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REVIEW |
Correspondence to:
Correspondence to:
Dr J J Reilly
University Division of Developmental Medicine, University of Glasgow/ Yorkhill Hospitals Glasgow, 1st Floor Tower Block QMH, Yorkhill, Glasgow G3 8SJ, Scotland; jjr2y{at}clinmed.gla.ac.uk
Submitted 28 November 2005
Accepted 24 January 2006
 | ABSTRACT |
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 TOP ABSTRACT DEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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Keywords: energy metabolism; nutrition; obesity; physical activity; child health
An epidemic of obesity affected children and adolescents across the developed and developing world in recent years. In most of the world,1,2,3,4,5,6,7,8,9,10,11 with the notable exceptions of parts of sub-Saharan Africa and the former Soviet Union, obesity is now the most common paediatric disease. Paediatric obesity has overtaken underweight in prevalence in many developing countries.5–7 Clinical management and public health strategies to combat the problem of paediatric obesity have been overtaken by the speed and scale of the epidemic. Recent Cochrane reviews on prevention and treatment of paediatric obesity have noted the mismatch between the scale of the problem and our comparatively weak and belated strategies for dealing with it.8,9 Nevertheless, recent systematic reviews and critical appraisal exercises have provided valuable summaries of best evidence to date and these should help in the development of future clinical and public health responses to the epidemic. The principal aim of this review is to summarise these recent systematic reviews.
| DEFINITIONS AND DIAGNOSIS |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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and 2), or by calculation of a standard deviation or (Z score or SD score) relative to population reference data.10–15
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98th centile on the UK 1990 charts) are highly likely to be excessively fat—that is, this obesity definition has high diagnostic specificity (low false positive rate). Such definitions have a moderate sensitivity10,11,15—that is, modest false negative rate. Such definitions are also clinically meaningful: they identify children and adolescents at high risk of the comorbidities of obesity.16–18
In the UK, the best evidence suggests that overweight and obesity should be defined as BMI 85th and 95th centiles in research and epidemiology.10,14 In clinical practice the UK charts only provide 91st and 98th centiles and for pragmatic reasons these should be the basis of our definitions of overweight and obesity respectively.10,14 A number of other countries now have BMI population reference data and centile charts. Where such "national" reference data are available, they should be used to define/diagnose overweight and obesity.11 Where national data are unavailable there is a choice of using either reference data/charts from another nation (such as the USA whose charts are available from the Centers for Disease Control and Prevention) or use of newer "international" definitions of overweight and obesity.12 The international approach attempts to link adult BMI based definitions of overweight (BMI25) and obesity (BMI30) to paediatric definitions by providing age and sex specific "equivalent" BMIs in childhood and adolescence. For ease of international comparisons these international definitions are practical. However, four recent studies have compared the diagnostic ability of the international definitions with that of the more traditional national definitions based on national BMI centiles.15,19–21 In all four cases diagnostic ability of the national approach was greatly superior, and so use of the international approach should be considered with caution.11,15,19–22
The scale of the obesity epidemic is also heavily dependent on the definition used. Using data from the same survey, prevalence of obesity can vary twofold to sevenfold11,15,19–23 depending on whether national reference data or the international approach is taken. Further discussion on the merits of national compared with international approaches is beyond the scope of this review, but detailed arguments can be found elsewhere.11,22
| PREVALENCE |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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). For the developed world, estimates from 2000 onward using national definitions (such as BMI 95th centile) suggest that 10%–25% of the paediatric population was obese.1,19,20,23–32 In England in 2003 for example, 28% of 2–11 year olds were overweight or obese (BMI 85th centile), up from 22% in 1995, while 14% were obese (BMI 95th centile), up from 10% in 1995.33
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In the developed world prevalence of paediatric obesity is generally as common in boys as girls. The picture with respect to sex differences in prevalence in the developing world is more complex and difficult to predict.4–7 In the developed world paediatric obesity is generally more common in children and adolescents from families of lower socioeconomic status,4,11 but the magnitude of these socioeconomic differences in prevalence is quite limited. In the developing world the picture is again more complex: higher socioeconomic status has usually been associated with higher risk of paediatric obesity, although as the epidemic progresses in the developing world lower socioeconomic status may become more of a risk for obesity.4–7
In the USA youth prevalence of obesity is much higher in some ethnic minorities than in the general population.2 Evidence from outside the USA is limited at present but suggests that some ethnic minority groups may also be at higher risk. Again, reasons for differences are complex and not entirely clear at present.
| HAS THE SCALE OF THE OBESITY EPIDEMIC BEEN UNDERESTIMATED? |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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| CONSEQUENCES—WHY DOES PAEDIATRIC OBESITY MATTER? |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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gives a summary of the principal health and other adverse effects. In the developed world the most widespread adverse effects in childhood are probably psychosocial.18 From a public health perspective the important concern is the impact of child and adolescent obesity on cardiovascular and metabolic health.16–18 It is becoming increasingly clear that the obesity epidemic is likely to herald an important public health burden in future from diabetes and cardiovascular disease,16–18 and evidence on its economic impact is also emerging.37,38 In developing countries the combination of fetal undernutrition followed by neonatal/infant overnutrition seems to be particularly likely to be associated with later obesity and metabolic/ cardiovascular morbidity.39,40 | Box 1 Principal consequences of paediatric obesity* In childhood and adolescence
In adulthood
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| PERCEPTIONS OF OBESITY AMONG HEALTH PROFESSIONALS AND FAMILIES |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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| CAUSES OF THE PAEDIATRIC OBESITY EPIDEMIC |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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It is increasingly being appreciated that the paradigm of identifying an energy imbalance (in intake expenditure or both) as a "cause" of obesity might be limited.43,45 The underlying causes of energy imbalance—that is, behaviours or risk factors, may not only be more readily measurable than energy intake and expenditure, but may also be more useful in that they represent possible behavioural targets for any future preventive interventions.45
One historical difficulty with this alternative—more epidemiological—approach to studying the causes of obesity has been that systematic reviews have reported that older epidemiological studies of "risk factors" for childhood and adolescent obesity were usually flawed.46 Many of these older epidemiological studies were underpowered and had serious limitations in design (many cross sectional studies that used simple univariable analysis). More recent epidemiological studies have been more likely to identify causes of obesity because they have been larger and have adopted longitudinal study designs with multivariable analysis (for example, to control for the confounding effects of socioeconomic status).11,47 These recent studies have identified a surprisingly large number of potential risk factors for the development of paediatric obesity, reviewed elsewhere.11
From these candidate risk factors for obesity we can apply "decision rules" to identify which are the most promising targets for interventions aimed at paediatric obesity prevention. Whitaker48 has suggested that candidate behaviours should meet certain criteria before they are selected as the basis of interventions. Firstly, the behaviour(s) targeted should be causally related to the development of maintenance of obesity—this requires reasonable evidence from energy balance studies or epidemiology, combined with biological plausibility. Secondly, the intervention should do no harm. Thirdly, the behaviour(s) to be modified should aid in child health/ development in other ways. Finally, the behavioural targets for prevention should be measurable: if families cannot measure the behaviour then it will be difficult for them to modify it; if the behaviour(s) cannot be measured objectively with sufficiently high accuracy and precision, then evaluation of the true magnitude of behaviour change is problematic. Many previous dietary interventions have probably been flawed by biased self reporting of changes in dietary intake by participants in intervention studies.49
Of all the candidate behaviours or risk factors those that are most likely to meet these Whitaker criteria at present are as follows: formula feeding during infancy (breast feeding provides modest protection against later obesity50,51); consumption of sugar sweetened drinks (energy consumed in dissolved sugar may not be adequately "recognised" and therefore compensated for by reductions in later energy intake); excessive television viewing (which may either reduce energy expenditure or increase energy intake, or both52,53); low physical activity.54,55 These four behaviours should therefore be regarded as the highest priorities for interventions aimed at prevention of paediatric obesity.
| EVIDENCE ON PREVENTIVE INTERVENTIONS |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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To date the only high quality RCT that has tested an intervention that is likely to be successful and generalisable is the Planet Health intervention (box 2) in schools in the Boston area of the USA.52 This comparatively large trial (1295 participants, mean age 11 at study entry) used a complex intervention over two school years. The intervention consisted of changes to the school curriculum (such as improved physical education), changes to school meal provision, targeted reductions in television viewing, and promotion of walking to/from school.52 The intervention was successful (in girls, not in boys) in that risk of becoming obese was significantly reduced (adjusted odds ratio, AOR 0.47, 95% CI 0.24 to 0.93), and there was a significant remission of existing obesity in those who were obese at the start of the trial (AOR 2.16, 95% CI 1.07 to 4.35). The benefits of the intervention were attributable largely to reductions in television viewing.52 Reduced television viewing is one of our most promising strategies for obesity prevention because it is a behaviour that seems to be fairly modifiable, and because reduced time spent watching television probably reduces food intake and/or increases energy expenditure modestly (by increasing physical activity).52–55
| Box 2 Planet Health: a school based intervention for obesity prevention* The intervention
Outcomes
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The Planet Health trial is a model of obesity prevention intervention, and is particularly promising because its authors have subsequently tackled issues of generalisability and sustainability of the intervention (for example, by producing a handbook for schools that describes how to implement a Planet Health approach into school curriculums). The Planet Health investigators also have promising data on the economic benefits of the intervention.55 Nevertheless, the Planet Health approach may not be generalisable to all settings and there is an urgent need to assess the success of other interventions in other populations. Despite the scale and impact of the obesity epidemic there are in fact comparatively few preventive interventions being tested in RCT, and most of these have focused on minority groups of adolescents in the USA.56 For other population groups in the developed world (for example, young children) there is an even greater dearth of evidence. There are few if any trials aimed at testing preventive interventions underway in the developing world and this is another important research gap that must be tackled urgently.
It has been argued that one of the reasons for the failure of many previous preventive interventions is that by targeting behaviour modification at the "micro" level (that is, individual children, their families, or schools) they are unable to have an impact on the many other influences on weight status that determine the environment at the "macro" level, such as economic or transport policies.57,58 Successful obesity prevention may therefore require a more macro-environmental approach (in addition to or as an alternative to the micro level behavioural changes that have been tested in interventions to date). Taking such an approach would require political/economic action on a scale that has not been attempted by governments yet, to "detoxify" the wider "obesogenic environment".59 Some governments may be at least considering actions of this kind. For example, the recent UK Parliament Health Select Committee Inquiry into Obesity38 listed a large number of political and economic options for tackling the obesity epidemic that would operate at the macro or societal level.
There is little doubt that governmental and policy issues such as transport and food pricing have had an important impact on the obesity epidemic. The evidence from the developing world has shown that there are a variety of features of societies in economic or nutritional "transition" that commonly underpin dramatic increases in obesity prevalence, and these are discussed in detail elsewhere.60 Even in the developed world apparently basic economic and political decisions such as regulations on food pricing may have been important "drivers" of the paediatric obesity epidemic.61
| PREVENTION OR TREATMENT? |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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From a public health perspective obesity in itself may be less of a problem than the pervasive nature of some of the health behaviours that cause it. For example, high levels of sedentary behaviour and low levels of habitual physical activity64 may be typical of modern children, and these behaviours may be established at an early age, well before school entry. This provides an argument for the promotion of lifestyle modification across the paediatric population, not just in those currently defined as overweight and obese. How this might be achieved is unclear and not without difficulties.
| EVIDENCE ON TREATMENT INTERVENTIONS |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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), and some "best bets" in treatment are clear from the treatment RCTs and expert committee/ consensus reports.9,10,14 The most promising results have been obtained using the pioneering multidisciplinary and intensive treatment approach of Epstein,65,66 and making this approach more generalisable is a promising strategy for treatment. Box 3 Treatment guidance
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Treatment should probably be limited to motivated families, where the child (and preferably the family) perceive the child’s obesity as a problem, and seem to be motivated to attempt lifestyle changes. The development of obesity is the result of a long term positive energy balance and treating it requires maintenance of a zero or slightly negative energy balance over a long period (months or years). From a theoretical point of view our treatments should probably continue for longer than is traditionally the case, and should entail more frequent and longer consultations with patients, and these recommendations are backed by some empirical evidence.9,10,14 In children (although possibly not in adolescents), treatment success is most probable if the approach taken is to treat the whole family, rather than just focusing treatment on the obese child. Treatment must entail dietary changes, and the "traffic light" approach of Epstein,65,66 or modified versions of it67 seem to be practical and promising dietary modification strategies. In brief, this entails children and their families being taught to group foods into three categories: red (high energy density foods, for strictly limited consumption), amber (medium energy density foods, for limited consumption, for example, to mealtimes only), and green (foods of low energy density, to be consumed freely as substitutes for red and amber foods).
Treatment should not focus solely on diet, and must aim to reduce sedentary behaviour (particularly television viewing), and/or increase physical activity. Targeting a reduction in sedentary behaviour, perhaps by introducing limits to television viewing time such as two hours/day (including media use such as computer games and internet use), is one of the most promising elements of treatment.9,10,14 As with obesity prevention interventions, reductions in television viewing may be associated with reductions in energy intake and/or with modest increases in physical activity and energy expenditure. Directly promoting increases in physical activity may also be helpful, although it is unclear whether the focus should be on promoting structured aerobic exercise and/or lifestyle physical activity. Obese children and adolescents generally have limited exercise tolerance and may be more amenable to increases in lifestyle physical activity (such as walking to school).
Recent systematic reviews have concluded that several alternative approaches to treatment, which have been the source of great interest, (specific dietary modifications, for example, modifying the glycaemic load of the diet; residential treatment; pharmacotherapy; surgery) are not currently based on high quality evidence.9,10,14 Again, there is a need for more high quality and long term RCTs to test the evidence for these approaches. The most recent evidence suggests that many of these newer approaches are promising. For example, glycaemic load modification holds out hope of changing appetite regulation and may eventually be a highly practical dietary strategy;68 residential treatments can produce very favourable outcomes at least in the short-medium term (including noticeable improvements in self esteem and psychosocial wellbeing)69; recent trials of pharmacotherapy in severely obese adolescents suggest that as an adjunct to lifestyle modification this may be beneficial70; surgery is promising for the more severely obese adolescents and/or those with serious comorbidity.71 Given this high degree of promise and the scale of the obesity epidemic it is a matter of some urgency that these trials are funded and carried out.
Audits of traditional dietetic and paediatric approaches to treatment of paediatric obesity are generally disappointing.72,73 For example, in a five year audit of 254 patients at the Sick Children’s Hospital in Edinburgh, mostly referred from primary care, 52% of the patients failed to attend any of the appointments made for them. In the remaining 48% of patients who attended at least one of the three appointments made, weight maintenance over six months (an aim of management) was achieved in only 22% (equivalent to about 12% of all those referred to the clinic). Audit results like these are probably not specific to particular clinic, but reflect a wider failure of treatment.72,73 They have been interpreted as being unsupportive of any efforts at treatment, but it may be that current treatment approaches are inadequate. Traditional approaches to treatment are probably not sufficiently evidence based, may be insufficiently client centred (see below), and/or insufficiently intense.
A degree of resistance to lifestyle changes must be expected even from patients who seem motivated to change lifestyle. Making and sustaining lifestyle changes is extremely difficult and is usually without any short term benefit to children or their families.74 Analogies to obesity treatment can be made to other chronic diseases of childhood that depend on long term lifestyle changes focused on diet, such as cystic fibrosis. Novel "behavioural" approaches to management of cystic fibrosis are more promising in achieving adherence to treatment than more traditional medical /dietary management,74,75 and these may provide useful lessons for treatment of other chronic childhood diseases such as obesity.74,75
Key points
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Key references
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| EVIDENCE ON MANAGEMENT STRATEGIES |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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Treatment should be reserved for families with obese patients (defined objectively using the BMI centile or Z score as described above) who seem to be motivated to change their lifestyle.
Referral from primary care should be considered when there is a possibility that there may be an underlying pathological cause of obesity, for example an endocrine cause or genetic syndrome. Such causes of obesity are extremely rare and in the vast majority of paediatric patients the origin of their obesity will lie in their lifestyle73,76,77: for these patients referral to secondary care will therefore entail ruling out any underlying pathology. An underlying pathological cause should be suspected in very young (pre-school) children who are severely obese (this may suggest an underlying genetic cause such as monogenic obesity), and in obese children who are short for their age (most obese children are comparatively tall and short stature may suggest a syndromic cause). Referral from primary care will also be necessary where a comorbid condition requires investigation or management (for example, hypertension, dyslipidaemia, metabolic syndrome, sleep apnoea, liver disease, type 2 diabetes).
The principal aim of treatment should be, for most patients, maintenance (not loss) of body weight. The underlying aim of treatment is sustainable lifestyle change: permanent changes to diet, sedentary behaviour, and physical activity. Maintenance of weight is difficult to achieve in the long term but is complemented by the fact that, so long as they are still growing, patients will "grow into their weight" to a degree. For more severely obese patients, and patients where comorbidities may be improved by weight loss (for example, patients with sleep apnoea or type 2 diabetes), then modest weight loss (usually no more than 0.5 kg/month) should be the aim, and a more intensive approach to treatment would be justified.65
It is possible that greater clinical and public health efforts should be directed at children and adolescents who are overweight rather than obese (for example, those above the 85th but below the 95th centile for BMI), but the evidence on treatment strategies for such patients is even more limited. At present most advice is simply to monitor such children as they are probably at high risk of progression to obesity.65
| CONCLUSIONS |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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| MULTIPLE CHOICE QUESTIONS (TRUE (T)/FALSE (F); ANSWERS AT THE END OF THE REFERENCES) |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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| ANSWERS |
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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| FOOTNOTES |
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Long term social and economic disadvantage pronounced in women, less obvious in men.
* For further information see Gortmaker et al.52
In girls, not boys.52
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TOPABSTRACTDEFINITIONS AND DIAGNOSISPREVALENCEHAS THE SCALE OF...CONSEQUENCES--WHY DOES...PERCEPTIONS OF OBESITY AMONG...CAUSES OF THE PAEDIATRIC...EVIDENCE ON PREVENTIVE...PREVENTION OR TREATMENT?EVIDENCE ON TREATMENT...EVIDENCE ON MANAGEMENT...CONCLUSIONSMULTIPLE CHOICE QUESTIONS (TRUE...ANSWERSREFERENCES |
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