CPE Monthly: Childhood Obesity Prevention and Treatment

August 2018 Issue

CPE Monthly: Childhood Obesity Prevention and Treatment
By Karolina Balkenbush, RDN
Today's Dietitian
Vol. 20, No. 8, P. 52

Suggested CDR Learning Codes: 4150, 5070, 5080, 5370
Suggested CDR Performance Indicators: 8.1.4, 8.2.1, 8.3.6, 12.2.1
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

One-third of children in the United States are overweight or obese. The prevalence of pediatric overweight and obesity has increased greatly since 1980, doubling in children aged 2 to 5 and tripling among those aged 6 to 11 and 12 to 19.1 The proportion of children affected by overweight and obesity is greatest among minority and underserved populations.2 As physicians may have limited nutrition expertise and time to counsel patients on obesity prevention and treatment, RDs should be actively involved as essential members of obesity management teams.

This continuing education course discusses the diagnosis of childhood obesity, its complications, evidence-based treatment strategies, and key messages for RDs to communicate to families. The key messages focus on the behavioral contributors to childhood obesity that families can modify by working with RDs. Some suggestions for effectively communicating these key messages also are included.

Assessment of Weight Status
Childhood overweight and obesity in children aged 2 to 18 are defined by percentiles of BMI. BMI percentile charts are available at the Centers for Disease Control and Prevention website (www.cdc.gov/growthcharts). Overweight in children is defined as having a BMI between the 85th and 94th percentile. Obesity in this group is defined as having a BMI greater than the 95th percentile. According to Gulati and colleagues in Pediatrics in 2012, severe obesity in childhood is defined as BMI greater than 120% of the 95th percentile values, or a BMI greater than 35 (whichever is lower). This corresponds to approximately the 99th percentile. Unlike in previous generations, a large majority of parents don't recognize when their children are overweight or obese.3 This is likely because there are many more overweight and obese children now than there were decades ago, so heavier children may be perceived as having a healthy weight. Since parents are unlikely to notice that their children are overweight, pediatricians have an important role in screening for high BMI during visits and subsequently providing an appropriate intervention or referring to another obesity intervention program if a child is found to be overweight or obese.4

Contributors to Childhood Obesity
Childhood obesity is a complex health issue because there are many contributing causes, associated health risks, and treatment approaches. The main causes of overweight and obesity in children are similar to those in adults. These include a combination of genetic predisposition, behavioral patterns, and environmental factors. Behavioral factors include dietary patterns, physical activity, inactivity, and medication use. Additional contributing factors in our society include food marketing and promotion, foods available for children to consume at home and in school, opportunities for children to be physically active at school and home, and education level and skills of children and parents.5 The Academy of Nutrition and Dietetics has published the organization's position on the prevention and treatment of childhood obesity. Combating the problem requires "systems-level approaches that include the skills of RDs, as well as consistent and integrated messages and environmental support across all sectors of society to achieve sustained dietary and physical-activity behavior change."6

Complications of Childhood Obesity
Overweight children aren't simply heavier than their peers. Their weight status puts them at greater risk of a variety of physical and mental health problems, even before reaching adulthood.5,7-18 Children who are obese are likely to remain obese as adults. In addition, their degree of obesity and severity of disease risk factors are likely to be more pronounced in adulthood.17,18

Childhood obesity adversely affects the endocrine, cardiovascular, orthopedic, gastrointestinal, and pulmonary systems. It's associated with greater risk of CVD later in life. Two risk factors of CVD more common in obese children than in healthy-weight children are hypertension and elevated cholesterol. In one study, 70% of obese children had at least one CVD risk factor, and 39% had two or more.7 Other studies have shown increased risk of impaired glucose tolerance, insulin resistance, and type 2 diabetes.8 Childhood obesity also is associated with breathing problems, such as sleep apnea and asthma.9,10 Moreover, obese children are likely to develop joint problems and musculoskeletal discomfort.11 They're at greater risk of having fatty liver disease, gallstones, and gastroesophageal reflux (ie, heartburn).9,10 Many of these comorbidities that used to be considered "adult diseases" are now regularly seen in obese children.

Mental health consequences of childhood obesity also are reported. These include a variety of eating disorders, ranging from generalized preoccupation with food and distorted body image to restrictive eating and bulimia nervosa, as well as depression.5 Psychological stress leading to behavioral problems and issues in school have been exhibited,12-14 along with low self-esteem and low self-reported quality of life.15,16

Prevention and Treatment
Evidence-based prevention of and treatment for childhood obesity is a priority in health care because targeting this problem early in children's lives may reduce the likelihood of developing various risk factors associated with obesity in adulthood. Prevention and treatment strategies for pediatric overweight and obesity are commonly categorized along a continuum. Population-level prevention approaches are interventions that are offered to the entire population of children in a community, school, or health care setting. This is referred to as primary prevention and is offered to children of all body sizes and weights.19

Secondary prevention strategies and interventions are more structured and directed at overweight and obese youth to help them achieve a healthier weight. Tertiary prevention interventions are the most intensive and comprehensive medical treatment programs for overweight and obese children and adolescents. These programs are conducted under medical supervision and are designed to resolve or decrease the severity of complications related to excess weight. RDs have a role at each level of prevention.

There are several components of a comprehensive intervention program that have been shown to be successful at improving weight and health status in the long term. Effective programs should include changes in nutrition and physical activity along with behavioral therapy.20 Treatment for childhood obesity is based on a child's age and health status, but it usually includes implementing changes in the child's diet and physical activity level. In certain circumstances, treatment also may include medications or weight loss surgery. The RD's role in secondary and tertiary prevention interventions is to provide evidence-based recommendations to families of overweight and obese children and use behavioral therapy techniques to help families apply knowledge. The following section summarizes appropriate recommendations based on review of evidence.

Early Prevention
Prevention of childhood obesity should begin early in life, during the fetal period and the first two years of life. Observational studies suggest that these early stages may be critical periods for learning behaviors that lead to obesity.21,22 In addition to learned behaviors, long-term taste preferences are developed in utero and during breast-feeding. Children are likely to prefer the foods their mothers exposed them to at these stages.23 For these reasons, RDs working with expectant mothers and parents of young children should be prepared to assess parental weight status and children's rate of weight gain as risk factors for later obesity as well as be prepared to assist parents with helping the whole family develop healthful eating and physical activity habits from the start to prevent the progression of childhood obesity. Since the frequency of doctor visits is highest for expectant mothers compared with any other time in the lifespan, RDs working in collaboration with OB/GYN clinicians and WIC have an excellent opportunity to provide dietary counseling to these women. For example, RDs can expect to assist with implementing a plan to gain only the recommended amount of weight during pregnancy. They also have a role in educating mothers about the importance of breast-feeding. For each additional month that a woman breast-feeds, the risk of childhood obesity decreases.24

Key Messages Used in Treatment and Prevention
The following key messages are a sampling of the evidence-based guidance currently available to RDs. They're used in prevention and treatment. In counseling, these messages should be communicated to families in a way that's culturally appropriate and memorable. Messages should be presented in a manner that's sensitive to each individual family's socioeconomic status and psychological characteristics, and to the child's developmental stage.4 Each section provides examples or information that help RDs translate research data into guidance that's most likely to yield behavior change.

Curb Calorie Intake
Evidence suggests that a calorie-restricted diet may be effective for short- and long-term weight management in children aged 6 to 12 when implemented as part of a multicomponent program.6,7 This reduced-calorie diet should have fewer calories than required to maintain weight but not less than 1,200 kcal per day.25 Low-glycemic load diets show the most promise for management of pediatric obesity.26 Typically, a balanced macronutrient nutrition prescription is appropriate. A balanced macronutrient diet for children is defined by the Institute of Medicine's Dietary Reference Intakes as 45% to 65% calories from carbohydrates, 10% to 35% calories from protein, and 20% to 35% calories from fat. A "nutrition prescription" should be provided as part of the dietary intervention in a weight-management program for children. The prescribed calorie level and nutrient specifications often form the basis of the recommended eating plan and corresponding nutrition interventions, such as smaller portion sizes or increased intake of fruits and vegetables. Research shows that when an individualized "nutrition prescription" is included, improvements in weight status are more consistently observed among overweight children and teens than when the specific eating guidelines aren't provided. Therefore, RDs are encouraged to provide specific guidance to families by providing sample meal plans or meal patterns to structure daily eating with a calorie goal in mind. Sample meal plans and eating patterns are available at ChooseMyPlate.gov.

Limit High-Calorie Foods and Sugar-Sweetened Drinks
Children are at greater risk of excess body fat when they consume a diet rich in high-energy density foods.27 High-energy density foods, commonly known as calorie-dense foods, are those that have a large number of calories in a small portion size. Examples of these foods are those high in fat and sugar such as pastries, cookies, crackers, chips, and sweets.28 These foods are common calorie sources in children's diets.

Beverages also are major contributors of calories in children's diets in the United States. In fact, sugar-sweetened beverages are the largest source of added sugars in their diets.29 Large consumption of sugary beverages, such as soda and sports drinks, has been associated with obesity.30 On a typical day, 80% of children drink sugar-sweetened beverages, which typically are devoid of nutrients.31 Reducing intake of sugary beverages may be one of the easiest and most effective ways to reduce excess calories in children's diets.32 RDs should educate families on identifying sugary beverages. Much like soda, fruit juice is an energy-dense beverage. While 100% fruit juice is nutrient rich, consumption should be limited to avoid excess calorie and sugar intake. Fruit juice should be limited to 6 oz per day for children aged 1 to 6 and 12 oz per day for children aged 7 to 18.33 Families should be reminded that plain water is the most healthful choice. The use of artificially sweetened beverages is controversial because these drinks may reinforce the habit of consuming sweet drinks, but they can provide an alternative to full-calorie sugary drinks as children transition to drinking plain water. The role of low-calorie beverages remains an area of ongoing research and debate, but use of nonnutritive sweeteners hasn't been associated with weight gain among children in several longitudinal studies.34-36 However, they should be used in limited quantities, as there's emerging evidence in humans that calorie-free sweeteners may alter gut bacteria, thereby impairing glucose tolerance.37

The American Heart Association recently released guidance on consumption of added sugars. While adults are instructed to consume no more than 10% of their daily calories from added sugars, children are advised to consume no more than 25 g added sugars per day.38 This amounts to approximately six teaspoons. RDs should be prepared to teach families how to read food labels and provide examples of alternatives to foods and beverages high in added sugars.

Appropriate Portion Sizes
Over the past several decades, portion sizes of high-calorie, low-nutrient density foods and drinks sold in restaurants, grocery stores, and vending machines have increased. Evidence suggests that children eat more if they're served larger portions.39 This can mean they're consuming many extra calories without realizing it, especially when eating high-calorie foods. RDs should instruct parents to offer healthful foods in age-appropriate portions at meals and snacks and let the child decide how much to eat of what's offered. The American Academy of Pediatrics has developed a helpful chart suggesting appropriate portion sizes for children based on age.40 RDs can use this chart to educate parents on the appropriate serving sizes for children.

Healthful Food Choices
It's been shown that consuming high-energy density foods is associated with excessive calorie intake and overweight in children.41 Since fiber-rich foods tend to be lower in calories, it's likely that diets rich in fruits, vegetables, whole grains, beans, and nuts may be effective in preventing and treating obesity in children. High-fiber diets also may have a role in the prevention of CVD and type 2 diabetes, independent of their effect on weight management.42 Increased fruit and vegetable intake is associated with a decreased risk of childhood obesity.43 RDs can help by advising families about food shopping, meal planning, food preparation, and making healthful choices while eating out to maximize intake of fiber and nutritious foods. RDs can lead creative interventions such as grocery shopping tours, group nutrition classes, and cooking classes to show families how to introduce unfamiliar foods. In addition, RDs can advise families about strategies to overcome picky eating when introducing healthful food choices such as fruits and vegetables.

Don't Skip Breakfast
Lean children are more likely to eat breakfast daily and eat larger breakfasts than are heavier children. Older children and teens appear to be especially at risk of higher body fat if they skip breakfast.44 RDs should encourage children to eat breakfast every day and help families overcome the common reasons for skipping breakfast, such as limited time or poor appetite in the morning.4

Limit Eating Out
Children, particularly adolescents, are at higher risk of obesity if they eat out frequently. This can be true if they eat at fast food restaurants often (more than twice per week). Furthermore, some evidence suggests that a greater degree of obesity results from eating fast food regularly year after year.45,46 RDs can help families devise a personalized plan to decrease fast food consumption and advise them on more healthful fast food and restaurant menu options. For example, if a family eats at a particular fast food chain often, an RD can print out a current list of menu items with less than 500 kcal for the family to reference. Alternatively, an RD can suggest quick and easy meals to prepare at home or identify strategies to add fresh produce to takeout meals to transition to eating meals prepared at home more often.

Regulate Screen Time
While there are many potential causes of childhood obesity stemming from physical inactivity and poor dietary habits, some of the strongest evidence of a behavioral risk suggests that excessive television viewing is largely to blame. In fact, limiting screen time is supported as a primary prevention strategy for reducing the risk of overweight and other chronic diseases.47 The American Academy of Pediatrics recommends that children younger than age 2 avoid screen time entirely and children older than age 2 should view no more than one hour per day.48 Because many forms of sedentary entertainment, such as smartphones, tablets, video games, and computers are widely available and less studied, it's reasonable to assume that use of these electronics also should be limited.4 RDs should encourage parents to be actively involved in setting, monitoring, and enforcing screen time limits. A key recommendation here is to keep televisions out of children's bedrooms. As smartphone and tablet technology is increasingly available to children, new applications also are being developed to make limiting time on these devices easier for families. RDs should be prepared to discuss suggestions for screen time alternatives to occupy children's time, such as age-appropriate chores, inexpensive family activities, and fun hobbies. A common misconception is to assume that it's fine for children to spend more than the recommended amount of time on electronics as long as they're exercising enough. It's important to stress to parents that limiting sedentary activities is warranted regardless of increases in exercise; both should be emphasized. In fact, limiting screen time appears to be more effective than increasing physical activity to control weight.49

Increase Physical Activity
In addition to encouraging children to reduce time spent in sedentary activities, RDs should encourage increases in both structured and nonstructured physical activity because time spent this way likely plays a role in preventing weight gain and associated health problems.50 On the other hand, physical inactivity puts school-age children at risk of obesity and insulin resistance.51 The USDA recommends children and adolescents participate in 60 minutes of moderate-intensity physical activity most days of the week, preferably daily.52 RDs can encourage parents to help children meet this activity goal by serving as role models and exercising together as a family. RDs should be able to provide information to families about community resources such as local parks, recreation centers, walking paths, family gyms, and sports leagues. If outdoor physical activity isn't a realistic option for families, indoor activities, such as exercising to videos, doing yoga, using hula hoops, dancing, or jumping rope, should be encouraged. Moreover, RDs should be realistic in setting goals for very obese or deconditioned children, who may need to start with lower-intensity exercise for shorter periods of time than the USDA-recommended 60 minutes.

Get Enough Sleep
Insufficient sleep may be one of many contributors to childhood obesity.53 Sleep deprivation impairs attention, impulse control, and higher-level problem solving, all of which can contribute to poor dietary choices.54 In their assessment of a child's obesity risk, RDs should ask parents about the child's sleep habits. RDs can determine any problematic sleeping patterns suspected and help parents improve their child's sleep habits. Helpful suggestions include removing electronics from children's bedrooms and enforcing boundaries around bedtime to achieve appropriate targets for sleep duration.4 The National Sleep Foundation has developed the following recommendations as of February 2015:55

newborns (0 to 3 months): 14 to 17 hours each day;
infants (4 to 11 months): 12 to 15 hours;
toddlers (1 to 2 years): 11 to 14 hours;
preschoolers (3 to 5): 10 to 13 hours;
school age children (6 to 13): 9 to 11 hours;
teenagers (14 to 17): 8 to 10 hours; and
younger adults (18 to 25): 7 to 9 hours.

Behavior Modification
It's clear from the evidence that the most effective treatment strategies for childhood obesity include changing dietary and physical activity habits; simply providing information about needed interventions, however, is ineffective.56 Lifestyle change resulting in weight loss must be facilitated through behavioral therapy, which commonly focuses on modifying and controlling the foods and opportunities for physical activity available to children. Stimulus control and regular self-monitoring of weight, eating, and physical activity have been shown to be effective behaviors for weight management.57 Stimulus control means restructuring the home to encourage healthful eating and activity behaviors and discourage unhealthful behaviors.

Children benefit from family-based interventions, in which parents are actively involved in treatment. Whether parents are successful in controlling their own weight predicts the success their children will have in weight management.58 Therefore, parents should be taught to serve as role models for their children by monitoring and modifying their own eating and exercise habits. Behavior change in children often results from a system of consequences and rewards. Rewards appear to be particularly effective in encouraging children to achieve their goals. RDs can instruct parents to have a system for rewarding achievements such as losing weight, cutting back on portion sizes, increasing exercise, or decreasing screen time. Instead of using food rewards, ideal incentives promote healthful behavior.59 Nonfood rewards include new sports equipment, family hikes, bike rides, and swimming.

In addition to role modeling and providing consistent reinforcement, parents should be taught how to implement stimulus control strategies. For example, RDs may suggest keeping nutritious foods readily available, perhaps by keeping a bowl of fruit on the counter while keeping sugary snacks out of the house. Ultimately, RDs should emphasize the importance of family involvement in making lifestyle changes and teach them the aforementioned skills to develop healthful behaviors and improve children's weight. Specific family praise also is effective in reinforcing positive behaviors.60

Within various practice settings, RDs are encouraged to develop creative interventions to address childhood obesity. The behavior-centered design, a relatively novel approach to behavior change, suggests that behavior change messages are more effective when the intervention is creative and surprising.61 Many inexpensive and effective visual demonstrations come to mind, particularly for communicating the excess of sugar in children's diets. To educate families about the importance of reducing intake of sugar-sweetened beverages, don't simply state the risks associated with excess sugar. Instead, show a soda can alongside a clear sandwich bag containing 10 teaspoons of sugar to make the message more memorable and shocking. This image can be made even more impactful by creating a similar prop to illustrate the amount of sugar consumed over the course of a week or even a year by someone who drinks just one can of soda per day. In addition to the counseling RDs provide, effective pediatric weight management programs can be structured to last 12 weeks and include behavioral therapy sessions with a psychologist as a complement to diet and exercise education.

Medications
Weight loss medications sometimes have a role in pediatric weight management. They're only prescribed to patients who haven't been successful in achieving a healthier weight with structured diet and lifestyle modification programs and have significant health risks associated with their weight. These patients must understand the limitations of pharmacotherapy and the need to make lifestyle changes in addition to taking weight loss medications. It's important for RDs to be aware of weight loss medications approved for use in children and teens and to appropriately counsel children and their parents stating that weight loss medication should be used only as part of weight loss therapy that includes diet, physical activity, and behavior modification.25 Obese children who may benefit from pharmacotherapy should be referred to a tertiary care center for evaluation and treatment. Currently, Orlistat is the only prescription weight loss medication in the United States that's approved for obesity treatment in adolescents aged 12 and older.6 It's not approved for use in children younger than 12. This medication blocks the absorption of fat in the intestine by inhibiting the enzyme lipase. It's been shown to be moderately effective in adolescents. Short-term weight loss of one year or less has been observed when orlistat was prescribed in conjunction with a weight loss program including diet, exercise, and behavior therapy.62 The use of orlistat is limited by unpleasant gastrointestinal symptoms, and its efficacy long term hasn't been thoroughly studied.

Metformin, a drug approved for treatment of type 2 diabetes in children aged 10 or older, is currently being considered as a weight loss drug as well, though it's not yet FDA approved for this purpose. Metformin is an antihyperglycemic drug that can reduce insulin resistance and hyperinsulinemia, thereby reducing hunger and decreasing fat storage.63 A recent review of literature has suggested that Metformin provides a statistically significant but modest reduction in BMI when combined with lifestyle interventions over the short term. It wasn't shown to be superior to other interventions for childhood obesity.64

Surgery
Bariatric surgery is an increasingly common option for some obese teens, typically those with severe comorbidities who have failed to benefit from a more conservative medically supervised treatment for at least six months.6 While overweight and obesity in teens are defined by BMI percentiles, indication for bariatric surgery is determined by BMI index thresholds. The most recent guidelines by the American Society for Metabolic and Bariatric Surgery recommend the following BMI thresholds for obese adolescents to be eligible: BMI greater than 35 with serious comorbidity or BMI greater than 40 with less severe comorbidity. This recommendation is backed by evidence that bariatric surgery in teens has been shown to consistently confer sustained and clinically significant weight loss as well as resolution of comorbidities.65 Despite positive outcomes, it's important to note that complications sometimes do arise. At five-year follow up postsurgery, many teens still have BMIs over 35, vitamin D and B12 deficiency, iron-deficiency anemia, and surgical complications that have resulted in reoperation.66 The most common bariatric procedures performed on adolescents are Roux-en-Y gastric bypass, which resections the stomach to a small pouch that limits the amount of food that can be consumed in one sitting, and sleeve gastrectomy.67 Sleeve gastrectomy is less complex than Roux-en-Y and has a lower theoretical risk of micronutrient deficiencies, but it may be less effective long term.68 Its popularity has increased rapidly over the past decade, now accounting for 80% of bariatric surgical procedures in adolescents.69 RDs assist with preparing the family for lifestyle changes required with bariatric surgery and, along with a team of specialists, participate in long-term follow-up care of the metabolic and psychosocial needs of the patient and family.

Weight Loss Goals
In most cases, the general goal for all ages is for BMI to trend downward until it's below the 85th percentile. Some children are healthy with BMI values between the 85th and 95th percentiles. If they have no additional cardiovascular risk factors at this BMI range, weight maintenance may be recommended. In the case of comorbid conditions and complications, resolution of these also is a goal.25 Once weight loss goals are met, it's imperative for RDs to continue assisting clients with a weight maintenance program.70 An optimal length of time between follow-up visits with RDs hasn't been established; therefore, RDs should work with families on a case-by-case basis to schedule timely assessments. A 2016 study reported that continuing to follow up with a dietitian was associated with greater improvements in BMI.71 Unfortunately, this study also stated that a majority of families don't seek continued support from a dietitian. Improving compliance with follow-up and dietary interventions is an important topic for further research.

Putting It Into Practice
The most effective way in which RDs can improve outcomes for overweight children and adolescents is by working as part of a multidisciplinary team in a multicomponent pediatric obesity program that teaches healthful eating, exercise, and behavior modification strategies to children and their parents or caregivers. RDs are reminded to provide nutrition education along with a diet prescription and training for parents or caregivers to be the key agents of change in the treatment of their child's obesity.72

The childhood obesity epidemic is an urgent public health problem; therefore, RDs working in this field are encouraged to develop, implement, and evaluate creative interventions to contribute to the flourishing research on the prevention and treatment of childhood obesity.

— Karolina Balkenbush, RDN, is program coordinator of the Healthy Hearts Program, a clinical-based, multicomponent pediatric obesity treatment program at the Children's Heart Center, a pediatric cardiology practice in Las Vegas.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Evaluate childhood overweight and obesity based on BMI percentiles.
2. Identify at least three risk factors for childhood obesity.
3. Distinguish at least three complications of childhood obesity.
4. Manage childhood obesity as part of a multidisciplinary team using evidence-based interventions.

CPE Monthly Examination
1. Obesity in children is determined by which of the following?
a. BMI greater than 25
b. BMI greater than 30
c. BMI greater than the 85th percentile for gender and age
d. BMI greater than the 95th percentile for gender and age

2. Which of the following is a tertiary prevention intervention for childhood obesity?
a. Serving more healthful school lunches
b. Enrolling the patient in a medically supervised weight loss program
c. Increasing the physical education requirement in schools
d. Having the patient make an annual pediatrician visit to screen for obesity

3. What's the best way for parents to address a child's weight problem?
a. Discuss the weight problem directly with the child.
b. Restrict second helpings at meals.
c. Teach the child to keep a detailed food log.
d. Model healthful eating and exercise behaviors.

4. The best evidence exists for which of the following diet types for treating childhood obesity?
a. Low-glycemic load, reduced-calorie diet
b. Ketogenic, reduced-calorie diet
c. Low-fat, reduced-calorie diet
d. High-protein, reduced-calorie diet

5. How much added sugar does the American Heart Association recommend for children aged 2 to 18?
a. Up to 25 g per day
b. Up to 10% of daily calories
c. Up to 50 g per day
d. Up to 20% of daily calories

6. What is the American Academy of Pediatrics' recommendation for screen time among school-aged children?
a. Up to 30 minutes per day
b. Up to one hour per day
c. Up to two hours per day
d. Up to three hours per day

7. What level of activity does the USDA recommend for children and adolescents?
a. Work up to at least 30 minutes of low-intensity physical activity daily.
b. Work up to at least one hour of moderate-intensity physical activity most days of the week.
c. Work up to at least 20 minutes of high-intensity physical activity daily.
d. Work up to at least two hours of moderate-intensity physical activity several days per week.

8. At what age should childhood obesity prevention begin?
a. Fetal period to age 2
b. Ages 2 to 5
c. As soon as children enter kindergarten
d. As soon as children pass through puberty

9. Which weight loss medication is approved for use in adolescents?
a. Metformin
b. Orlistat
c. Ephedra
d. Phentermine

10. Which of the following is a key message for RDs to communicate to families as recommendations for their overweight children?
a. Engage in time-restricted eating.
b. Avoid skipping breakfast.
c. Pack lunch for school.
d. Avoid eating dinner after 5 PM.

References
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23. Mennella JA, Jagnow CP, Beauchamp GK. Prenatal and postnatal flavor learning by human infants. Pediatrics. 2001;107(6):E88.

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27. Johnson L, Mander AP, Jones LR, Emmett PM, Jebb SA. Energy-dense, low-fiber, high-fat dietary pattern is associated with increased fatness in childhood. Am J Clin Nutr. 2008;87(4):846-854.

28. Francis LA, Lee Y, Birch LL. Parental weight status and girls' television viewing, snacking, and body mass indexes. Obes Res. 2003;11(1):143-151.

29. Reedy J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc. 2010;110(10):1477-1484.

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