Redefining care model could improve pediatric obesity prevention, treatment

WASHINGTON – Physicians have a role in combating early childhood obesity, but experts say the clinical setting is not ideal for effective treatment and prevention of this emerging epidemic.

“Pediatricians have high access to kids, parents, and guardians, and we are trusted sources of information for them,” Dr. Ian Paul, professor and chief of academic pediatrics at Penn State University Hershey Medical Center, said at an Institute of Medicine forum on early childhood obesity.

Emerging data underscore obesity’s complex societal components, which include an imbalance of diet and physical activity complicated by less tangible factors such as cultural attitudes, maternal habits, and socio-economic status. And then there is the question of the best way to reimburse physicians for applying the few proven long-term interventions they have.

“I think it’s one of those things where it takes a village,” Dr. Paul said in an interview. “You need multiple people going in the same direction. The pediatrician can give advice, and support what is happening, but it can’t just be the pediatrician by him- or herself.”

The U.S. Centers for Disease Control and Prevention says that pediatric obesity affects a third of the nation’s youth. But there are only vague policies and guidelines for how to intervene in the preschool years, a time when research now shows risk factors present can set the stage for obesity later in a child’s life. This all leaves pediatricians unsure of how to treat young patients who present with signs of overweight and obesity. To date, there are no proven clinical-based obesity interventions for birth to age 5 years, Dr. Paul said. “Pediatricians don’t always feel equipped to handle questions about obesity prevention and treatment,” compounded, by the fact that, “reimbursement for these services has been poor.”

However, through partnerships with community organizations and other clinicians, more effective models of care are emerging, particularly in minority and lower income communities where obesity rates are among the highest nationally (Contemp Clin Trials. 2013 Nov;36[3]:544-54. doi: 10.1016/j.cct.2013.09.015. Epub 2013 Oct 9), noted Dr. Paul.

“In poorer households, high rates of maternal stress and less access to resources such as time with a nutritionist or higher quality produce and other foods, are risk factors for obesity,” Dr. Mary Jo Messito, director of the Starting Early Child Obesity Prevention Program at Bellevue Hospital in New York, said in an interview.

As part of their program, Dr. Messito, clinical associate professor of pediatrics at New York University, and her colleagues conducted a study of a family-based, early obesity intervention and prevention program with nutrition support groups as the central component.

The study involved 534 expectant mothers in their last trimester who were randomly assigned to receive either standard prenatal care followed by standard well-child care, or prenatal nutritional counseling, in addition to well-child visits coupled with continued nutritional counseling in a group setting, which they attend with their babies. The study group met regularly to learn how to make their own minimally processed baby foods, read and understand food labels, and offer peer support for any issues they might be encountering in raising their babies to eat healthfully.

Although many Hispanic families are affected by obesity, there is a need to teach and reinforce these skills in all families of young children affected by poverty, said Dr. Messito. “Middle and upper income people can also be affected by obesity, but they have the resources to deal with it, including education and nutritional support provided by insurance plans.”

The currently unpublished results of the study, based on 3 years of follow-up, are both statistically and clinically significant, said Dr. Messito. Only 6% of the families in the study group prematurely introduced complementary foods such as juices and solids compared with 17% in controls, according to Dr. Messito.

Exclusively breastfed babies in the control group totaled 34% compared with an impressive 46% in the study group, Dr. Messito said.

The potentially devastating consequences of resorting to quick-fixes such as cereal and juice at too young an age to sooth a fussy baby, is that at age 2 or 3 years, when it is still tricky to determine if they’ve exceeded the 95th percentile for their weight, these overfed babies can be on a trajectory that lasts long after they grow up. “If you are obese then, the odds are great you will be for life,” said Dr. Messito.

Much of the Starting Early study’s “plain language” materials, published in both English and Spanish, distributed to families as reinforcement to what they learn in their groups, was based on what is routinely provided by the federal Women, Infants, and Children (WIC) program, said Dr. Messito. “We see ourselves as collaborators with WIC and with primary care.”

This pleases Dr. Paul. “Pediatricians only have a limited amount of time for each visit, and an office setting is not very conducive to get in as in-depth a conversation as you would like, especially in well-child care. By meeting with several families at once, instead of delivering the same information five times, it can be done once in 100 minutes where everyone can be in on the discussion,” he said in an interview.

Partnering with others in the community not only adds another layer of support, it also takes the burden off the physician to do it all.

The NET-Works study (Now Everybody Together for Amazing and Healthful Kids), currently underway at the University of Minnesota, on the Twin Cities campus, includes the families of 500 preschoolers, followed for 3 years after being randomly assigned to standard care or an integrated model that features nutritional counseling, both at the primary care and community level, as well as a home-based intervention, and support from neighborhood and community resources to promote optimal healthful lifestyle habits, including diet and physical activity, and screen time limits. Results from the study are due in 2017.

“What I like about this study is that the pediatrician has a supporting, rather than leading, role in a community-wide effort to prevent and treat childhood obesity,” said Dr. Paul. “I think that’s the answer.”

Another model of community-based care, promoted by the CDC, leverages the time more than 60% of U.S. children spend in early education and care centers by linking various community resources with these early learning facilities to ensure that children learn to consume healthful foods and exercise.

Dr. Dianne Ward, professor of nutrition at the University of North Carolina, Chapel Hill, and a panelist at the IOM roundtable, noted that one hitch is that often the child care providers themselves are often unhealthy. “A number of studies show these women often have poor diets, stress, inactivity, and smoke, yet these are the same women we ask to be role models for our children and lead the healthy eating educational programs. It’s unclear whether their health status has a negative effect on the children.”

Dr. Paul’s own work with others such as Dr. Leann Birch, the William P. “Bill” Flatt Childhood Obesity Professor at the University of Georgia, Athens, focuses on home-based interventions delivered by nurses. By training parents and caregivers in what they call “responsive feeding,” their SLIM-Time study addresses how and why parents feed their children, rather than what they feed them, with the essential byproduct being greater capacity in both parents and children to self-soothe and exert self-control.

Similar to Dr. Messito’s work, SLIM-Time (Sleeping and Intake Methods Taught to Infants and Mothers Early in Life) “teaches people how to respond appropriately to a baby’s cues earlier in life. If you take a baby and give it a bottle, it will stop crying, whether or not [the baby is] hungry. Food should be used for hunger,” Dr. Paul said. “We teach parents to use food for hunger, not comfort.”

The results of the randomly controlled SLIM-Time study of 110 mother-infant dyads, published online in 2010, were that by teaching parents soothing and sleep strategies other than bottle feeding, and helping them to recognize satiety cues, as well as educating them on the appropriate time to introduce solid foods, study babies were encouraged to finish their bottles only half as often as were controls. At 1 year, study babies were in the 35th percentile for weight-for-length compared with 50% of controls. Babies in the test group also required fewer nighttime feedings than did controls at weeks 3, 4, 8, and 16 (P = .003) (Obesity. 2011 Feb; 19[2]: 353-61).

The results led Dr. Paul and his colleagues to create the similarly structured INSIGHT Study (Preventing Obesity Through Interventions During Infancy), the results of which are still in preparation, but preliminarily seem to reinforce SLIM-Time’s results, with 15% of controls being in the 95th or higher weight-per-length percentiles at 1 year compared with 5% of intervention group babies being in that range.

Dr. Birch stated during the IOM round table that the effects in each study group were similar, regardless of whether a child was fed formula or breast milk. “We still have a lot of data to analyze, but at this point, it looks like the effects aren’t limited to intense breastfeeding.” Breastfeeding has been found protective against obesity (Am J Epidemiol. 2005 Sept 1;162[5]:397-403. Epub 2005 Aug 2; Int J Obes Relat Metab Disord. 2004 Oct;28[10]:1247-56.)

Even though the literature for early childhood obesity intervention and prevention is nascent, it’s already evident that to see obesity primarily as a clinical issue is too limiting, according to Dr. Paul.

“This is the focus of my career, and I have state-of-the-art techniques. Yet, I still have plenty of obese patients of all ages in my care,” he said. How should he be reimbursed for treating these patients, particularly if some of them are already on the road to a lifetime of obesity, having been set upon it long before being diagnosed?

“I think a pediatrician should be responsible for delivering content and good advice, and addressing the health issues. That can be documented, and we can be scored on that” said Dr. Paul, but “it might be unfair to judge a pediatrician on the proportion of the number of children who are overweight or obese in his or her practice because there are so many factors that are going to be involved in that outcome.

“There is only so much we can do in the clinic.”

There were no conflicts of interest to report.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Physicians have a role in combating early childhood obesity, but experts say the clinical setting is not ideal for effective treatment and prevention of this emerging epidemic.

“Pediatricians have high access to kids, parents, and guardians, and we are trusted sources of information for them,” Dr. Ian Paul, professor and chief of academic pediatrics at Penn State University Hershey Medical Center, said at an Institute of Medicine forum on early childhood obesity.

Emerging data underscore obesity’s complex societal components, which include an imbalance of diet and physical activity complicated by less tangible factors such as cultural attitudes, maternal habits, and socio-economic status. And then there is the question of the best way to reimburse physicians for applying the few proven long-term interventions they have.

“I think it’s one of those things where it takes a village,” Dr. Paul said in an interview. “You need multiple people going in the same direction. The pediatrician can give advice, and support what is happening, but it can’t just be the pediatrician by him- or herself.”

The U.S. Centers for Disease Control and Prevention says that pediatric obesity affects a third of the nation’s youth. But there are only vague policies and guidelines for how to intervene in the preschool years, a time when research now shows risk factors present can set the stage for obesity later in a child’s life. This all leaves pediatricians unsure of how to treat young patients who present with signs of overweight and obesity. To date, there are no proven clinical-based obesity interventions for birth to age 5 years, Dr. Paul said. “Pediatricians don’t always feel equipped to handle questions about obesity prevention and treatment,” compounded, by the fact that, “reimbursement for these services has been poor.”

However, through partnerships with community organizations and other clinicians, more effective models of care are emerging, particularly in minority and lower income communities where obesity rates are among the highest nationally (Contemp Clin Trials. 2013 Nov;36[3]:544-54. doi: 10.1016/j.cct.2013.09.015. Epub 2013 Oct 9), noted Dr. Paul.

“In poorer households, high rates of maternal stress and less access to resources such as time with a nutritionist or higher quality produce and other foods, are risk factors for obesity,” Dr. Mary Jo Messito, director of the Starting Early Child Obesity Prevention Program at Bellevue Hospital in New York, said in an interview.

As part of their program, Dr. Messito, clinical associate professor of pediatrics at New York University, and her colleagues conducted a study of a family-based, early obesity intervention and prevention program with nutrition support groups as the central component.

The study involved 534 expectant mothers in their last trimester who were randomly assigned to receive either standard prenatal care followed by standard well-child care, or prenatal nutritional counseling, in addition to well-child visits coupled with continued nutritional counseling in a group setting, which they attend with their babies. The study group met regularly to learn how to make their own minimally processed baby foods, read and understand food labels, and offer peer support for any issues they might be encountering in raising their babies to eat healthfully.

Although many Hispanic families are affected by obesity, there is a need to teach and reinforce these skills in all families of young children affected by poverty, said Dr. Messito. “Middle and upper income people can also be affected by obesity, but they have the resources to deal with it, including education and nutritional support provided by insurance plans.”

The currently unpublished results of the study, based on 3 years of follow-up, are both statistically and clinically significant, said Dr. Messito. Only 6% of the families in the study group prematurely introduced complementary foods such as juices and solids compared with 17% in controls, according to Dr. Messito.

Exclusively breastfed babies in the control group totaled 34% compared with an impressive 46% in the study group, Dr. Messito said.

The potentially devastating consequences of resorting to quick-fixes such as cereal and juice at too young an age to sooth a fussy baby, is that at age 2 or 3 years, when it is still tricky to determine if they’ve exceeded the 95th percentile for their weight, these overfed babies can be on a trajectory that lasts long after they grow up. “If you are obese then, the odds are great you will be for life,” said Dr. Messito.

Much of the Starting Early study’s “plain language” materials, published in both English and Spanish, distributed to families as reinforcement to what they learn in their groups, was based on what is routinely provided by the federal Women, Infants, and Children (WIC) program, said Dr. Messito. “We see ourselves as collaborators with WIC and with primary care.”

This pleases Dr. Paul. “Pediatricians only have a limited amount of time for each visit, and an office setting is not very conducive to get in as in-depth a conversation as you would like, especially in well-child care. By meeting with several families at once, instead of delivering the same information five times, it can be done once in 100 minutes where everyone can be in on the discussion,” he said in an interview.

Partnering with others in the community not only adds another layer of support, it also takes the burden off the physician to do it all.

The NET-Works study (Now Everybody Together for Amazing and Healthful Kids), currently underway at the University of Minnesota, on the Twin Cities campus, includes the families of 500 preschoolers, followed for 3 years after being randomly assigned to standard care or an integrated model that features nutritional counseling, both at the primary care and community level, as well as a home-based intervention, and support from neighborhood and community resources to promote optimal healthful lifestyle habits, including diet and physical activity, and screen time limits. Results from the study are due in 2017.

“What I like about this study is that the pediatrician has a supporting, rather than leading, role in a community-wide effort to prevent and treat childhood obesity,” said Dr. Paul. “I think that’s the answer.”

Another model of community-based care, promoted by the CDC, leverages the time more than 60% of U.S. children spend in early education and care centers by linking various community resources with these early learning facilities to ensure that children learn to consume healthful foods and exercise.

Dr. Dianne Ward, professor of nutrition at the University of North Carolina, Chapel Hill, and a panelist at the IOM roundtable, noted that one hitch is that often the child care providers themselves are often unhealthy. “A number of studies show these women often have poor diets, stress, inactivity, and smoke, yet these are the same women we ask to be role models for our children and lead the healthy eating educational programs. It’s unclear whether their health status has a negative effect on the children.”

Dr. Paul’s own work with others such as Dr. Leann Birch, the William P. “Bill” Flatt Childhood Obesity Professor at the University of Georgia, Athens, focuses on home-based interventions delivered by nurses. By training parents and caregivers in what they call “responsive feeding,” their SLIM-Time study addresses how and why parents feed their children, rather than what they feed them, with the essential byproduct being greater capacity in both parents and children to self-soothe and exert self-control.

Similar to Dr. Messito’s work, SLIM-Time (Sleeping and Intake Methods Taught to Infants and Mothers Early in Life) “teaches people how to respond appropriately to a baby’s cues earlier in life. If you take a baby and give it a bottle, it will stop crying, whether or not [the baby is] hungry. Food should be used for hunger,” Dr. Paul said. “We teach parents to use food for hunger, not comfort.”

The results of the randomly controlled SLIM-Time study of 110 mother-infant dyads, published online in 2010, were that by teaching parents soothing and sleep strategies other than bottle feeding, and helping them to recognize satiety cues, as well as educating them on the appropriate time to introduce solid foods, study babies were encouraged to finish their bottles only half as often as were controls. At 1 year, study babies were in the 35th percentile for weight-for-length compared with 50% of controls. Babies in the test group also required fewer nighttime feedings than did controls at weeks 3, 4, 8, and 16 (P = .003) (Obesity. 2011 Feb; 19[2]: 353-61).

The results led Dr. Paul and his colleagues to create the similarly structured INSIGHT Study (Preventing Obesity Through Interventions During Infancy), the results of which are still in preparation, but preliminarily seem to reinforce SLIM-Time’s results, with 15% of controls being in the 95th or higher weight-per-length percentiles at 1 year compared with 5% of intervention group babies being in that range.

Dr. Birch stated during the IOM round table that the effects in each study group were similar, regardless of whether a child was fed formula or breast milk. “We still have a lot of data to analyze, but at this point, it looks like the effects aren’t limited to intense breastfeeding.” Breastfeeding has been found protective against obesity (Am J Epidemiol. 2005 Sept 1;162[5]:397-403. Epub 2005 Aug 2; Int J Obes Relat Metab Disord. 2004 Oct;28[10]:1247-56.)

Even though the literature for early childhood obesity intervention and prevention is nascent, it’s already evident that to see obesity primarily as a clinical issue is too limiting, according to Dr. Paul.

“This is the focus of my career, and I have state-of-the-art techniques. Yet, I still have plenty of obese patients of all ages in my care,” he said. How should he be reimbursed for treating these patients, particularly if some of them are already on the road to a lifetime of obesity, having been set upon it long before being diagnosed?

“I think a pediatrician should be responsible for delivering content and good advice, and addressing the health issues. That can be documented, and we can be scored on that” said Dr. Paul, but “it might be unfair to judge a pediatrician on the proportion of the number of children who are overweight or obese in his or her practice because there are so many factors that are going to be involved in that outcome.

“There is only so much we can do in the clinic.”

There were no conflicts of interest to report.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Physicians have a role in combating early childhood obesity, but experts say the clinical setting is not ideal for effective treatment and prevention of this emerging epidemic.

“Pediatricians have high access to kids, parents, and guardians, and we are trusted sources of information for them,” Dr. Ian Paul, professor and chief of academic pediatrics at Penn State University Hershey Medical Center, said at an Institute of Medicine forum on early childhood obesity.

Emerging data underscore obesity’s complex societal components, which include an imbalance of diet and physical activity complicated by less tangible factors such as cultural attitudes, maternal habits, and socio-economic status. And then there is the question of the best way to reimburse physicians for applying the few proven long-term interventions they have.

“I think it’s one of those things where it takes a village,” Dr. Paul said in an interview. “You need multiple people going in the same direction. The pediatrician can give advice, and support what is happening, but it can’t just be the pediatrician by him- or herself.”

The U.S. Centers for Disease Control and Prevention says that pediatric obesity affects a third of the nation’s youth. But there are only vague policies and guidelines for how to intervene in the preschool years, a time when research now shows risk factors present can set the stage for obesity later in a child’s life. This all leaves pediatricians unsure of how to treat young patients who present with signs of overweight and obesity. To date, there are no proven clinical-based obesity interventions for birth to age 5 years, Dr. Paul said. “Pediatricians don’t always feel equipped to handle questions about obesity prevention and treatment,” compounded, by the fact that, “reimbursement for these services has been poor.”

However, through partnerships with community organizations and other clinicians, more effective models of care are emerging, particularly in minority and lower income communities where obesity rates are among the highest nationally (Contemp Clin Trials. 2013 Nov;36[3]:544-54. doi: 10.1016/j.cct.2013.09.015. Epub 2013 Oct 9), noted Dr. Paul.

“In poorer households, high rates of maternal stress and less access to resources such as time with a nutritionist or higher quality produce and other foods, are risk factors for obesity,” Dr. Mary Jo Messito, director of the Starting Early Child Obesity Prevention Program at Bellevue Hospital in New York, said in an interview.

As part of their program, Dr. Messito, clinical associate professor of pediatrics at New York University, and her colleagues conducted a study of a family-based, early obesity intervention and prevention program with nutrition support groups as the central component.

The study involved 534 expectant mothers in their last trimester who were randomly assigned to receive either standard prenatal care followed by standard well-child care, or prenatal nutritional counseling, in addition to well-child visits coupled with continued nutritional counseling in a group setting, which they attend with their babies. The study group met regularly to learn how to make their own minimally processed baby foods, read and understand food labels, and offer peer support for any issues they might be encountering in raising their babies to eat healthfully.

Although many Hispanic families are affected by obesity, there is a need to teach and reinforce these skills in all families of young children affected by poverty, said Dr. Messito. “Middle and upper income people can also be affected by obesity, but they have the resources to deal with it, including education and nutritional support provided by insurance plans.”

The currently unpublished results of the study, based on 3 years of follow-up, are both statistically and clinically significant, said Dr. Messito. Only 6% of the families in the study group prematurely introduced complementary foods such as juices and solids compared with 17% in controls, according to Dr. Messito.

Exclusively breastfed babies in the control group totaled 34% compared with an impressive 46% in the study group, Dr. Messito said.

The potentially devastating consequences of resorting to quick-fixes such as cereal and juice at too young an age to sooth a fussy baby, is that at age 2 or 3 years, when it is still tricky to determine if they’ve exceeded the 95th percentile for their weight, these overfed babies can be on a trajectory that lasts long after they grow up. “If you are obese then, the odds are great you will be for life,” said Dr. Messito.

Much of the Starting Early study’s “plain language” materials, published in both English and Spanish, distributed to families as reinforcement to what they learn in their groups, was based on what is routinely provided by the federal Women, Infants, and Children (WIC) program, said Dr. Messito. “We see ourselves as collaborators with WIC and with primary care.”

This pleases Dr. Paul. “Pediatricians only have a limited amount of time for each visit, and an office setting is not very conducive to get in as in-depth a conversation as you would like, especially in well-child care. By meeting with several families at once, instead of delivering the same information five times, it can be done once in 100 minutes where everyone can be in on the discussion,” he said in an interview.

Partnering with others in the community not only adds another layer of support, it also takes the burden off the physician to do it all.

The NET-Works study (Now Everybody Together for Amazing and Healthful Kids), currently underway at the University of Minnesota, on the Twin Cities campus, includes the families of 500 preschoolers, followed for 3 years after being randomly assigned to standard care or an integrated model that features nutritional counseling, both at the primary care and community level, as well as a home-based intervention, and support from neighborhood and community resources to promote optimal healthful lifestyle habits, including diet and physical activity, and screen time limits. Results from the study are due in 2017.

“What I like about this study is that the pediatrician has a supporting, rather than leading, role in a community-wide effort to prevent and treat childhood obesity,” said Dr. Paul. “I think that’s the answer.”

Another model of community-based care, promoted by the CDC, leverages the time more than 60% of U.S. children spend in early education and care centers by linking various community resources with these early learning facilities to ensure that children learn to consume healthful foods and exercise.

Dr. Dianne Ward, professor of nutrition at the University of North Carolina, Chapel Hill, and a panelist at the IOM roundtable, noted that one hitch is that often the child care providers themselves are often unhealthy. “A number of studies show these women often have poor diets, stress, inactivity, and smoke, yet these are the same women we ask to be role models for our children and lead the healthy eating educational programs. It’s unclear whether their health status has a negative effect on the children.”

Dr. Paul’s own work with others such as Dr. Leann Birch, the William P. “Bill” Flatt Childhood Obesity Professor at the University of Georgia, Athens, focuses on home-based interventions delivered by nurses. By training parents and caregivers in what they call “responsive feeding,” their SLIM-Time study addresses how and why parents feed their children, rather than what they feed them, with the essential byproduct being greater capacity in both parents and children to self-soothe and exert self-control.

Similar to Dr. Messito’s work, SLIM-Time (Sleeping and Intake Methods Taught to Infants and Mothers Early in Life) “teaches people how to respond appropriately to a baby’s cues earlier in life. If you take a baby and give it a bottle, it will stop crying, whether or not [the baby is] hungry. Food should be used for hunger,” Dr. Paul said. “We teach parents to use food for hunger, not comfort.”

The results of the randomly controlled SLIM-Time study of 110 mother-infant dyads, published online in 2010, were that by teaching parents soothing and sleep strategies other than bottle feeding, and helping them to recognize satiety cues, as well as educating them on the appropriate time to introduce solid foods, study babies were encouraged to finish their bottles only half as often as were controls. At 1 year, study babies were in the 35th percentile for weight-for-length compared with 50% of controls. Babies in the test group also required fewer nighttime feedings than did controls at weeks 3, 4, 8, and 16 (P = .003) (Obesity. 2011 Feb; 19[2]: 353-61).

The results led Dr. Paul and his colleagues to create the similarly structured INSIGHT Study (Preventing Obesity Through Interventions During Infancy), the results of which are still in preparation, but preliminarily seem to reinforce SLIM-Time’s results, with 15% of controls being in the 95th or higher weight-per-length percentiles at 1 year compared with 5% of intervention group babies being in that range.

Dr. Birch stated during the IOM round table that the effects in each study group were similar, regardless of whether a child was fed formula or breast milk. “We still have a lot of data to analyze, but at this point, it looks like the effects aren’t limited to intense breastfeeding.” Breastfeeding has been found protective against obesity (Am J Epidemiol. 2005 Sept 1;162[5]:397-403. Epub 2005 Aug 2; Int J Obes Relat Metab Disord. 2004 Oct;28[10]:1247-56.)

Even though the literature for early childhood obesity intervention and prevention is nascent, it’s already evident that to see obesity primarily as a clinical issue is too limiting, according to Dr. Paul.

“This is the focus of my career, and I have state-of-the-art techniques. Yet, I still have plenty of obese patients of all ages in my care,” he said. How should he be reimbursed for treating these patients, particularly if some of them are already on the road to a lifetime of obesity, having been set upon it long before being diagnosed?

“I think a pediatrician should be responsible for delivering content and good advice, and addressing the health issues. That can be documented, and we can be scored on that” said Dr. Paul, but “it might be unfair to judge a pediatrician on the proportion of the number of children who are overweight or obese in his or her practice because there are so many factors that are going to be involved in that outcome.

“There is only so much we can do in the clinic.”

There were no conflicts of interest to report.

[email protected]

On Twitter @whitneymcknight