Pediatrics Subject Collection: Nutrition & Metabolism

Using BMI to Determine Cardiovascular Risk in Childhood: How Do the BMI Cutoffs Fare? [ARTICLES]

Skinner, A. C. — 2009-11-01

OBJECTIVE: Although adverse health outcomes are increased among children with BMI above the 85th (overweight) and 95th (obese) percentiles, previous studies have not clearly defined the BMI percentile at which adverse health outcomes begin to increase. We examined whether the existing BMI percentile cutoffs are optimal for defining increased risk for dyslipidemia, dysglycemia, and hypertension. METHODS: This was a cross-sectional analysis of the National Health and Nutrition Examination Survey from 2001 to 2006. Studied were 8216 children aged 6 to 17 years, representative of the US population. BMI was calculated by using measured height and weight and converted to percentiles for age in months and gender. Outcome measures (dyslipidemia, dysglycemia, and hypertension) were based on laboratory and physical examination results; these were analyzed as both continuous and categorical outcomes. RESULTS: Significant increases for total cholesterol values and prevalence of abnormal cholesterol begin at the 80th percentile. Significant increases in glycohemoglobin values and prevalence of abnormal values begin at the 99th percentile. Consistent significant increases in the prevalence of high or borderline systolic blood pressure begin at the 90th percentile. CONCLUSIONS: Intervening for overweight children and their health requires clinical interventions that target the right children. On the basis of our data, a judicious approach to screening could include consideration of lipid screening for children beginning at the 80th percentile but for dysglycemia at the 99th percentile. Current definitions of overweight and obese may be more useful for general recognition of potential health problems and discussions with parents and children about the need to address childhood obesity.

High-Dose Cysteine Administration Does Not Increase Synthesis of the Antioxidant Glutathione Preterm Infants [ARTICLES]

te Braake, F. W.J. — 2009-11-01

OBJECTIVE: Our aim was to evaluate whether administration of additional cysteine is safe and stimulates glutathione synthesis in preterm infants in early life. METHODS: We conducted a prospective, randomized, clinical trial with infants with birth weights of <1500 g (N = 20). The infants were assigned randomly to receive either a standard dose (45 mg/kg per day) or a high dose (81 mg/kg per day) of cysteine. Intakes of other amino acids were similar, providing a total protein intake of 2.4 g/kg per day in both groups. We recorded base requirements in the first 6 days of life. On postnatal day 2, we conducted a stable isotope study to determine glutathione concentrations and synthesis rates in erythrocytes. RESULTS: Base requirements were higher in the high-dose cysteine group on days 3, 4, and 5. Despite an 80% increase in cysteine intake, plasma cystine concentrations did not increase. Glutathione concentrations and synthesis rates did not increase with additional cysteine administration. CONCLUSIONS: Administration of a high dose of cysteine (81 mg/kg per day) to preterm infants seems clinically safe but does not stimulate glutathione synthesis, compared with a lower dose (45 mg/kg per day). Further research is required to determine whether there is significant benefit associated with cysteine supplementation.

Snacking in Children: The Role of Urban Corner Stores [ARTICLES]

Borradaile, K. E. — 2009-11-01

OBJECTIVE: Childhood obesity is higher among ethnic minorities. One reason may be the limited access to affordable, healthy options. The disparate prevalence of urban corner stores in low-income and high-minority communities has been well documented. There are no data, however, on what children purchase in these environments before and after school. The purpose of this study was to document the nature of children's purchases in corner stores proximal to their schools. METHODS: This was an observational study from January to June 2008. Participants were children in grades 4 through 6 from 10 urban K-8 schools with [≥]50% of students eligible for free or reduced-price meals. A total of 833 intercept surveys of children's purchases were conducted outside 24 corner stores before and after school. The main outcomes were type and energy content of items purchased. RESULTS: The most frequently purchased items were energy-dense, low-nutritive foods and beverages, such as chips, candy, and sugar-sweetened beverages. Students spent $1.07 {+/-} 0.93 on 2.1 {+/-} 1.3 items (1.6 {+/-} 1.1 food items and 0.5 {+/-} 0.6 beverage items) per purchase. The total number of calories purchased per trip was 1497.7 {+/-} 1219.3 kJ (356.6 {+/-} 290.3 kcal). More calories came from foods than from beverages. CONCLUSIONS: Purchases made in corner stores contribute significantly to energy intake among urban school children. Obesity prevention efforts, as well as broader efforts to enhance dietary quality among children in urban settings, should include corner store environments proximal to schools.

Serum 25-Hydroxyvitamin D Levels Among US Children Aged 1 to 11 Years: Do Children Need More Vitamin D? [ARTICLES]

Mansbach, J. M. — 2009-11-01

OBJECTIVE: Single-center studies have suggested that hypovitaminosis D is widespread. Our objective was to determine the serum levels of 25-hydroxyvitamin D (25[OH]D) in a nationally representative sample of US children aged 1 to 11 years. METHODS: Data were obtained from the 2001-2006 National Health and Nutrition Examination Survey. Serum 25(OH)D levels were determined by radioimmunoassay and categorized as <25, <50, and <75 nmol/L. National estimates were obtained by using assigned patient visit weights and reported with 95% confidence intervals (CIs). RESULTS: During the 2001-2006 time period, the mean serum 25(OH)D level for US children aged 1 to 11 years was 68 nmol/L (95% CI: 66-70). Children aged 6 to 11 years had lower mean levels of 25(OH)D (66 nmol/L [95% CI: 64-68]) compared with children aged 1 to 5 years (70 nmol/L [95% CI: 68-73]). Overall, the prevalence of levels at <25 nmol/L was 1% (95% CI: 0.7-1.4), <50 nmol/L was 18% (95% CI: 16-21), and <75 nmol/L was 69% (95% CI: 65-73). The prevalence of serum 25(OH)D levels of <75 nmol/L was higher among children aged 6 to 11 years (73%) compared with children aged 1 to 5 years (63%); girls (71%) compared with boys (67%); and non-Hispanic black (92%) and Hispanic (80%) children compared with non-Hispanic white children (59%). CONCLUSIONS: On the basis of a nationally representative sample of US children aged 1 to 11 years, millions of children may have suboptimal levels of 25(OH)D, especially non-Hispanic black and Hispanic children. More data in children are needed not only to understand better the health implications of specific serum levels of 25(OH)D but also to determine the appropriate vitamin D supplement requirements for children.

Defining Vitamin D Deficiency in Children: Beyond 25-OH Vitamin D Serum Concentrations [COMMENTARIES]

Greer, F. R. — 2009-11-01

It is generally accepted that of the circulating vitamin D metabolites, serum 25-OH vitamin D (25[OH]D) measurements best reflect clinical vitamin D status. In this issue of Pediatrics, Mansbach et al1 address this issue, namely, what serum levels of 25(OH)D in infants and children should be used to define vitamin D sufficiency and deficiency states? Using the 2001-2006 National Health and Nutrition Examination Survey's cross-sectional surveys of 25(OH)D serum concentrations in a presumed healthy population of 4558 US children between ages 1 and 11 years, the authors estimate that 320000 US children (95% confidence interval [CI]: 220000-430000) have 25(OH)D levels at <25 nmol/L, 6.3 million children (95% CI: 5.4-7.2 million) have levels at <50 nmol/L, and 24 million children (95% CI: 21-26 ...

Closing the Quality Gap: Promoting Evidence-Based Breastfeeding Care in the Hospital [SPECIAL ARTICLES]

Bartick, M. — 2009-10-01

Evidence shows that hospital-based practices affect breastfeeding duration and exclusivity throughout the first year of life. However, a 2007 CDC survey of US maternity facilities documented poor adherence with evidence-based practice. Of a possible score of 100 points, the average hospital scored only 63 with great regional disparities. Inappropriate provision and promotion of infant formula were common, despite evidence that such practices reduce breastfeeding success. Twenty-four percent of facilities reported regularly giving non-breast milk supplements to more than half of all healthy, full-term infants. Metrics available for measuring quality of breastfeeding care, range from comprehensive Baby-Friendly Hospital Certification to compliance with individual steps such as the rate of in-hospital exclusive breastfeeding. Other approaches to improving quality of breastfeeding care include (1) education of hospital decision-makers (eg, through publications, seminars, professional organization statements, benchmark reports to hospitals, and national grassroots campaigns), (2) recognition of excellence, such as through Baby-Friendly hospital designation, (3) oversight by accrediting organizations such as the Joint Commission or state hospital authorities, (4) public reporting of indicators of the quality of breastfeeding care, (5) pay-for-performance incentives, in which Medicaid or other third-party payers provide additional financial compensation to individual hospitals that meet certain quality standards, and (6) regional collaboratives, in which staff from different hospitals work together to learn from each other and meet quality improvement goals at their home institutions. Such efforts, as well as strong central leadership, could affect both initiation and duration of breastfeeding, with substantial, lasting benefits for maternal and child health.

Family-Based Treatment of Severe Pediatric Obesity: Randomized, Controlled Trial [ARTICLES]

Kalarchian, M. A. — 2009-10-01

OBJECTIVE: We evaluated the efficacy of family-based, behavioral weight control in the management of severe pediatric obesity. METHODS: Participants were 192 children 8.0 to 12.0 years of age (mean {+/-} SD: 10.2 {+/-} 1.2 years). The average BMI percentile for age and gender was 99.18 (SD: 0.72). Families were assigned randomly to the intervention or usual care. Assessments were conducted at baseline, 6 months, 12 months, and 18 months. The primary outcome was percent overweight (percent over the median BMI for age and gender). Changes in blood pressure, body composition, waist circumference, and health-related quality of life also were evaluated. Finally, we examined factors associated with changes in child percent overweight, particularly session attendance. RESULTS: Intervention was associated with significant decreases in child percent overweight, relative to usual care, at 6 months. Intent-to-treat analyses documented that intervention was associated with a 7.58% decrease in child percent overweight at 6 months, compared with a 0.66% decrease with usual care, but differences were not significant at 12 or 18 months. Small significant improvements in medical outcomes were observed at 6 and 12 months. Children who attended [≥]75% of intervention sessions maintained decreases in percent overweight through 18 months. Lower baseline percent overweight, better attendance, higher income, and greater parent BMI reduction were associated with significantly greater reductions in child percent overweight at 6 months among intervention participants. CONCLUSIONS: Intervention was associated with significant short-term reductions in obesity and improvements in medical parameters and conferred longer-term weight change benefits for children who attended [≥]75% of sessions.

Introduction to Issues and Implications of Screening, Surveillance, and Reporting of Children's BMI [SUPPLEMENT ARTICLES]

Dietz, W. H. — 2009-09-01

On January 16 and 17, 2008, the Robert Wood Johnson Foundation convened a forum of researchers and practitioners working on the issue of childhood obesity to discuss the issues related to surveillance, screening, and reporting of children's BMI. Because obesity has become a major concern of the foundation, it seemed essential to understand the use and limitations of the BMI measurement on which the diagnosis of obesity depended. The goals of the meeting were to gather and review experience in the collection of BMI data and to understand how to communicate BMI results to parents. In addition, the group explored cultural differences in how the BMI was interpreted, and considered the legal and confidentiality implications of collecting and reporting BMI data. Because of the ease and reliability of measures of height and weight that ...

Challenges of Accurately Measuring and Using BMI and Other Indicators of Obesity in Children [SUPPLEMENT ARTICLES]

Himes, J. H. — 2009-09-01

BMI is an important indicator of overweight and obesity in childhood and adolescence. When measurements are taken carefully and compared with appropriate growth charts and recommended cutoffs, BMI provides an excellent indicator of overweight and obesity that is sufficient for most clinical, screening, and surveillance purposes. Accurate measurements of height and weight require that adequate attention be given to data collection and management. Choosing appropriate equipment and measurement protocols and providing regular training and standardization of data collectors are critical aspects that apply to all settings in which BMI will be measured and used. Proxy measures for directly measured BMI, such as self-reports or parental reports of height and weight, are much less preferred and should only be used with caution and cognizance of the limitations, biases, and uncertainties attending these measures. There is little evidence that other measures of body fat such as skinfolds, waist circumference, or bioelectrical impedance are sufficiently practicable or provide appreciable added information to be used in the identification of children and adolescents who are overweight or obese. Consequently, for most clinical, school, or community settings these measures are not recommended for routine practice. These alternative measures of fatness remain important for research and perhaps in some specialized screening situations that include a specific focus on risk factors for cardiovascular or diabetic disease.

The Validity of BMI as an Indicator of Body Fatness and Risk Among Children [SUPPLEMENT ARTICLES]

Freedman, D. S. — 2009-09-01

PURPOSE OF REVIEW: Although the prevalence of childhood obesity, as assessed by BMI (kg/m2), has tripled over the last 3 decades, this index is a measure of excess weight rather than excess body fatness. In this review we focus on the relation of BMI to body fatness and health risks, particularly on the ability of BMI for age [≥]95th Centers for Disease Control and Prevention [CDC] percentile to identify children who have excess body fatness. We also examine whether these associations differ according to race/ethnicity and whether skinfold and circumference measurements provide additional information on body fatness or health risks. RESULTS: The accuracy of BMI varies according to the degree of body fatness. Among relatively fat children, BMI is a good indicator of excess adiposity, but differences in the BMIs of relatively thin children can be largely due to fat-free mass. Although the accuracy of BMI in identifying children with excess body fatness depends on the chosen cut points, we have found that a high BMI-for-age has a moderately high (70%-80%) sensitivity and positive predictive value, along with a high specificity (95%). Children with a high BMI are much more likely to have adverse risk factor levels and to become obese adults than are thinner children. Skinfold thicknesses and the waist circumference may be useful in identifying children with moderately elevated levels of BMI (85th to 94th percentiles) who truly have excess body fatness or adverse risk factor levels. CONCLUSION: A BMI for age at [≥]95th percentile of the CDC reference population is a moderately sensitive and a specific indicator of excess adiposity among children.