CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care The Role of the Pediatrician in Primary Prevention of Obesity

The adoption of healthful lifestyles by individuals and families can result in a reduction in many chronic diseases and conditions of which obesity is the most prevalent. Obesity prevention, in addition to treatment, is an important public health priority. This clinical report describes the rationale for pediatricians to be an integral part of the obesity-prevention effort. In addition, the 2012 Institute of Medicine report “Accelerating Progress in Obesity Prevention” includes health care providers as a crucial component of successful weight control. Research on obesity prevention in the pediatric care setting as well as evidence-informed practical approaches and targets for prevention are reviewed. Pediatricians should use a longitudinal, developmentally appropriate life-course approach to help identify children early on the path to obesity and base prevention efforts on family dynamics and reduction in high-risk dietary and activity behaviors. They should promote a diet free of sugar-sweetened beverages, of fewer foods with high caloric density, and of increased intake of fruits and vegetables. It is also important to promote a lifestyle with reduced sedentary behavior and with 60 minutes of daily moderate to vigorous physical activity. This report also identifies important gaps in evidence that need to be filled by future research. INTRODUCTION AND RATIONALE FOR OBESITY PREVENTION This clinical report updates and replaces the 2003 American Academy of Pediatrics (AAP) policy statement “Prevention of Pediatric Overweight and Obesity”1 and complements the AAP-endorsed 2007 expert committee “Recommendations for Prevention of Childhood Obesity”2 and the chapter “Promoting Healthy Weight” in the 2008 third edition of Bright Futures: Prevention and Health Promotion for Infants, Children, Adolescents, and Their Families.3 Since 2003, much has been written in the scientific literature and the lay press regarding childhood obesity. The prevalence of pediatric obesity has increased significantly (twoto threefold, depending on the age group) in the past few decades in the United States and in other countries.4–6 Because of the numerous medical and psychosocial complications of childhood obesity and the burden of pediatric obesity on current and future health care costs, this condition is now recognized as The American Academy of Pediatrics Committee on Nutrition used review of the literature, including reports from other groups, but did not conduct a formal systematic review of the literature. Comments also were solicited from committees, sections, and councils of the American Academy of Pediatrics; 18 entities responded. Additional comments were sought from the Centers for Disease Control and Prevention, the National Institutes of Health, the US Department of Agriculture, and the US Food and Drug Administration, because these governmental agencies have official liaisons to the Committee on Nutrition who served the on the committee during the development of the statement. Comments also were solicited from various professional societies and other entities interested in childhood obesity; 4 entities responded. For recommendations for which high levels of evidence are absent, the expert opinions and suggestions of the members of the Committee on Nutrition and other groups and authorities consulted were taken into consideration in developing this clinical report. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (American Academy of Pediatrics) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. www.pediatrics.org/cgi/doi/10.1542/peds.2015-1558 DOI: 10.1542/peds.2015-1558 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics PEDIATRICS Volume 136, number 1, July 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on April 15, 2017 Downloaded from a public health priority by many groups and experts.7–13 Although treatment of obesity in the pediatric age group, as well as secondary and tertiary prevention, will remain a key component of a comprehensive strategy to address this public health problem, the results of treatment remain modest, and primary prevention is recognized as a critical part of a sustainable solution.8,9,12 It is also increasingly recognized that both clinical interventions and supportive institutional and community environments are required to adopt more healthful lifestyles for the prevention of obesity and other noncommunicable diseases.9,14–19 For example, a comprehensive review of strategies for obesity prevention in the United Kingdom concluded that “the deceptively simple issue of encouraging physical activity and modifying dietary habits, in reality, raises complex social and economic questions about the need to reshape public policy in food production, food manufacturing, healthcare, retail, education, culture and trade.”14 Pediatricians can and should play an important role in obesity prevention because they are in a unique position to partner with families and patients and to influence key components of the broader strategy of developing community support. Prevention of obesity is clearly not only the responsibility of pediatricians but of all elements of society, including the public and the private sectors. Unlike most schools, community-based organizations, or governmental programs, pediatricians often follow children over a long period of time, sometimes from fetal life through college, giving them a unique longterm perspective in preventing chronic conditions such as obesity. Furthermore, pediatricians, in the context of the medical home, have a family-centered perspective and are seen by families as a reliable source of health advice and as experts in developmentally appropriate approaches to prevention. This clinical report reviews the role of the pediatrician in practice and in the community as a behavior-change agent and advocate for healthful lifestyles for the prevention of childhood obesity. It is not a systematic review of evidence but rather an assessment of the bestavailable evidence that weighs the potential benefits of possible interventions. This report also focuses on clinical practice. However, the role that a pediatrician can play in the community is also critical. Although the role of pediatricians as advocates for community and policy changes is not reviewed in detail here, resources to assist pediatricians in this role can be found on the AAP Institute for Healthy Childhood Weight Web site (http://ihcw.aap. org).20 INDIVIDUAL/CLINICAL APPROACHES TO OBESITY PREVENTION The prevention of childhood obesity has been the subject of many research studies, reviews, and guidelines, primarily in the school or community setting, and these studies were taken into consideration for this report.2,9,21–25 However, little is known about the feasibility, effectiveness, and cost of childhood obesity prevention in the primary care setting. Because research on pediatric obesity treatment began earlier than the research on pediatric obesity prevention, and because more data are available on treatment, many of the tools and behavior targets used for prevention derive from our knowledge of treatment. Because the motivation for prevention differs from that for treatment, and because an individual with obesity frequently differs metabolically from a person of healthy weight, this approach may have limitations that further increase the challenges of obesity prevention in a clinical setting designed for treatment. Despite these limitations, obesity-prevention strategies in the pediatric clinical setting can be informed by findings about obesity treatment, obesity prevention in other settings, and obesity prevention