type 2 diabetes mellitus,22 represent“adult” morbidities that are now seen more fre-quently among overweight adolescents.23 Most med-ical complications, however, do not become clinicallyapparent for decades.10

Overweight is associated with a higher prevalenceof intermediate metabolic consequences and risk fac-tors, such as insulin resistance, elevated blood lipidlevels, increased blood pressure, and impaired glu-cose tolerance.24–29 Perhaps the most significantshort-term morbidities for overweight/obese chil-dren are psychosocial and include social marginal-ization, decreased self-esteem, and decreased qualityof life.30–33 Risk factors for developing childhoodoverweight include increased parental adiposity, lowparental education, social deprivation, and perhapsinfant feeding patterns, early or more rapid puberty,extreme birth weights, gestational diabetes, and var-ious social and environmental factors, such as child-hood diet and time spent in sedentary behaviors.4

The US Preventive Services Task Force (USPSTF)makes recommendations about clinical preventiveservices to assist primary care clinicians using an ex-plicit, evidence-based approach. In 1996, the USPSTFrecommended periodic height and weight measure-ments for all patients (B recommendation).34 Com-paring height and weight measures against appro-priate age and gender normative values to determineadditional evaluation, intervention, or referral wasrecommended, with BMI (�85th percentile) for ado-lescents and weight and height (or length, as appro-priate) plotted on growth charts or compared with

average weight tables for age, gender, and height foryounger children. Previously, the USPSTF has notmade separate recommendations about screening cri-teria or specific interventions for overweight or obesityin childhood populations. To assist the USPSTF inmaking its recommendation, the Oregon Evidence-Based Practice Center undertook a systematic reviewand summary of the strength of the evidence con-cerning screening and interventions for overweightin childhood populations. We combined the findingsof prior fair- or good-quality35 systematic evidencereviews with fair- to good-quality studies not cov-ered in these reviews or published subsequently.

METHODS

TerminologyBecause BMI is the primary clinical measure and is a measure

of relative weight, we adopted the use of the term “overweight”for children, as opposed to obesity.7 Considering the limitations ofBMI in defining adiposity and concerns about labeling (stigma orconcern resulting from being labeled obese), overweight is moreaccurate than obesity when the designation is based on a BMIvalue alone. Using accepted conventions, we use “overweight” todescribe those with �95th percentile BMI for age and gender and“at risk for overweight” to describe those in the 85th to 95thpercentile for age and gender.5,6

Key Questions and Analytic FrameworkWe developed an analytic framework (Fig 2) and 7 key ques-

tions, with USPSTF methods, to guide our literature search.35 Thefirst key question examined direct evidence that screening toidentify and to treat overweight among children and adolescentsimproves age-appropriate behavioral, anthropometric, or physio-logic measures. Because we found no evidence addressing this keyquestion, we searched for indirect evidence for key questions 2through 6, to estimate the benefits and harms of overweightscreening and interventions. Key question 2 concerned appropri-ate standards for overweight among children and adolescents, theoverweight prevalence based on appropriate standards, and va-lidity of clinical screening tests for predicting poorer health out-comes and obesity in adulthood. Key question 3 examined adverseeffects of screening for overweight. Key questions 4 and 5 exam-ined the efficacy of behavioral counseling, pharmacotherapeutic,and surgical interventions for improving age-appropriate anthro-

0%

5%

10%

15%

20%

1963-

1965

1966-

1970

1971-

1974

1976-

1980

1988-

1994

1999-

2002

2-5 yrs.

6-11 yrs.

12-19 yrs.

Fig 1. Overweight trends among children and adolescents.45

e126 CHILDHOOD OVERWEIGHT SCREENING AND INTERVENTIONS. Provided by Univ Of Arizona on May 17, 2010 www.pediatrics.orgDownloaded from


TA

BL

E1.

Ove

rwei

ght-

and

Obe

sity

-Ass

ocia

ted

Hea

lth

Con

dit

ions

Am

ong

Chi

ldre

nan

dA

dol

esce

nts

Hea

lth

Con

dit

ion

Popu

lati

onSo

urce

Age

/R

ace

Eth

nici

ty/

Gen

der

Lev

elof

Ove

rwei

ght

Prev

alen

ce,%

Ref

eren

ceC

ited

inSo

urce

Bib

liogr

aphy

Dia

bete

sm

ellit

usD

iabe

tes

mel

litus

,typ

e2

Com

mun

ity

(N�

2066

)Pi

ma

Nat

ive

Am

eric

an*

Dab

elea

etal

23

(199

8)15

–19

yG

irls

5.31

Boy

s3.

7810

–14

yG

irls

2.88

Boy

s1.

4C

omm

unit

y(N

�14

2)N

avaj

oN

ativ

eA

mer

ican

,12–

19y

1.41

Lob

stei

net

al4

(200

4)N

HA

NE

SII

I(N

�28

67)

Non

-His

pani

cw

hite

,no

n-H

ispa

nic

blac

k,M

exic

anA

mer

ican

adol

esce

nts,

12–1

9y

0.04

(inc

lud

esty

pe1

dia

bete

sm

ellit

us)

Dia

bete

sm

ellit

usty

pe2

Obe

sity

clin

ic(N

�55

)M

ulti

ethn

icbo

ysan

dgi

rls,

4–10

yB

MI

�95

thpe

rcen

tile

for

age

and

gend

er0

Sinh

aet

al24

(200

2)

Obe

sity

clin

ic(N

�11

2)M

ulti

ethn

icbo

ysan

dgi

rls,

11–1

8y

BM

I�

95th

perc

enti

le4

(all

wer

eno

n-H

ispa

nic

blac

kor

His

pani

c)A

sthm

aPa

rent

alre

port

ofd

octo

rN

HA

NE

SII

I,su

bset

ofch

ildre

nM

ulti

ethn

icgi

rls

and

BM

I�

85th

perc

enti

le31

Rod

rigu

ezet

al15

dia

gnos

edas

thm

ain

child

wit

hfa

mily

hist

ory

ofpa

rent

alas

thm

a(N

�62

5)bo

ys,1

0–16

yB

MI

�85

thpe

rcen

tile

14.5

(200

2)

Slee

pap

nea

Slee

p-as

soci

ated

abno

rmal

brea

thin

gte

sts

Obe

sech

ildre

nre

ferr

edfo

rhi

stor

yof

slee

pd

isor

der

edbr

eath

ing

(N�

32)

Mul

tiet

hnic

boys

and

girl

s,2.

7–13

.8y

196

�45

%m

ean

IBW

40–9

0Si

lves

tri

etal

17

(199

3)

�1

abno

rmal

poly

som

nogr

aphy

test

Obe

sity

clin

ic(N

�22

2)C

hild

ren

and

adol

esce

nts,

3–20

y“S

ever

eob

esit

y,”

�15

0%IB

W;m

ean:

208%

IBW

6.8

(cal

c),

Mal

lory

etal

18

(198

9)Se

vere

lyab

norm

alte

sts

(sev

ere

slee

pap

nea)

1(c

alc)

�1

abno

rmal

poly

som

nogr

aphy

test

Obe

sity

clin

icpa

tien

tsw

ith

hist

ory

ofsl

eep

dis

ord

ered

brea

thin

g(N

�41

)

32

Seve

rely

abno

rmal

test

(sev

ere

slee

pap

nea)

5

Non

alco

holic

fatt

yliv

erd

isea

seT

omin

aga

etal

19

(199

5)St

eato

sis

byul

tras

onog

raph

yG

ener

alpe

dia

tric

(N�

810)

Japa

nese

scho

olbo

ysan

dgi

rls,

4–12

yPo

pula

tion

sam

ple

3

Stea

tosi

sby

ultr

ason

ogra

phy

Obe

sity

clin

ic(N

�72

)It

alia

nbo

ysan

dgi

rls,

4.5–

15.9

yO

bese

,�12

0%IB

W53

Fran

zese

etal

20

(199

7)St

eato

sis

and

elev

ated

tran

sam

inas

es(p

resu

mpt

ive

NA

SH)

Of

thes

e,32

%ha

del

evat

edtr

ansa

min

ases

(cal

c)

Stea

tosi

sby

ultr

ason

ogra

phy

Obe

sity

clin

ic(N

�84

)C

hine

sech

ildre

n;m

ean

age:

12y

BM

Iof

�95

thpe

rcen

tile

for

age

and

gend

er77

Cha

net

al21

(200

4)St

eato

sis

and

elev

ated

tran

sam

inas

es(p

resu

mpt

ive

NA

SH)

24

Slip

ped

capi

tal

fem

oral

epip

hysi

s3.

4ca

ses

per

100

000

child

ren

(50–

70%

are

“obe

se”)

Kel

sey1

6(1

973)

Chi

ldho

odm

orbi

dit

ies

dis

cuss

edin

revi

ews

wit

hout

repo

rted

prev

alen

cew

ere

bing

e-ea

ting

dis

ord

ers

and

low

self

-est

eem

.IB

Win

dic

ates

idea

lbod

ywei

ght;

NA

SH,n

onal

coho

licst

eato

hepa

titi

s;ca

lc,

calc

ulat

ed.

*T

hehi

ghes

t-ri

skpo

pula

tion

inth

ew

orld

.

www.pediatrics.org/cgi/doi/10.1542/peds.2005-0242 e127. Provided by Univ Of Arizona on May 17, 2010 www.pediatrics.orgDownloaded from


TA

BL

E2.

Ove

rwei

ght-

and

Obe

sity

-Ass

ocia

ted

Ris

kFa

ctor

sfo

rC

hild

ren

and

Ad

oles

cent

s

Ris

kFa

ctor

Popu

lati

onSo

urce

Age

/R

ace

Eth

nici

ty/

Gen

der

Lev

elof

Ove

rwei

ght

(Per

cent

ileof

BM

Ifo

rA

gean

dG

end

erif

Giv

en)

Prev

alen

ce,%

Ref

eren

ceC

ited

inSo

urce

Bib

liogr

aphy

Impa

ired

gluc

ose

tole

ranc

eIm

pair

edgl

ucos

eto

lera

nce

Obe

sity

clin

ic(N

�55

)M

ulti

ethn

icbo

ysan

dgi

rls,

4–10

y�

95th

25Si

nha

etal

24(2

002)

Obe

sity

clin

ic(N

�11

2)M

ulti

ethn

icbo

ysan

dgi

rls,

11–1

8y

�95

th21

Sinh

aet

al24

(200

2)

Hyp

erin

sulin

emia

Insu

linle

vels

�95

thpe

rcen

tile

Bog

alus

aH

eart

Stud

yB

lack

and

whi

tebo

ysan

dgi

rls,

5–10

y�

95th

�4

Free

dm

anet

al25

(200

2)95

th–9

7th

10�

97th

27M

etab

olic

synd

rom

eH

yper

tens

ion,

hype

rtri

glyc

erid

emia

,lo

wH

DL

chol

este

rol,

hype

rins

ulin

emia

NH

AN

ES

Ad

oles

cent

boys

and

girl

s,12

–19

y�

85th

0.1

Coo

ket

al26

(200

3)85

th–9

5th

6.8

�95

th28

.7W

ith

�3

of:S

BP

orD

BP

�95

thpe

rcen

tile

,tri

glyc

erid

es�

95th

perc

enti

le,2

-hG

TT

�14

0m

g/d

L,

BM

Iz

scor

e�

2.0

(97t

hpe

rcen

tile

),H

DL

chol

este

rol

�5t

hpe

rcen

tile

Obe

sesa

mpl

e(N

�43

9)41

%w

hite

,31%

blac

k,27

%H

ispa

nic,

4–20

y

zsc

ore:

2–2.

538

.7W

eiss

etal

27(2

004)

zsc

ore:

�2.

549

.7ov

eral

l(3

9in

blac

ks)

Hyp

erte

nsio

nH

yper

tens

ion

Popu

lati

onba

sed

Mul

tiet

hnic

boys

and

girl

s,5–

11y

Obe

seU

pto

30Fi

guer

oa-C

olon

etal

29

(199

7)H

yper

tens

ion

Mus

cati

neH

eart

Stud

y(�

6600

)5–

18y

Com

mun

ity

dis

trib

utio

n1

(60%

ofth

ese

had

rela

tive

wei

ght

�12

0%)

Die

tz28

(199

8)

Incr

ease

dSB

Pm

easu

res

�95

thpe

rcen

tile

Bog

alus

aH

eart

Stud

yB

lack

and

whi

tebo

ysan

dgi

rls,

5–10

y�

952–

7Fr

eed

man

etal

25(2

002)

95th

–97t

h12

�97

th22

Incr

ease

dD

BP

�95

thpe

rcen

tile

Bog

alus

aH

eart

Stud

yB

lack

and

whi

tebo

ysan

dgi

rls,

5–10

y�

95th

2–7

Free

dm

anet

al25

(200

2)95

th–9

7th

9�

97th

14D

islip

idem

iaL

DL

chol

este

rol

�13

0m

g/d

LB

ogal

usa

Hea

rtSt

udy

(N�

3599

)B

lack

and

whi

tebo

ysan

dgi

rls,

5–10

y�

85th

8–10

acro

ssal

lpe

rcen

tile

sFr

eed

man

etal

25(2

002)

85th

–94t

h18

95th

–97t

h12

�97

th23

HD

Lch

oles

tero

l�

35m

g/d

LB

ogal

usa

Hea

rtSt

udy

Bla

ckan

dw

hite

boys

�85

th5–

8an

dno

nlin

ear

Free

dm

anet

al25

(200

2)(N

�35

99)

and

girl

s,5–

10y

85th

–94t

h8

95th

–97t

h7

�97

th18

TG

leve

ls�

130

mg/

dL

Bog

alus

aH

eart

Stud

y(N

�35

99)

Bla

ckan

dw

hite

boys

and

girl

s,5–

10y

�85

th2–

6Fr

eed

man

etal

25(2

002)

85th

–94t

h10

95th

–97t

h10

�97

th21

Ris

kfa

ctor

sd

iscu

ssed

inre

view

sw

itho

utre

port

edpr

eval

ence

wer

em

enst

rual

dis

ord

ers,

poly

cyst

icov

aria

nsy

ndro

me,

earl

ym

atur

atio

n(g

irls

),la

tem

atur

atio

n(b

oys)

.HD

Lin

dic

ates

high

-den

sity

lipop

rote

in;L

DL

,low

-den

sity

lipop

rote

inT

G,t

rigl

ycer

ide;

SBP,

syst

olic

bloo

dpr

essu

re;D

BP,

dia

stol

icbl

ood

pres

sure

;GT

T, �

-glu

tam

yltr

ansf

eras

e.



pometric, physiologic, and health outcomes, and key question 6addressed intervention-associated harms. The relationship be-tween intervention-associated improvements in intermediatehealth measures and decreased morbidity in childhood or adult-hood (key question 7) was examined only in the presence ofadequate evidence for intervention efficacy (key questions 4 and5). We did not examine key question 7 because of limited andinconsistent evidence for key questions 4 and 5. Review methodsare summarized below and detailed elsewhere.36

Literature Search StrategyWe developed literature search strategies and terms for each

key question and conducted 4 separate literature searches (for keyquestions 1 and 2, for key questions 4 and 5, for key question 3,and for key question 6) in Medline, PsycINFO, CINAHL, and theCochrane Library, to update the literature from previous good-quality systematic reviews (key questions 4, 5, and 6) or to exam-ine comprehensively literature from 1966 to the present (key ques-tions 1, 2, and 3). Literature searches were supplementedextensively with source material from experts in the field, bibli-ographies of included trials, and other reviews. We also conductedlimited hand-searching of pediatric obesity-focused editions ofselected journals. A single investigator reviewed abstracts. A sec-ond investigator reviewed all excluded abstracts for all key ques-tions, except key question 2. Because of this search’s large yield,we conducted blinded dual reviews for a random subset (27%),with acceptable agreement (97.5%) between reviewers. Inter-re-viewer discrepancies were resolved through consensus.

Article Review and Data AbstractionWith prespecified inclusion criteria,36 we reviewed 2162 ab-

stracts and 353 complete articles for key questions 1 and 2, 949abstracts and 198 complete articles for key questions 4 and 5, and1176 abstracts and 36 complete articles for key questions 3 and 6.We included 0 articles for key question 1, 41 articles for keyquestion 2, 0 articles for key question 3, 22 articles for key ques-tions 4 and 5, and 4 articles for key question 6. Two investigators

quality-rated all included articles and those excluded for qualityreasons, using the USPSTF criteria.35

One primary reviewer abstracted relevant information fromincluded studies into standardized evidence tables.36 To be withinthe USPSTF scope, interventions needed to be conducted in pri-mary care or be feasible for primary care conduct or referral(defined elsewhere),36 and they were categorized as pharmaceu-tical, surgical, or behavioral counseling interventions. Abstractedbehavioral counseling intervention details included setting, typeof professional delivering the intervention, parent/family partic-ipation, intervention components, number and type of contacts,and intervention duration.37 Comprehensive behavioral treat-ments were those using a combination of behavioral modification(eg, self-monitoring, stimulus control, or cognitive-behavioraltechniques), dietary modification (eg, Traffic Light Diet,38 reducedglycemic load, or reduced-fat or reduced-energy diets), and phys-ical activity components (broadly specified as aerobic, callisthenic,lifestyle, or decreased sedentary behaviors).37

Studies needed to report weight outcomes, preferably as BMI orBMI percentile changes, to be included. We also recorded allreported behavioral, physiologic, and health outcomes specifiedon our analytic framework (Fig 2).

Literature SynthesisThere were insufficient homogeneous studies for any key ques-

tion to allow quantitative synthesis. To better illustrate the studyparticipants’ degree of overweight and the treatment impact ofclinical interventions on overweight, we converted baseline mea-sures and outcomes to BMI percentiles and plotted the results onthe Centers for Disease Control and Prevention (CDC) growthcharts. Treatment effects that were typical of interventions in thisage group (10–20% reductions in percent overweight after 1 year)were modeled and plotted for 8-, 10-, and 12-year-old girls. Weplotted reported mean BMI treatment effects at �6 months for 6trials with adolescents included in our review (1 adolescent trialdid not report BMI or percent overweight outcomes). These meth-ods are described in more detail elsewhere.36 With the USPSTF

Fig 2. Screening and interventions for overweight in childhood: analytic framework and key questions (KQs).



approach,35 we summarized the overall quality of the evidence foreach key question.

RESULTS

Key Question 1: Is There Direct Evidence ThatScreening (and Intervention) for Overweight AmongChildren/Adolescents Improves Age-AppropriateBehavioral or Physiologic Measures or HealthOutcomes?

Our searches found no studies addressing this keyquestion, and neither did examination of all individ-ual trials included in previous systematic evidencereviews.39–43

Key Question 2

Key Question 2a: What Are Appropriate Standards forOverweight Among Children/Adolescents and What Is thePrevalence of Overweight Based on These Standards?

Eight nationally representative, health examina-tion surveys that included children have been con-ducted in the United States since 1963.44,45 Thesesurveys have gathered a variety of anthropometricmeasures for a range of ages (2 months to 18 years),providing growth references46 and trend analyses ofchanges within the population over time. To provideuseful trend analyses, measures must be valid, mustbe gathered consistently in surveys, and must use asingle source for comparison. Because of these limi-tations, almost all data on prevalence and trendsamong US children are based on BMI measures cal-culated from standardized weight and height infor-mation.47

BMI measurements for an individual, or for deter-mination of population prevalence, must be com-pared with a reference population to determine theage- and gender-specific percentile ranking. Al-though multiple reference data sets to determinechildhood BMI percentiles are available, where pos-sible we used the CDC 2000 gender-specific BMIgrowth charts (for ages 2–19 years).48 Prevalence es-timates and trend information were taken primarilyfrom the National Health and Nutrition ExaminationSurvey (NHANES) program conducted from 1971 to2000, which provides the most comprehensive dataavailable on boys and girls of age 6 months through19 years, with recent over-sampling of black andMexican American children. These prevalence esti-mates use the CDC 2000 gender-specific BMI growthcharts as their reference data set to assign BMI per-centiles.

PrevalenceWith the BMI �95th percentile, overweight prev-

alence in 1999–2002 was 10% among 2- to 5-year-oldchildren and 16% among �6-year-old children49

(Fig 3). For children 2 to 5 years of age, the preva-lences were similar for all racial/ethnic subgroupsand both genders but were lower than those for olderchildren in the same racial/ethnic subgroups.Among children 6 to 11 years of age, differenceswere seen between racial/ethnic subgroups, withsignificantly more Mexican American (21.8%) andnon-Hispanic black (19.8%) children being catego-

rized as overweight, compared with non-Hispanicwhite children (13.5%) (P � .05). Gender-specific dif-ferences were also apparent, with the highest prev-alence of overweight among 6- to 11-year-old chil-dren being noted for Mexican American boys(26.5%); the prevalence was significantly higher thanthose for non-Hispanic black boys (17%), non-His-panic white boys (14%), and Mexican American girls(17.1%) and was similar to that for non-Hispanicblack girls (22.8%). Among youths 12 to 19 years ofage, significantly more non-Hispanic black (21.1%)and Mexican American (22.5%) youths had over-weight BMI measurements than did non-Hispanicwhite youths (13.7%) (P � .05), with no differencesbetween male and female youths.

Key Question 2b: What Clinical Screening Tests forOverweight in Childhood Are Reliable and Valid in PredictingObesity in Adulthood?

We found 19 fair- or good-quality, longitudinal,cohort studies (in 20 publications) that reported onBMI and other weight status measurements in child-hood and adulthood.50–69 BMI measurements inchildhood and adulthood correlated with each otheras well as, or better than, other overweight measures,such as Ponderal Index or skinfold measurements, inchildhood and adulthood correlated. Table 3 illus-trates that BMI tracking from childhood to adult-hood varies according to age.50–52,55,62,63 Single BMImeasures track reasonably well from childhood andadolescence (ages 6–18) into young adulthood (ages20–37), as evidenced by longitudinal studies show-ing low/moderate (r � 0.2–0.4) or moderate/high(0.5–0.8) correlations between childhood and adultBMI measures. Increased tracking (r � 0.6 or ele-vated odds of adult obesity) is seen for older children(after age 8),55 particularly with sexual maturity,70,71

for younger children (ages 6–12) who are more over-weight (usually above the 95th or 98th percen-tile),36,72 and for children with an obese parent.12,56

Data on tracking for children before the age of 12 arenot extensive. Gender differences in tracking are notconsistent across ages or within age categories. Lim-ited data are available comparing white and blackchildren. Table 4 illustrates the probability of adultobesity (BMI of �30 kg/m2) at various BMI percen-tiles for children of various ages, taken from ourlarger report.36 A �50% probability of adult obesityis seen generally for children �13 years of age withBMI measures of �95th percentile. Combiningyounger and older children in these analyses mayobscure the increased probability of adult obesitywith older ages of childhood overweight.

Key Question 2c: What Clinical Screening Tests forOverweight in Childhood Are Reliable and Valid for PoorHealth Outcomes in Adulthood?

Although many (n � 11) US studies50,54,57,65–67,73–77

examined the risks associated with childhood over-weight and adult outcomes, including socioeco-nomic outcomes, mortality rates, and a range ofadult cardiovascular risk factors and morbidities,studies rarely controlled for adult BMI, a criticalconfounder.36 In one study that did, the apparent



association between elevated BMI at age 10 and sev-eral elevated adult cardiovascular risk factors (totalcholesterol level, low-density lipoprotein and high-density lipoprotein cholesterol levels, insulin level,and systolic and diastolic blood pressure) in the Bo-galusa Heart Study was eliminated after controllingfor adult BMI.57

Key Question 3: Does Screening Have Adverse Effects,Such as Labeling or Unhealthy Psychological orBehavioral Consequences?

We found no direct evidence on the harms ofscreening. Potential harms include labeling, inducedself-managed dieting with its negative sequelae,poorer self-concept, poorer health habits, disorderedeating, and negative impact from parental con-cerns.5,13,32,78–84

Key Question 4: Do Interventions (BehavioralCounseling, Pharmacotherapy, or Surgery) That AreFeasible to Conduct in Primary Care Settings orAvailable for Primary Care Referral Lead to ImprovedIntermediate Behavioral or Physiologic Measures, Withor Without Weight-Related Measures?

Behavioral Counseling InterventionsThe most extensive treatment literature for child-

hood overweight involves behavioral counseling in-terventions. Behavioral counseling interventions in-clude behavioral modification, special diets, and/oractivity components delivered to children and/orparents as individuals or in groups by primary careclinicians or related health care staff members, tohelp patients adopt, change, or maintain health be-haviors affecting overweight and related outcomes.85

Fig 3. Prevalence of overweight and at risk for overweight, 1999–2002. NHW indicates non-Hispanic white; NHB, non-Hispanic black;MA, Mexican American.



We considered all trials published since 1985 fromWestern industrialized nations (n � 22 from 23 pub-lications) that addressed interventions feasible forprimary care conduct or primary care referral (in-cluding one that combined comprehensive behav-ioral treatment with pharmacotherapy, which is de-scribed separately below) (Table 5). 86–108 We limitedour search to post-1985 trials, because of the dramaticincreases in overweight among children that oc-

curred during the 1980s and 1990s, suggesting a verydifferent treatment environment.1,8,109 A previousgood-quality, systematic review including 16 of thesetrials concluded that this behavioral counselingtreatment literature is limited, with marginal-qualitytrials involving small samples of primarily white,school-aged children receiving short-term, noncom-parable, nongeneralizable interventions.40 Thesetrials typically tested intensive, often family-based,

TABLE 3. Effects of Age and Race on the Correlation of Childhood With Young Adult BMI

Reference Population Childhood Age, y Probability

Male Female

Effect of age on correlationGuo et al55 (1994) 100% white (n � 555) 3 0.18 0.22Lauer and Clark62 (1989) 100% white (n � 109

observations)7–8 0.57 0.45

Lauer and Clark62 (1989) 100% white (n � 603observations)

9–10 0.63 0.61

Clarke and Lauer63 (1993) 100% white (n � 1286observations)

9–10 0.61 0.59

Lauer and Clark62 (1989) 100% white (n � 1018observations)

11–12 0.67 0.65

Guo et al55 (1994) 100% white (n � 555) 13 0.5 0.65Lauer and Clark62 (1989) 100% white (n � 1041

observations)13–14 0.64 0.68


13–14 0.7 0.7

Lauer and Clarke62 (1989) 100% white (n � 615observations)

17–18 0.74 0.73


17–18 0.81 0.72

Effect of race on correlationHulman et al51 (1998) 100% black (n � 137) 13 0.37 0.37Wattigney et al52 (1995) 100% black (n � 147) 13–17 0.69 0.72Wattigney et al52 (1995) 100% white (n � 327) 13–17 0.63 0.48Freedman et al50 (2004) 67% white (n � 2212) 14–17 0.76 0.73

TABLE 4. Probability of Adult Obesity (BMI of �30 kg/m2) Based on Childhood BMI Percentile Measures at Various Ages

Study ID OverweightMeasure inChildhood,

BMIPercentile

Child’s AgeWhen

Measured, y

Adult’s AgeWhen

Measured, y

Probability ofAdult Overweight(Male and Female

Combined)

Probability ofAdult

Overweight(Male)

Probability ofAdult

Overweight(Female)

Gortmaker et al66

(1993) (n � 10 039),80% white, 14%black, 6% Hispanic51% female

�95th 16–24 23–31 0.77* 0.66*

Freedman et al57 (2001)(n � 2617), 67%white, 32% black,57% female

�50th 5–17 18–37 0.07

Freedman et al57 (2001)(as above)

85th–94th 5–17 18–37 0.51

Freedman et al57 (2001)(as above)

�95th 5–17 18–37 0.77

Guo et al58 (2002)(n � 347), 100%white, 52% female

�75th 3 35 0.1 0.14�85th 0.1 0.17�95th 0.2 0.24

Guo et al58 (2002)(as above)

�75th 8 35 0.1 0.16�85th 0.1 0.23�95th 0.2 0.46


�75th 13 35 0.2 0.16�85th 0.2 0.27�95th 0.5 0.64


�75th 18 35 0.2 0.15�85th 0.3 0.26�95th 0.8 0.68

* In this study, adult overweight was defined as �95th percentile on NHANES.



TA

BL

E5.

Ran

dom

ized

Tri

als

Ad

dre

ssin

gO

verw

eigh

tA

mon

gC

hild

ren

and

Ad

ults

Stud

yR

efer

ence

NR

and

omiz

ed,

Cou

ntry

Age

,y(%

Mal

e,%

Non

whi

te)

Rel

ativ

eO

verw

eigh

tat

Bas

elin

eIn

terv

enti

onC

hara

cter

isti

cs*

Gro

upU

nits

ofM

easu

reSt

udy

Dur

atio

n,m

o

Out

com

eat

Lat

est

Follo

w-U

pT

ime

P,C

ompa

riso

nsB

etw

een

Gro

ups†

Oth

erO

utco

mes

USP

STF

Qua

lity

Gra

de

Com

pone

nts

(Com

preh

ensi

ve?;

§Pa

rent

Part

icip

atio

n?;

Gro

upV

ersu

sIn

div

idua

l)

Tim

ePe

riod

,No.

ofSe

ssio

ns,S

essi

onL

engt

h,T

otal

Con

tact

Tim

e,m

in

Berk

owitz

etal

86(2

003)

82ad

oles

cent

s,U

SA13

–17

(33,

45)

BMI:

37.8

kg/m

2(3

.8);

BMI:

zsc

ore:

2.4

(0.2

)

BM,D

,E(y

es;y

es;G

)6

mo

(pha

seI)

,19

(pha

seI)

,NR

,NR

Sibu

tram

ine

Cha

nge

inBM

I(%

chan

gefr

omen

try

BMI)

6�

8.5%

.001

P,A

Goo

d

Plac

ebo

�4.

0%

Duf

fyan

dSp

ence

87

(199

3)

29ch

ildre

n,A

ustr

alia

7–13

(21,

NR

)48

.4%

over

wei

ght

BM,D

,E(y

es;y

es;N

R)

8w

k,8,

90m

in,

720

min

BT�

cogn

itive

self-

man

agem

ent

%O

verw

eigh

tch

ange

6�

8.9%

NS

BFa

ir/p

oor

BT�

rela

xatio

npl

aceb

o�

9.2%

Ebbe

ling

etal

88(2

003)

16ad

oles

cent

s,U

SA13

–21

(31,

19)

BMI:

34.9

kg/m

2

(red

uced

glyc

emic

grou

p);3

7.1

kg/m

2

(red

uced

fat

diet

grou

p)

BM,D

(no;

no;N

R)

12m

o,14

,NR

,NR

Red

uced

-gly

cem

iclo

addi

etA

bsol

ute

chan

gein

BMI

12�

1.2

kg/m

2�

.05

B,P

Fair

Red

uced

-fat

diet

0.6

kg/m

2

Epst

ein

etal

89

(198

5)

41fa

mili

es,

USA

8–12

(40,

NR

)48

%ov

erw

eigh

tBM

,D,E

(yes

;yes

;NR

)12

mo,

18,N

R,N

RLi

fest

yle

PA%

Ove

rwei

ght

chan

ge24

�18

.0%

�.0

5(li

fest

yle

PAvs

aero

bic

PA);

�.0

5(li

fest

yle

PAvs

calis

then

ics

PA)

B,P

Fair

Aer

obic

PA�

6.8%

Low

-inte

nsity

calis

then

ics

PA�

7.2%

Epst

ein

etal

90

(198

5)

23ch

ildre

n,U

SA8–

12(0

,NR

)48

%ov

erw

eigh

tBM

,D,E

(yes

;yes

;NR

)12

mo,

NR

,NR

,NR

Die

t�

PA%

Ove

rwei

ght

chan

ge12

�25

.4%

NS

B,P

Fair

Die

tal

one

�18

.7%

Epst

ein

etal

91

(198

5)

24ch

ildre

n,U

SA5–

8(0

,NR

)39

–42%

over

wei

ght

BM,D

,E(y

es;y

es;

G,u

ncle

arif

I)12

mo,

uncl

ear,

�26

,N

R,N

R

BT%

Ove

rwei

ght

chan

ge12

�26

.3%

�.0

5B

Fair

Educ

atio

non

ly�

11.2

%Ep

stei

net

al92

(199

4)

44fa

mili

es,

USA

8–12

(26,

NR

)59

.6%

�50

thpe

rcen

tile

for

BMI

BM,D

,E(y

es;y

es;

uncl

ear)

1y,

32,N

R,N

RM

aste

rycr

iteri

aan

dco

ntin

gent

rein

forc

emen

tgr

oup

%O

verw

eigh

tch

ange

24�

15.4

%N

SB

Fair

Com

pari

son

grou

p�

10.6

%Ep

stei

net

al93

(199

5)

61fa

mili

es,

USA

8–12

(27,

4)51

.8%

over

wei

ght

BM,D

,E(y

es;y

es;

I�

G)

6m

o,18

,NR

,NR

Com

bine

d%

Ove

rwei

ght

chan

ge12

�8.

7%�

.05

(com

bine

dvs

incr

ease

dPA

)B,

PFa

ir

Dec

reas

edSB

�10

.3%

Incr

ease

dPA

�18

.7%

Epst

ein

etal

94

(200

0)

90fa

mili

es,

USA

8–12

(32,

NR

)62

%ov

erw

eigh

tBM

,D,E

(yes

;yes

;I

�G

)6

mo,

20,4

5–60

min

,90

0–12

00m

inD

ecre

ased

SBhi

ghdo

se%

Ove

rwei

ght

chan

ge24

�14

.3%

NS

B,P

Fair

Dec

reas

edSB

low

dose

�11

.6%

PAhi

ghdo

se�

13.2

%PA

low

dose

�12

.4%

Epst

ein

etal

95

(200

0)

67ch

ildre

n,U

SAN

R‡

(48;

4)BM

I:27

.4(3

.2)

kg/m

2BM

,D,E

(yes

;yes

;I

�G

)6

mo,

18,4

5–60

min

,81

0–10

80m

inPS

topa

rent

and

child

Cha

nge

inBM

Iz

scor

e24

�0.

5�

0.5

(PS

topa

rent

and

child

vsno

PS);

�.0

5(P

Sto

pare

ntan

dch

ildvs

PSto

child

only

)

H,A

Fair

PSto

child

only

�0.

9

No

PS�

1.1



TA

BL

E5.

Con

tinu

ed

Stud

yR

efer

ence

NR

and

omiz

ed,

Cou

ntry

Age

,y(%

Mal

e,%

Non

whi

te)

Rel

ativ

eO

verw

eigh

tat

Bas

elin

eIn

terv

enti

onC

hara

cter

isti

cs*

Gro

upU

nits

ofM

easu

reSt

udy

Dur

atio

n,m

o

Out

com

eat

Lat

est

Follo

w-U

pT

ime

P,C

ompa

riso

nsB

etw

een

Gro

ups†

Oth

erO

utco

mes

USP

STF

Qua

lity

Gra

de

Com

pone

nts

(Com

preh

ensi

ve?;

§Pa

rent

Part

icip

atio

n?;

Gro

upV

ersu

sIn

div

idua

l)

Tim

ePe

riod

,No.

ofSe

ssio

ns,S

essi

onL

engt

h,T

otal

Con

tact

Tim

e,m

in

Epst

ein

etal

96

(200

1)

67fa

mili

es,

USA

8–12

(52,

NR

)60

.2%

over

wei

ght

(com

pare

dw

ith50

thpe

rcen

tile

BMI

for

age

and

gend

er);

BMI:

27.4

kg/m

2

(3.6

kg/m

2 )

BM,D

,E(y

es;y

es:I

�G

)6

mo,

20,3

0m

in,

600

min

Incr

ease

dPA

Cha

nge

inab

solu

teBM

I(s

tatis

tical

com

pari

sons

,do

neon

%ov

erw

eigh

tch

ange

)

12G

irls

;�0.

27kg

/m2 ;

boys

;�

0.65

kg/m

2

�.0

1(in

tera

ctio

nof

grou

pby

gend

er);

�.0

01(b

oys

inco

mbi

ned

grou

pvs

girl

sin

com

bine

dgr

oup)

;�

.05

(boy

sin

com

bine

dgr

oup

vsgi

rls

inin

crea

sed

PAgr

oup)

Non

eFa

ir

Com

bine

din

crea

sed

PA�

decr

ease

dSB

Gir

ls:1

.0kg

/m

2 ;bo

ys:

�1.

76kg

/m2

Flod

mar

ket

al97

(199

3)44

child

ren,

(plu

s50

mat

ched

cont

rol

subj

ects

),Sw

eden

10–1

1(4

8,N

R)

24.7

kg/m

2(f

amily

ther

apy

grou

p);

25.5

kg/m

2

(con

vent

iona

ltr

eatm

ent

grou

p);

25.1

kg/m

2(c

ontr

olgr

oup)

D,E

(no;

yes;

I)14

–18

mo,

5(�

6fa

mily

ther

apy

sess

ions

),N

R,N

R

Fam

ilyth

erap

yC

hang

ein

BMI

26–3

01.

1kg

/m2

�.0

5(f

amily

ther

apy

vsun

trea

ted

cont

rols

ubje

cts)

PFa

ir

Con

vent

iona

ltr

eatm

ent

1.6

kg/m

2

Mat

ched

cont

rol

subj

ects

,un

trea

ted

2.8

kg/m

2

Gol

anet

al98

(199

8)60

child

ren,

Isra

el6–

11(3

8,N

R)

39.1

%ov

erw

eigh

t(c

onve

ntio

nal

grou

p);3

9.6%

(par

ents

agen

tsof

chan

gegr

oup)

BM,D

,E(y

es;n

o*;G

�I)

1y,

30,6

0m

in,

1800

min

Con

vent

iona

l:ch

ildre

nre

spon

sibl

efo

row

nw

eigh

tlo

ss

%O

verw

eigh

tch

ange

12�

8.1%

�.0

5N

one

Fair

Pare

nts

excl

usiv

eag

ents

ofch

ange

�14

.7%

Gra

ves

etal

99

(198

8)

40ch

ildre

n,U

SA6–

12(N

R,N

R)

52–5

6%ov

erw

eigh

tBM

,D,E

(yes

;yes

;G)

8w

k,8,

60m

in,

480

min

BT�

pare

ntPS

%O

verw

eigh

tch

ange

6�

24.5

%�

.05

(PS

vsBT

only

);�

.05

(PS

vsin

stru

ctio

non

ly)

BFa

irBT

only

�10

.2%

Inst

ruct

ion

only

�9.

5%Is

rael

etal

100

(198

5)33

child

ren,

USA

8–12

(30,

NR

)45

.88%

over

wei

ght

(par

ent

trai

ning

grou

p),5

3.13

%(B

Ton

ly),

56.0

2%(c

ontr

olsu

bjec

ts)

BM,D

,E(y

es;y

es;G

)12

mo,

17,2

60-m

inse

ssio

ns,�

930

min

BT�

pare

nttr

aini

ngin

child

man

agem

ent

%O

verw

eigh

tch

ange

12�

10.2

%�

.001

BFa

ir/p

oor

BTon

ly�

1.3%

Wai

t-lis

tco

ntro

lsu

bjec

tsN

R

Isra

elet

al10

1

(199

4)36

fam

ilies

,U

SA8–

13(N

R,N

R)

48.1

%ov

erw

eigh

t(e

nhan

ced

child

invo

lvem

ent

grou

p),4

6.0%

(sta

ndar

dtr

eatm

ent

grou

p)

BM,D

,E(y

es;y

es;G

)26

wk,

17,9

0m

in,

1530

min

Enha

nced

child

invo

lvem

ent

%O

verw

eigh

tch

ange

36�

4.8%

NS

Non

eFa

ir/p

oor

Stan

dard

trea

tmen

t(p

aren

tspr

imar

ilyre

spon

sibl

e)

6.4%

Kan

get

al10

3

(200

2)/

Gut

inet

al10

2

(200

2)

80ad

oles

cent

s,U

SA13

–16

(33,

69)

40.7

%bo

dyfa

t(w

hite

boys

),45

.8%

body

fat(

whi

tegi

rls)

,43

.9%

body

fat

(bla

ckbo

ys),

45.2

%bo

dyfa

t(bl

ack

girl

s)

BM,E

(no;

no;G

)8

mo,

160,

60m

info

rLS

E,va

riab

lefo

rPA

NR

LSE

�hi

ghin

tens

ityPA

Cha

nge

in%

body

fat

8�

2.9%

NS

B,P

Fair

/poo

r

LSE

�m

oder

ate

PA�

1.4%

LSE

�0.

1%



TA

BL

E5.

Con

tinu

ed

Stud

yR

efer

ence

NR

and

omiz

ed,

Cou

ntry

Age

,y(%

Mal

e,%

Non

whi

te)

Rel

ativ

eO

verw

eigh

tat

Bas

elin

eIn

terv

enti

onC

hara

cter

isti

cs*

Gro

upU

nits

ofM

easu

reSt

udy

Dur

atio

n,m

o

Out

com

eat

Lat

est

Follo

w-U

pT

ime

P,C

ompa

riso

nsB

etw

een

Gro

ups†

Oth

erO

utco

mes

USP

STF

Qua

lity

Gra

de

Com

pone

nts

(Com

preh

ensi

ve?;

§Pa

rent

Part

icip

atio

n?;

Gro

upV

ersu

sIn

div

idua

l)

Tim

ePe

riod

,No.

ofSe

ssio

ns,S

essi

onL

engt

h,T

otal

Con

tact

Tim

e,m

in

Mel

lin etal

104

(198

7)

66ad

oles

cent

s,U

SA12

–18

(21,

22)

30–3

7%ov

erw

eigh

tBM

,D,E

(yes

;yes

;G)

14w

k,16

,90

min

,14

40m

inSH

APE

DO

WN

grou

p(c

ogni

tive,

beha

vior

al,

affe

ctiv

etr

eatm

ent)

%O

verw

eigh

tch

ange

15�

9.9%

NR

(bet

wee

n-gr

oup

com

pari

son;

15m

ovs

base

line:

�.0

1,SH

APE

DO

WN

;N

S,co

ntro

lgr

oup)

B,H

Fair

No

trea

tmen

t,co

ntro

lsub

ject

s�

0.1%

Sael

ens

etal

105

(200

2)

44ad

oles

cent

s,U

SA12

–16

(59,

30)

BMI:

30.7

(3.1

)kg

/m2

BM,D

,E(y

es;n

o;1)

4m

o,13

,10–

20m

in,

�20

0m

inH

ealth

yha

bits

inte

rven

tion

%O

verw

eigh

tch

ange

and

chan

gein

BMI

(sta

tistic

alan

alys

eson

BMI

zsc

ores

)

7�

2.4%

,0.

1kg

/m2

NS

B,A

Goo

d

Typi

calc

are

4.1%

,1.

4kg

/m2

Sene

diak

and

Spen

ce10

6

(198

5)

45ch

ildre

n,U

SA6–

13(�

66,N

R)

37.2

2%ov

erw

eigh

tBM

,D,E

(yes

;yes

;G)

4w

k,8,

90m

in,

720

min

Rap

id-s

ched

ule

BT%

Ove

rwei

ght

chan

ge6

�14

.7%

�.0

5(r

apid

and

grad

uals

ched

ule

BTgr

oups

com

bine

dvs

nons

peci

ficco

ntro

lsub

ject

s);

NS

(com

pari

son

ofra

pid

vsgr

adua

lsch

edul

eBT

grou

ps)

BFa

ir/p

oor

Gra

dual

lyde

crea

sing

sche

dule

BT

�18

.3%

Non

spec

ific

trea

tmen

t,co

ntro

lsub

ject

s

�10

.9%

Wai

t-lis

tco

ntro

lsu

bjec

tsN

R

Wad

den

etal

107

(199

0)

47gi

rls,

USA

12–1

6(0

,100

[all

blac

k])

95.1

kg;B

MI:

35.6

kg/m

2

BM,D

,E(y

es;y

es;G

)10

mo,

22,6

0m

in(f

irst

16se

ssio

ns),

othe

rsN

R,�

960

min

Mot

her

and

child

toge

ther

Cha

nge

inw

eigh

t6

1.7

kgN

SP,

HFa

ir/p

oor

Chi

ldal

one

3.0

kgM

othe

ran

dch

ildse

para

te3.

5kg

Whi

te10

8

(200

3)/

Will

iam

son,

unpu

blis

hed

data

57ad

oles

cent

s,U

SA11

–15

(0,1

00)

BMI:

36.3

4kg

/m2 ;

98.3

BMI

perc

entil

eBM

,D,E

(yes

;yes

:I)

6m

o,4

and

wee

kly

Web

-site

logi

ns,

NR

,NR

Beha

vior

alC

hang

ein

%bo

dyfa

t,ch

ange

inBM

I

6�

1.12

%;�

0.19

kg/m

2

�.0

5(%

body

fat)

;�

.05

(cha

nge

inBM

I)

BG

ood

Educ

atio

non

ly0.

43%

;0.6

5kg

/m

2

NH

Sin

dic

ates

Nat

iona

lHea

lth

Serv

ice;

NS,

nots

igni

fica

nt;B

M,b

ehav

ior

mod

ific

atio

n;D

,spe

cial

die

t;E

,exe

rcis

epr

ogra

m;G

,gro

up;I

,ind

ivid

ual;

othe

rou

tcom

es:B

,beh

avio

ral;

P,ph

ysio

logi

c;H

,chi

ldho

odhe

alth

outc

omes

;A,a

dve

rse

effe

cts;

NR

,not

repo

rted

;LSE

,lif

esty

leed

ucat

ion;

BT

,beh

avio

ral

ther

apy;

TC

,tot

alch

oles

tero

l;SB

,sed

enta

rybe

havi

or;P

A,p

hysi

cal

acti

vity

;PS,

prob

lem

solv

ing.

*Fo

rm

ost

inte

nsiv

ein

terv

enti

on,w

hich

islis

ted

firs

t.†

Ifm

ulti

ple

com

pari

sons

,the

npr

esen

ted

only

ifP

�.0

5.‡

The

actu

alnu

mbe

rw

asno

tre

port

ed;t

hem

ean

(SD

)w

as10

.3(1

.1)

year

s.§

Inte

rven

tion

that

uses

aco

mbi

nati

onof

beha

vior

mod

ific

atio

npr

oced

ures

,asp

ecia

ld

iet,

and

anex

erci

sepr

ogra

m.



interventions conducted in specialty obesity clinicsettings to address overweight among school-agedchildren who were �40% to 50% above ideal weight.Figure 4 models the short-term (1-year) results fromthese types of studies, translated to BMI percentiles.

Figure 5 demonstrates results from all behavioralcounseling studies among adolescents86,88,104,105,107,108

that reported, or could be translated into, BMI per-centiles. Most studies addressed extremely over-weight patients, with short-term results showingmodest to no change in BMI percentiles. Only 2good-quality studies among adolescents were partic-ularly relevant to primary care.105,108

One short-term, primary care-conducted trial thatused a computer-based approach to generate tai-lored plans for counseling obese (above the adult

BMI cutoff of 30 kg/m2) adolescents (12–16 years ofage) showed small but significant improvements105

(Fig 5). An Internet-based, short-term trial targeting57 overweight (mean BMI: 36.37 kg/m2), non-His-panic black, female youths (11–15 years of age) with�1 obese biological parent resulted in statisticallysignificant differences in weight and BMI.108 Al-though both trials showed small but statistically sig-nificant benefits in BMI measures at 6 to 12 months,it is not clear that these BMI changes would haveclinical benefits.

Considering other intermediate outcomes in addi-tion to weight, more than one half (n � 13) of fair-or good-quality trials86,88–94,97,99,104,105,108 reportedintermediate behavioral (n � 11) or physiologic (n �7) measures (Table 5). Two good-quality trials105,108

Fig 4. Modeled effects of behavioral weight loss treatment on BMI among children 8 to 13 years of age, using CDC US growth charts(BMI-for-age percentiles for girls 2–20 years of age). Large black circles indicate the mean BMI of study participants at a given age at thetime of entry into a typical behavioral counseling weight loss trial. The bracket to the right of each circle indicates the typical range of meanparticipant BMI values 1 year after trial entry. Top and bottom bars of brackets indicate 10% and 20% reductions in percent overweight(converted to BMI), respectively, which was the typical range of weight lost. Source: National Center for Health Statistics in collaborationwith the National Center for Chronic Disease Prevention and Health Promotion, 2000.



reported behavioral changes but no physiologic out-comes. Although one108 indicated reduced total dailyenergy intake in the active treatment group, neitherindicated changes in physical activity. One fair-qual-ity study reported reductions in targeted dietarycomponents (fat or glycemic load of diet), but notenergy,88 whereas other fair-quality studies89–94,99,104

measured changes in eating behaviors, physical ac-tivity, and sedentary behaviors but did not provide aclear picture because of differences in subjects, inter-ventions, and measures.

No good-quality trials of behavioral treatment re-ported intermediate physiologic outcomes, such aslipid or lipoprotein levels, glucose tolerance, orblood pressure, or physical fitness measures. Onlyone trial of at least fair quality reported intermediate

physiologic measures. An intensive, 6-month, behav-ioral, weight control program comparing a reduced-glycemic load diet with a reduced-fat diet increasedinsulin resistance scores (measured with the homeo-static model) significantly less in the reduced-glyce-mic load diet group than the reduced-fat diet group(�0.4 � 0.9 vs 2.6 � 1.2, P � .03).88 Insulin resistanceincreases with sexual maturation, however, whichwas not assessed. These results are also limited bybaseline differences between groups and lack of con-sideration of physical activity as a confounder.Among the fair-quality studies that measured phys-ical work capacity or physical fitness, most reportedsome improvement when physical activity or seden-tary behaviors were addressed in the interven-tion.89,90,93,94

Fig 5. Effects of behavioral weight loss treatment on BMI among adolescents, using CDC US growth charts (BMI-for-age percentiles forgirls 2–20 years of age). Boxes represent mean BMI at entry for each behavioral counseling intervention trial. The white box indicates astudy of behavioral counseling plus sibutramine. Numbers inside boxes identify studies in the reference list. Arrows indicate the meanchange in BMI at study follow-up assessment 6 months or later. No arrow indicates that the mean BMI for the treatment group did notchange significantly. Source: National Center for Health Statistics in collaboration with the National Center for Chronic DiseasePrevention and Health Promotion, 2000.



PharmacotherapyOne randomized, placebo-controlled trial of sib-

utramine within a comprehensive behavioral treat-ment program for adolescents showed superiorweight change outcomes after 6 months (4.6-kggreater weight loss; 95% CI: 2.0–7.4 kg) in an intent-to-treat analysis86 (Fig 5). With continued use, weightloss at 6 months was maintained through 12 months.It is not clear whether the additional short-termweight change achieved with the addition of sibutra-mine to a comprehensive behavioral treatment pro-gram among adolescents86 would provide a net ben-efit, because changes in serum lipid levels, seruminsulin levels, serum glucose levels, and homeostaticmodel of insulin sensitivity values did not differbetween groups. Among all trial completers (63–76%of all participants) at 12 months, significant improve-ments from baseline were seen in high-density li-poprotein cholesterol levels, serum insulin levels,and homeostatic model of insulin sensitivity values.Blood pressure was not improved, and in some casesincreased blood pressure was a reason for discontin-uation. The rate of adverse effects and discontinua-tion was fairly high (12% discontinued and 28% re-duced the medication) (see also key question 6). Wefound no evidence for metformin use for weightloss/disease prevention among normoglycemicobese adolescents with weight outcomes after �3months, nor did we find acceptable evidence on al-ternative or complementary therapies.

SurgeryNo acceptable quality evidence is available for

adolescents, evaluating surgical approaches to over-weight. There are no controlled treatment outcomedata on bariatric surgery approaches among adoles-cents.

Key Question 5: Do Interventions Lead to ImprovedAdult Health Outcomes, Reduced Childhood MorbidityRates, and/or Improved Psychosocial and FunctionalChildhood Outcomes?

Few (n � 3) studies reported health outcomes asdefined in our analytic framework,94,104,107 and only2 were rated at least fair quality (Table 5). In onefair-quality trial, depression scores measured withreliable and valid instruments showed improvementfrom baseline among treated adolescent girls but notcontrol subjects, whereas reliably measured self-es-teem scores improved from baseline in bothgroups.104 In a second fair-quality study, signifi-cantly fewer children 8 to 12 years of age, receivingcomprehensive behavioral treatment, had elevatedtotal behavior problem scores or elevated internaliz-ing behavior problem scores at the 24-month fol-low-up assessment than at baseline.95

Key Question 6: Do Interventions Have AdverseEffects, Such as Stigmatization, Binging or PurgingBehaviors, Eating Disorders, Suppressed Growth, orExercise-Induced Injuries?

Behavioral Counseling InterventionsAdverse effect reporting for behavioral counseling

interventions was limited to 3 of 22 intervention

trials. Potential eating problems or weight manage-ment behaviors were the only harms addressed in2 trials. One good-quality trial reported no adverseeffects on problematic eating (using validated mea-sures for dietary restraint, eating disinhibition, prob-lematic weight management behaviors, weight con-cerns, and eating disorder psychopathologic features)after primary care-based comprehensive behavioraltreatment for 37 of 44 adolescent trial completers.105

One fair-quality trial reported no effect on eatingdisorder symptoms, weight dissatisfaction, or purg-ing/restricting behaviors among 47 children 8 to12 years of age in a family-based comprehensivebehavioral treatment program, using a reliable mea-sure (Kids’ Eating Disorder Survey).95,110 Differencesbetween boys (no effect) and girls (elevated totalscores) were not significant but may be revealed instudies with larger sample sizes.

PharmacotherapyIn the placebo-controlled phase of the sibutramine

trial,86 44% of patients (19 of 43 patients) in the activemedication group reduced or discontinued the med-ication because of elevated blood pressure, pulserate, or both, which were the main adverse eventsreported.

SurgeryWe attempted to estimate the rate of harms from

the uncontrolled cohort literature, but loss to fol-low-up monitoring (25–60% at 4–24 months)111–113

and inadequate reporting prevented us from makingreasonable estimates of surgery-associated harms.

Summary of Evidence QualityTable 6 summarizes the overall quality of evi-

dence, according to USPSTF criteria,35 for each keyquestion addressed in this review (see Appendix).The overall evidence is poor for the direct effects ofscreening (and intervention) programs (key question1), screening harms (key question 3), and bariatricsurgery (key questions 4 and 5). The overall evidenceis fair/poor for behavioral counseling interventions(key questions 4 and 5), because of small, noncom-parable, short-term studies with limited generaliz-ability that reported health or intermediate out-comes, such as cardiovascular risk factors, rarely.Trials are particularly inadequate for nonwhite sub-jects and children 2 to 5 years of age. Fair/poorevidence is available for behavioral counseling inter-vention harms because of very limited reporting (keyquestion 6). Fair evidence supports childhood BMIas a risk factor for adult overweight, although dataare limited for nonwhite subjects (key question 2b),and data addressing BMI as a risk factor for adultmorbidities generally do not control for confoundingby adult BMI (key question 2c). Good evidence isavailable for overweight prevalence based on BMImeasures in all groups, except Native American andAsian groups (key question 2a).

CONCLUSIONSOverweight has at least doubled among children

and adolescents in the United States in the past 25



years and is particularly common among racial/ethnic minorities. This increase represents a majorpublic health concern, with the potential for futurehealth risks and growing burdens on the health caresystem. In terms of evidence, however, little haschanged since a 1998 Journal of Pediatrics editorialconcluded that, “In the case of obesity, the primarycare physician is left in the uncomfortable (but famil-iar) position of needing to do something now for thepatient and family seeking help, regardless of theuncertainty about the nature of the disease and theabsence of a cure.”114 Given the nature of the prob-lem, effective solutions will likely require substantialcollaboration between the medical and public healthcommunities.115 Greater understanding of how toexpand the appropriate role of clinicians in commu-nity public health, such as through advocating nec-essary environmental and political changes, wouldbe helpful.116,117

A major limitation for clinicians addressing over-weight among children, most of whom are not mor-bidly overweight, is the uncertain criteria for deter-mining clinically significant overweight. AlthoughBMI is the best clinically available measure of over-weight, uncertainty in its application to individualpatients remains, because of limited knowledge ofthe current and future health effects of BMI and thepossible limits in the applicability of current BMIcutoff points, particularly for minority race/ethnic-ity. Understanding normal variations in body com-position with age, gender, race/ethnicity, sexual ma-turity, and other factors will be critical for definingaccurately unhealthy excess fat or other componentsof overweight, and appropriate measurement meth-ods. Similarly, as has been done elsewhere, examin-ing the sensitivity and specificity of BMI percentilecutoff values for identifying overweight children,with large representative samples of US children ofall ages and races/ethnicities, would increase ourunderstanding of BMI as a screening tool.118

The risk for overweight children becoming over-weight or obese adults has been judged as the best

available criterion to judge the clinical validity ofBMI in the pediatric age group.119 Adult BMI hasbeen associated clearly with morbidity and mortalityrates, particularly at higher BMI levels, althoughthere is no single threshold for increased healthrisks.120 Adolescents in �95th percentile for age- andgender-specific BMI clearly have an increased prob-ability of adult obesity, and early interventions couldbe very beneficial. Recent intervention research tar-geting this age group primarily addressed subjectswho were very overweight, with some studies show-ing short-term (6–12-month) weight-related im-provements. The treatment evidence in this agegroup could be strengthened with larger trials test-ing generalizable interventions that can demonstratesustained effects on overweight status and weight-related outcomes. Many trials among adolescentshave targeted minorities specifically107,108 or enrolledreasonable proportions in their studies,86,102,105 andthis should continue. Trials among mildly over-weight adolescents, as well as those more severelyaffected, are needed. With limited to no evidenceavailable, experts agree that surgical approachesshould be considered only for adolescents with ex-treme morbid obesity, and pharmacologic ap-proaches should be limited to a second-tier approachafter failed behavioral counseling.111,121

In contrast, current data suggest that a substantialproportion of children under age 12 or 13, even withBMIs of �95th percentile, will not develop adultobesity. Children 8 to 12 years of age have been themost well studied for behavioral overweight treat-ment, but we still have very limited informationabout interventions that would be applicable to pri-mary care. No current, randomized, controlled trialof clinical interventions of any type is available forchildren 2 to 5 years of age.

For all ages, there is very limited evidence forbehavioral or other overweight treatment that is fea-sible for primary care delivery or referral. Few stud-ies have taken place in primary care setting; mosthave been conducted in research or specialty obesity

TABLE 6. Summary of Evidence Quality for Key Questions Addressing Childhood and Adolescent Overweight

Key Question Study Hierarchy Overall USPSTF Quality

1. Screening Poor2a. Prevalence II-2 Good but lacking for specific nonwhite racial/ethnic subgroups2b and 2c. Screening tests as a risk factor II-2 Fair; data for BMI as a risk factor for adult overweight from

childhood overweight are the most valid but are very limitedfor nonwhite subjects; data for BMI as a risk factor for adultmorbidities generally do not control for confounding byadult BMI

3. Screening harms Poor; because of lack of screening studies, possible harms canonly be inferred from other sources

4 and 5. BCI interventions I Fair/poor; data are limited by very small samples,noncomparable interventions, and not using intent-to-treatanalyses; little reporting of intermediate outcomes, includingrisk factor changes or changes in health outcomes; poorgeneralizability because of specialist interventions not widelyavailable and addressing mostly 8–12 y; no data for 2–5 y;few trials include nonwhite subjects

4 and 5. Pharmacotherapy with BCI I Fair; one good quality trial with adolescents4 and 5. Surgery Poor6. Intervention harms I, II-2 Fair/poor; very limited reporting of harms for BCI

interventions.

BCI indicates behavioral counseling.



clinics with intensive, comprehensive, behavioraltreatment. Experts have cautioned that behavioraltherapy represents an expertise-driven approach toimproving diet and physical activity with behavioralprinciples and is not simply an add-on to a diet andexercise plan.122 If larger studies confirm that behav-ioral skills and approaches are key to treatment suc-cess, then creation of referral clinics or involvementof clinic team members with behavioral medicine/psychology weight management expertise will becritical.

Experts recommend referring certain children topediatric obesity treatment centers for expert man-agement. These include children who are massivelyoverweight (defined through clinical judgment)5 orwho have a BMI exceeding the 95th percentile, withassociated severe morbidities that require immediateweight loss. For asymptomatic children with a BMIof �95th percentile, experts recommend an in-depthmedical assessment to detect treatable causes of obe-sity, risk factors, and comorbidities. For childrenwhose BMI falls between the 85th and 95th percen-tiles for age and gender, they also recommend clin-ical evaluations for secondary effects of overweight,such as hypertension and hyperlipidemia. We didnot find adequate evidence meeting our criteria toaddress the impact of BMI screening and/or treat-ment of overweight (or at risk for overweight) on anyof these risks factors or morbidities.

Experts emphasize talking to families about en-ergy balance behaviors that might help prevent obe-sity and would also promote other aspects of healthand likely cause no harms.123 These behaviors in-clude limiting television viewing, encouraging out-door play, and limiting the consumption of sugar-sweetened soft drinks. For interested clinicians,pragmatic approaches for all children (particularlyyoung children) that emphasize the “healthy lifestyleprescription” approach over targeting overweightidentification seem appropriate, because we foundlimited evidence for secondary prevention or treat-ment. However, clinicians should be aware that oth-ers have found limited evidence for the effectivenessof primary prevention in clinical settings.124

Given the current evidence, BMI measurementsamong older adolescents may provide an early rea-sonable indication of future adult health risks attrib-utable to obesity. BMI measurements for youngerchildren should be performed as a growth-monitor-ing tool that might indicate future risk for adultoverweight and its attendant morbidities, with re-duced emphasis on defining current overweight.Children, particularly those �13 years of age, with-out clinical weight-related morbidities would notnecessarily be labeled overweight but might be con-sidered at risk or at high risk, depending on the BMIlevel. Experts recommend regular longitudinal mon-itoring and careful documentation of BMI amongchildren and adolescents.125 Such monitoring willlikely prove even more valuable as our understand-ing grows about the predictive value of levels andpatterns of growth and overweight status changesover time and about effective ways to address pat-

terns that indicate overweight that affects currenthealth or a high future risk of adult overweight.

In the absence of direct evidence of the effects ofscreening on improved weight and health outcomesamong children and/or adults, we evaluated indirectevidence for screening and intervention. In the cur-rent literature, evidence linkages between screeningand intervention are hampered by divergent defini-tions of overweight. It is important that a consistentdefinition of overweight be accepted, to encouragerapid progress in our understanding of how to ad-dress this critical problem.

Limited evidence on normal body compositionamong children and adolescents and lack of criterionstandards for adiposity among children hamperedour ability to determine the test characteristics (sen-sitivity and specificity) of clinically feasible screeningtests. Valid, feasible, body composition measures forchildren are becoming established,126 which shouldallow examination of the sensitivity and specificity ofBMI percentiles and overweight in US populations,as elsewhere.118 Similarly, clearly establishing cur-rent or future health consequences of elevated BMI(and other overweight measures) for boys and girlsof all ages and racial/ethnic origins will enable fu-ture diagnostic research. By confining our review ofchildhood BMI and adult health consequences tolongitudinal US studies, we gained some advantagesfrom more similar overweight definitions, measure-ments, and reference standards72 but might haveeliminated applicable data unnecessarily. Becausethe reviewed research was primarily among non-Hispanic white subjects, its applicability to minoritygroups, in which the prevalence of overweight isincreasing particularly, may be limited.

We did not locate adequate longitudinal data re-lating childhood weight status to childhood healthoutcomes; therefore, we did not review it formally.Current literature is primarily cross-sectional, pre-sents relative risks without absolute risks, or reportson the relationship of growth measures (or changesin the measures over time) to intermediate measures,such as blood pressure or lipid levels, rather thanhealth outcomes.

Although we made an effort to review severalareas of the literature comprehensively, some areaswere not reviewed. We did not review any evidencefor children �2 years of age, although this is anactive area for research. We did not attempt to ex-amine risk factors for childhood overweight, but oth-ers have done so.71 Similarly, research on changingchildren’s daily life habits that might also affect orprevent pediatric overweight, such as changing di-etary intake, increasing physical activity, or limitingactivities such as television viewing, that did notaddress weight effects directly was beyond the scopeof this study.

There are critical research gaps in answering themost basic questions needed to enable clinicians toengage strategies to prevent current and futureweight-related morbidities among children. Despitethe fact that many of these gaps were pointed out�10 years ago,127 little subsequent research has ad-dressed the most clinically relevant questions. In ad-



dition to the clinical research already underway toaddress childhood overweight prevention and treat-ment, we strongly urge the research community toprioritize research studies that would supply neededevidence to address the key questions formulated forthis report, to guide pragmatic clinical and publichealth prevention strategies. Some of these studiescould involve reporting from existing, good-quality,cross-sectional and longitudinal cohort studies, inaddition to new studies and clinical trials. For a morecomplete list of research recommendations, readerscan consult the full review.36

ACKNOWLEDGMENTSThis report was prepared by the Oregon Evidence-Based Prac-

tice Center under contract 290-02-0024 (task order 2) from theAgency for Healthcare Research and Quality.

We thank Daphne Plaut, MLS, Tracy Beil, MS, Betsy Garlitz,MD, and Kevin Lutz, MFA, for assistance in the preparation of thismanuscript. We thank the reviewers of the full evidence report forcontributions to this project. We also relied on guidance from ourUS Preventive Services Task Force liaisons at key points through-out the review process, including Janet Allan, PhD, RN, CS,FAAN; Mark Johnson MD, MPH; Jonathan Klein, MD, MPH;Virginia Moyer, MD, MPH; Judith Ockene, PhD; Steven Teutsch,MD, MPH; and former USPSTF liaison C. Tracy Orleans, PhD.

REFERENCES1. Flegal KM. The obesity epidemic in children and adults: current evi-

dence and research issues. Med Sci Sports Exerc. 1999;31(suppl):S509–S514

2. Kohn M, Booth M. The worldwide epidemic of obesity in adolescents.Adolesc Med State Art Rev. 2003;14:1–9

3. Sokol RJ. The chronic disease of childhood obesity: the sleeping gianthas awakened. J Pediatr. 2000;136:711–713

4. Lobstein T, Baur L, Uauy R. Obesity in children and young people: acrisis in public health. Obes Rev. 2004;(suppl 1):4–85

5. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Com-mittee recommendations: the Maternal and Child Health Bureau,Health Resources and Services Administration and the Department ofHealth and Human Services. Pediatrics. 1998;102(3). Available at:www.pediatrics.org/cgi/content/full/102/3/e29

6. Himes JH, Dietz WH. Guidelines for overweight in adolescent preven-tive services: recommendations from an expert committee: the ExpertCommittee on Clinical Guidelines for Overweight in Adolescent Pre-ventive Services. Am J Clin Nutr. 1994;59:307–316

7. Troiano RP, Flegal KM. Overweight children and adolescents: descrip-tion, epidemiology, and demographics. Pediatrics. 1998;101:497–504

8. Koplan JP, Dietz WH. Caloric imbalance and public health policy.JAMA. 1999;282:1579–1581

9. Dwyer JT, Stone EJ, Yang M, et al. Prevalence of marked overweightand obesity in a multiethnic pediatric population: findings from theChild and Adolescent Trial for Cardiovascular Health (CATCH) study.J Am Diet Assoc. 2000;100:1149–1156

10. Must A, Strauss RS. Risks and consequences of childhood and adoles-cent obesity. Int J Obes Relat Metab Disord. 1999;23(suppl 2):S2–S11

11. Must A. Morbidity and mortality associated with elevated bodyweight in children and adolescents. Am J Clin Nutr. 1996;63(suppl):445S–447S

12. Reilly JJ, Methven E, McDowell ZC, et al. Health consequences ofobesity. Arch Dis Child. 2003;88:748–752

13. Zametkin AJ, Zoon CK, Klein HW, Munson S. Psychiatric aspects ofchild and adolescent obesity: a review of the past 10 years. J Am AcadChild Adolesc Psychiatry. 2004;43:134–150

14. Must A, Anderson SE. Effects of obesity on morbidity in children andadolescents. Nutr Clin Care. 2003;6:4–12

15. Rodriguez MA, Winkleby MA, Ahn D, Sundquist J, Kraemer HC.Identification of population subgroups of children and adolescentswith high asthma prevalence: findings from the Third National Healthand Nutrition Examination Survey. Arch Pediatr Adolesc Med. 2002;156:269–275

16. Kelsey JL. Epidemiology of slipped capital femoral epiphysis: a reviewof the literature. Pediatrics. 1973;51:1042–1050

17. Silvestri JM, Weese-Mayer DE, Bass MT, Kenny AS, Hauptman SA,Pearsall SM. Polysomnography in obese children with a history ofsleep-associated breathing disorders. Pediatr Pulmonol. 1993;16:124–129

18. Mallory GB Jr, Fiser DH, Jackson R. Sleep-associated breathing disor-ders in morbidly obese children and adolescents. J Pediatr. 1989;115:892–897

19. Tominaga K, Kurata JH, Chen YK, et al. Prevalence of fatty liver inJapanese children and relationship to obesity: an epidemiological ul-trasonographic survey. Dig Dis Sci. 1995;40:2002–2009

20. Franzese A, Vajro P, Argenziano A, et al. Liver involvement in obesechildren: ultrasonography and liver enzyme levels at diagnosis andduring follow-up in an Italian population. Dig Dis Sci. 1997;42:1428–1432

21. Chan DF, Li AM, Chu WC, et al. Hepatic steatosis in obese Chinesechildren. Int J Obes Relat Metab Disord. 2004;28:1257–1263

22. Rosenbloom AL, Joe JR, Young RS, Winter WE. Emerging epidemic oftype 2 diabetes in youth. Diabetes Care. 1999;22:345–354

23. Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, PettittDJ. Increasing prevalence of type II diabetes in American Indian chil-dren. Diabetologia. 1998;41:904–910

24. Sinha R, Fisch G, Teague B, et al. Prevalence of impaired glucosetolerance among children and adolescents with marked obesity. N EnglJ Med. 2002;346:802–810

25. Freedman DS, Srinivasan SR, Berensen GS. Risk of cardiovascularcomplication. In: Burniat W, Cole T, Lissau I, Poskitt EME, eds. Childand Adolescent Obesity Causes and Consequences, Prevention and Manage-ment. Cambridge, United Kingdom: Cambridge University Press; 2002:221–239

26. Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence ofa metabolic syndrome phenotype in adolescents: findings from theThird National Health and Nutrition Examination Survey, 1988–1994.Arch Pediatr Adolesc Med. 2003;157:821–827

27. Weiss R, Dziura J, Burgert TS, et al. Obesity and the metabolic syn-drome in children and adolescents. N Engl J Med. 2004;350:2362–2374

28. Dietz WH. Health consequences of obesity in youth: childhood pre-dictors of adult disease. Pediatrics. 1998;101:518–525

29. Figueroa-Colon R, Franklin FA, Lee JY, Aldridge R, Alexander L.Prevalence of obesity with increased blood pressure in elementaryschool-aged children. South Med J. 1997;90:806–813

30. Dietz WH. Childhood weight affects adult morbidity and mortality.J Nutr. 1998;128(suppl):411S–414S

31. French SA, Story M, Perry CL. Self-esteem and obesity in children andadolescents: a literature review. Obes Res. 1995;3:479–490

32. Strauss RS. Childhood obesity and self-esteem. Pediatrics. 2000;105(1).Available at: www.pediatrics.org/cgi/content/full/105/1/e15

33. Strauss RS, Pollack HA. Social marginalization of overweight children.Arch Pediatr Adolesc Med. 2003;157:746–752

34. US Preventive Services Task Force. Guide to Clinical Preventive Services.2nd ed. Baltimore, MD: Williams & Wilkins; 1996

35. Harris RP, Helfand M, Woolf SH, et al. Current methods of the USPreventive Services Task Force: a review of the process. Am J Prev Med.2001;20(suppl):21–35

36. Whitlock EP, Williams SB, Gold R, Smith P, Shipman S. Screening andInterventions for Childhood Overweight: A Systematic Review for the USPreventive Services Task Force: Systematic Evidence Review. Rockville,MD: Agency for Healthcare Research and Quality; 2005

37. Haddock CK, Shadish WR, Klesges RC, Stein RJ. Treatments for child-hood and adolescent obesity. Ann Behav Med. 1994;16:235–244

38. Epstein LH, Roemmich JN, Raynor HA. Behavioral therapy in thetreatment of pediatric obesity. Pediatr Clin North Am. 2001;48:981–993

39. Glenny AM, O’Meara S, Melville A, Sheldon TA, Wilson C. Thetreatment and prevention of obesity: a systematic review of the liter-ature. Int J Obes Relat Metab Disord. 1997;21:715–737

40. Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, WatersE. Interventions for treating obesity in children. Cochrane Database SystRev. 2003;(3):CD001872

41. Reilly JJ, Wilson ML, Summerbell CD, Wilson DC. Obesity: diagnosis,prevention, and treatment: evidence based answers to common ques-tions. Arch Dis Child. 2002;86:392–394

42. Reilly JJ, McDowell ZC. Physical activity interventions in the preven-tion and treatment of paediatric obesity: systematic review and criticalappraisal. Proc Nutr Soc. 2003;62:611–619

43. McLean N, Griffin S, Toney K, Hardeman W. Family involvement inweight control, weight maintenance and weight-loss interventions: asystematic review of randomised trials. Int J Obes Relat Metab Disord.2003;27:987–1005



44. Kuczmarski RJ. Trends in body composition for infants and children inthe U.S. Crit Rev Food Sci Nutr. 1993;33:375–387

45. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trendsin overweight among US children and adolescents, 1999–2000. JAMA.2002;288:1728–1732

46. WHO Working Group. Use and interpretation of anthropometric in-dicators of nutritional status. Bull World Health Organ. 1986;64:929–941

47. Ogden CL, Carroll MD, Flegal KM. Epidemiologic trends in over-weight and obesity. Endocrinol Metab Clin North Am. 2003;32:741–760

48. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts forthe United States: methods and development. Vital Health Stat 11.2002;(246):1–190

49. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, FlegalKM. Prevalence of overweight and obesity among US children, ado-lescents, and adults, 1999–2002. JAMA. 2004;291:2847–2850

50. Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Be-renson GS. Inter-relationships among childhood BMI, childhoodheight, and adult obesity: the Bogalusa Heart Study. Int J Obes RelatMetab Disord. 2004;28:10–16

51. Hulman S, Kushner H, Katz S, Falkner B. Can cardiovascular risk bepredicted by newborn, childhood, and adolescent body size? An ex-amination of longitudinal data in urban African Americans. J Pediatr.1998;132:90–97

52. Wattigney WA, Webber LS, Srinivasan SR, Berenson GS. The emer-gence of clinically abnormal levels of cardiovascular disease risk factorvariables among young adults: the Bogalusa Heart Study. Prev Med.1995;24:617–626

53. Garn SM, Lavelle M. Two-decade follow-up of fatness in early child-hood. Am J Dis Child. 1985;139:181–185

54. Lauer RM, Clarke WR, Burns TL. Obesity in childhood: the MuscatineStudy. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi. 1997;38:432–437

55. Guo SS, Roche AF, Chumlea WC, Gardner JD, Siervogel RM. Thepredictive value of childhood body mass index values for overweightat age 35 y. Am J Clin Nutr. 1994;59:810–819

56. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predictingobesity in young adulthood from childhood and parental obesity.N Engl J Med. 1997;337:869–873

57. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS.Relationship of childhood obesity to coronary heart disease risk factorsin adulthood: the Bogalusa Heart Study. Pediatrics. 2001;108:712–718

58. Guo SS, Wu W, Chumlea WC, Roche AF. Predicting overweight andobesity in adulthood from body mass index values in childhood andadolescence. Am J Clin Nutr. 2002;76:653–658

59. Freedman DS, Shear CL, Burke GL, et al. Persistence of juvenile-onsetobesity over eight years: the Bogalusa Heart Study. Am J Public Health.1987;77:588–592

60. Casey VA, Dwyer JT, Coleman KA, Valadian I. Body mass index fromchildhood to middle age: a 50-y follow-up. Am J Clin Nutr. 1992;56:14–18

61. Lauer RM, Lee J, Clarke WR. Factors affecting the relationship betweenchildhood and adult cholesterol levels: the Muscatine Study. Pediatrics.1988;82:309–318

62. Lauer RM, Clarke WR. Childhood risk factors for high adult bloodpressure: the Muscatine Study. Pediatrics. 1989;84:633–641

63. Clarke WR, Lauer RM. Does childhood obesity track into adulthood?Crit Rev Food Sci Nutr. 1993;33:423–430

64. Valdez R, Greenlund KJ, Wattigney WA, Bao W, Berenson GS. Use ofweight-for-height indices in children to predict adult overweight: theBogalusa Heart Study. Int J Obes Relat Metab Disord. 1996;20:715–721

65. Sinaiko AR, Donahue RP, Jacobs DR Jr, Prineas RJ. Relation of weightand rate of increase in weight during childhood and adolescence tobody size, blood pressure, fasting insulin, and lipids in young adults:the Minneapolis Children’s Blood Pressure Study. Circulation. 1999;99:1471–1476

66. Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social andeconomic consequences of overweight in adolescence and youngadulthood. N Engl J Med. 1993;329:1008–1012

67. Srinivasan SR, Bao W, Wattigney WA, Berenson GS. Adolescent over-weight is associated with adult overweight and related multiple car-diovascular risk factors: the Bogalusa Heart Study. Metab Clin Exp.1996;45:235–240

68. Lauer RM, Clarke WR, Mahoney LT, Witt J. Childhood predictors forhigh adult blood pressure: the Muscatine Study. Pediatr Clin North Am.1993;40:23–40

69. Webber LS, Cresanta JL, Croft JB, Srinivasan SR, Berenson GS. Tran-sitions of cardiovascular risk from adolescence to young adulthood:

the Bogalusa Heart Study, II: alterations in anthropometric bloodpressure and serum lipoprotein variables. J Chronic Dis. 1986;39:91–103

70. Power C, Lake JK, Cole TJ. Body mass index and height from child-hood to adulthood in the 1958 British born cohort. Am J Clin Nutr.1997;66:1094–1101

71. Parsons TJ, Power C, Logan S, Summerbell CD. Childhood predictorsof adult obesity: a systematic review. Int J Obes Relat Metab Disord.1999;(suppl 8):S1–107

72. Power C, Lake JK, Cole TJ. Measurement and long-term health risks ofchild and adolescent fatness. Int J Obes Relat Metab Disord. 1997;21:507–526

73. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-termmorbidity and mortality of overweight adolescents: a follow-up of theHarvard Growth Study of 1922 to 1935. N Engl J Med. 1992;327:1350–1355

74. Nieto FJ, Szklo M, Comstock GW. Childhood weight and growth rateas predictors of adult mortality. Am J Epidemiol. 1992;136:201–213

75. Lauer RM, Lee J, Clarke WR. Predicting adult cholesterol levels frommeasurements in childhood and adolescence: the Muscatine Study.Bull NY Acad Med. 1989;65:1127–1142

76. Srinivasan SR, Myers L, Berenson GS. Predictability of childhoodadiposity and insulin for developing insulin resistance syndrome (syn-drome X) in young adulthood: the Bogalusa Heart Study. Diabetes.2002;51:204–209

77. Bao W, Srinivasan SR, Wattigney WA, Bao W, Berenson GS. Useful-ness of childhood low-density lipoprotein cholesterol level in predict-ing adult dyslipidemia and other cardiovascular risks: the BogalusaHeart Study. Arch Intern Med. 1996;156:1315–1320

78. Kaplan KM, Wadden TA. Childhood obesity and self-esteem. J Pediatr.1986;109:367–370

79. Davison KK, Birch LL. Weight status, parent reaction, and self-conceptin five-year-old girls. Pediatrics. 2001;107:46–53

80. Cameron JW. Self-esteem changes in children enrolled in weight man-agement programs. Issues Compr Pediatr Nursing. 1999;22:75–85

81. Erickson SJ, Robinson TN, Haydel KF, Killen JD. Are overweightchildren unhappy? Body mass index, depressive symptoms, and over-weight concerns in elementary school children. Arch Pediatr AdolescMed. 2000;154:931–935

82. Berkey CS, Rockett HR, Gillman MW, Field AE, Colditz GA. Longitu-dinal study of skipping breakfast and weight change in adolescents.Int J Obes Relat Metab Disord. 2003;27:1258–1266

83. Strauss RS, Mir HM. Smoking and weight loss attempts in overweightand normal-weight adolescents. Int J Obes Relat Metab Disord. 2001;25:1381–1385

84. Fulkerson JA, French SA. Cigarette smoking for weight loss or controlamong adolescents: gender and racial/ethnic differences. J AdolescHealth. 2003;32:306–313

85. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating primary carebehavioral counseling interventions: an evidence-based approach.Am J Prev Med. 2002;22:267–284

86. Berkowitz RI, Wadden TA, Tershakovec AM, Cronquist JL. Behaviortherapy and sibutramine for the treatment of adolescent obesity: arandomized controlled trial. JAMA. 2003;289:1805–1812

87. Duffy G, Spence SH. The effectiveness of cognitive self-management asan adjunct to a behavioural intervention for childhood obesity: aresearch note. J Child Psychol Psychiatry. 1993;34:1043–1050

88. Ebbeling CB, Leidig MM, Sinclair KB, Hangen JP, Ludwig DS. Areduced-glycemic load diet in the treatment of adolescent obesity. ArchPediatr Adolesc Med. 2003;157:773–779

89. Epstein LH, Wing RR, Koeske R, Valoski A. A comparison of lifestyleexercise, aerobic exercise, and calisthenics on weight loss in obesechildren. Behav Ther. 1985;16:356

90. Epstein LH, Wing RR, Penner BC, Kress MJ. Effect of diet and con-trolled exercise on weight loss in obese children. J Pediatr. 1985;107:358–361

91. Epstein LH. Effects of family-based behavioral treatment on obese5-to-8-year-old children. Behav Ther. 1985;16:212

92. Epstein LH, McKenzie SJ, Valoski A, Klein KR, Wing RR. Effects ofmastery criteria and contingent reinforcement for family-based childweight control. Addict Behav. 1994;19:135–145

93. Epstein LH, Valoski AM, Vara LS, et al. Effects of decreasing sedentarybehavior and increasing activity on weight change in obese children.Health Psychol. 1995;14:109–115

94. Epstein LH, Paluch RA, Gordy CC, Dorn J. Decreasing sedentarybehaviors in treating pediatric obesity. Arch Pediatr Adolesc Med. 2000;154:220–226



95. Epstein LH, Paluch RA, Gordy CC, Saelens BE, Ernst MM. Problemsolving in the treatment of childhood obesity. J Consult Clin Psychol.2000;68:717–721

96. Epstein LH, Paluch RA, Raynor HA. Sex differences in obese childrenand siblings in family-based obesity treatment. Obes Res. 2001;9:746–753

97. Flodmark CE, Ohlsson T, Ryden O, Sveger T. Prevention of progres-sion to severe obesity in a group of obese schoolchildren treated withfamily therapy. Pediatrics. 1993;91:880–884

98. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusiveagents of change in the treatment of childhood obesity. Am J Clin Nutr.1998;67:1130–1135

99. Graves T, Meyers AW, Clark L. An evaluation of parental problem-solving training in the behavioral treatment of childhood obesity.J Consult Clin Psychol. 1988;56:246–250

100. Israel AC, Stolmaker L, Andrian CAG. The effects of training parentsin general child management skills on behavioral weight loss programfor children. Behav Ther. 1985;16:169–180

101. Israel AC, Guile CA, Baker JE, Silverman WK. An evaluation of en-hanced self-regulation training in the treatment of childhood obesity.J Pediatr Psychol. 1994;19:737–749

102. Gutin B, Barbeau P, Owens S, et al. Effects of exercise intensity oncardiovascular fitness, total body composition, and visceral adiposityof obese adolescents. Am J Clin Nutr. 2002;75:818–826

103. Kang HS, Gutin B, Barbeau P, et al. Physical training improves insulinresistance syndrome markers in obese adolescents. Med Sci SportsExerc. 2002;34:1920–1927

104. Mellin LM, Slinkard LA, Irwin CE Jr. Adolescent obesity intervention:validation of the SHAPEDOWN program. J Am Diet Assoc. 1987;87:333–338

105. Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R. Behav-ioral weight control for overweight adolescents initiated in primarycare. Obes Res. 2002;10:22–32

106. Senediak C, Spence SH. Rapid versus gradual scheduling of therapeu-tic contact in a family based behavioural weight control programmefor children. Behav Psychother. 1985;13:287

107. Wadden TA, Stunkard AJ, Rich L, Rubin CJ, Sweidel G, McKinney S.Obesity in black adolescent girls: a controlled clinical trial of treatmentby diet, behavior modification, and parental support. Pediatrics. 1990;85:345–352

108. White MA. Mediators of Weight Loss in an Internet-Based Intervention forAfrican-American Adolescent Girls [dissertation]. Baton Rouge, LA: Lou-isiana State University; 2003.

109. Strauss RS, Pollack HA. Epidemic increase in childhood overweight,1986–1998. JAMA. 2001;286:2845–2848

110. Epstein LH, Paluch RA, Saelens BE, Ernst MM, Wilfley DE. Changes ineating disorder symptoms with pediatric obesity treatment. J Pediatr.2001;139:58–65

111. Inge TH, Garcia V, Daniels S, et al. A multidisciplinary approach to theadolescent bariatric surgical patient. J Pediatr Surg. 2004;39:442–447

112. Stanford A, Glascock JM, Eid GM, et al. Laparoscopic Roux-en-Ygastric bypass in morbidly obese adolescents. J Pediatr Surg. 2003;38:430–433

113. Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adoles-cents with morbid obesity. J Pediatr. 2001;138:499–504

114. Charney E. Childhood obesity: the measurable and the meaningful.J Pediatr. 1998;132:193–195

115. Institute of Medicine (US). Committee on Prevention of Obesity inChildren and Youth. Preventing Childhood Obesity: Health in the Balance.Washington, DC: National Academies Press; 2005

116. Stettler N. Comment: the global epidemic of childhood obesity: is therea role for the paediatrician? Obes Rev. 2004;5(suppl 1):1–3

117. Gruen RL, Pearson SD, Brennan TA. Physician-citizens: public rolesand professional obligations. JAMA. 2004;291:94–98

118. Reilly JJ, Dorosty AR, Emmett PM. Identification of the obese child:adequacy of the body mass index for clinical practice and epidemiol-ogy. Int J Obes Relat Metab Disord. 2000;24:1623–1627

119. Dietz WH, Robinson TN. Use of the body mass index (BMI) as ameasure of overweight in children and adolescents. J Pediatr. 1998;132:191–193

120. Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med. 1993;119:655–660

121. Daniels S. Pharmacological treatment of obesity in paediatric patients.Paediatr Drugs. 2001;3:405–410

122. Stunkard A. Diet, exercise and behavior therapy: a cautionary tale.Obes Res. 1996;4:293–294

123. Whitaker RC. Obesity prevention in pediatric primary care: four be-haviors to target. Arch Pediatr Adolesc Med. 2003;157:725–727

124. Campbell K, Waters E, O’Meara S, Kelly S, Summerbell C. Interven-tions for preventing obesity in children. Cochrane Database Syst Rev.2002;(2):CD001871

125. Krempf M, Louvet JP, Allanic H, Miloradovich T, Joubert JM, Attali JR.Weight reduction and long-term maintenance after 18 months treat-ment with orlistat for obesity. Int J Obes Relat Metab Disord. 2003;27:591–597

126. Sopher AB, Thornton JC, Wang J, Pierson RN Jr, Heymsfield SB,Horlick M. Measurement of percentage of body fat in 411 children andadolescents: a comparison of dual-energy X-ray absorptiometry with afour-compartment model. Pediatrics. 2004;113:1285–1290

127. Robinson TN. Defining obesity in children and adolescents: clinicalapproaches. Crit Rev Food Sci Nutr. 1993;33:313–320



APPENDIX 1. USPSTF Hierarchy of Research Design and Quality Rating Criteria35

Hierarchy of research designI Properly conducted randomized, controlled trialII-1 Well-designed controlled trial without randomizationII-2 Well-designed cohort or case-control analytic studyII-3 Multiple time series with or without the intervention; dramatic results from uncontrolled experimentsIII Opinions of respected authorities, based on clinical experience; descriptive studies or case reports;

reports of expert committees

Design-specific criteria and quality category definitionsSystematic reviews

Comprehensiveness of sources considered/search strategy usedStandard appraisal of included studiesValidity of conclusionsRecency and relevance especially important

Case-control studiesAccurate ascertainment of casesNonbiased selection of case/control subjects with exclusion criteria applied equally to bothResponse rateDiagnostic testing procedures applied equally to each groupMeasurement of exposure accurate and applied equally to each groupAppropriate attention to potential confounding variables

Randomized, controlled trials and cohort studiesInitial assembly of comparable groups

For randomized, controlled trials: adequate randomization, including first concealment and whether potential confounderswere distributed equally among groups

For cohort studies: consideration of potential confounders with either restriction or measurement for adjustment in theanalysis; consideration of inception cohorts

Maintenance of comparable groups (includes attrition, crossovers, adherence, contamination)Important differential loss to follow-up monitoring or overall high loss to follow-up monitoringMeasurements: equal, reliable, and valid (includes masking of outcome assessment)Clear definition of the interventionsAll important outcomes considered

Diagnostic accuracy studiesScreening test relevant, available for primacy care, adequately describedStudy uses credible reference standard, performed regardless of test resultsReference standard interpreted independently of screening testHandles indeterminate result in a reasonable mannerSpectrum of patients included in studySample sizeAdministration of reliable screening test

144 CHILDHOOD OVERWEIGHT SCREENING AND INTERVENTIONS. Provided by Univ Of Arizona on May 17, 2010 www.pediatrics.orgDownloaded from


DOI: 10.1542/peds.2005-0242 2005;116;e125-e144 PediatricsShipman

Evelyn P. Whitlock, Selvi B. Williams, Rachel Gold, Paula R. Smith and Scott A. for the US Preventive Services Task Force

Screening and Interventions for Childhood Overweight: A Summary of Evidence

& ServicesUpdated Information

http://www.pediatrics.org/cgi/content/full/116/1/e125including high-resolution figures, can be found at:

References

http://www.pediatrics.org/cgi/content/full/116/1/e125#BIBLfree at: This article cites 105 articles, 47 of which you can access for

Citations

eshttp://www.pediatrics.org/cgi/content/full/116/1/e125#otherarticlThis article has been cited by 14 HighWire-hosted articles:

Subspecialty Collections

mhttp://www.pediatrics.org/cgi/collection/nutrition_and_metabolis

Nutrition & Metabolismfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.pediatrics.org/misc/Permissions.shtmltables) or in its entirety can be found online at: Information about reproducing this article in parts (figures,

Reprints http://www.pediatrics.org/misc/reprints.shtml

Information about ordering reprints can be found online:


http://www.pediatrics.org/cgi/content/full/116/1/e125

http://www.pediatrics.org/cgi/content/full/116/1/e125#BIBL

http://www.pediatrics.org/cgi/content/full/116/1/e125#otherarticles

http://www.pediatrics.org/cgi/collection/nutrition_and_metabolism

http://www.pediatrics.org/misc/Permissions.shtml

http://www.pediatrics.org/misc/reprints.shtml


Documents

Screening and Interventions for Childhood Overweight: A Systematic Review for the US Preventive Services Task Force