Childhood Obesity:
An American Perspective
Eliana M. Perrin, MD, MPH
Associate Professor of Pediatrics
Department of Pediatrics
University of North Carolina at Chapel Hill
North Carolina, USA
Road Map for Today
• The problem of pediatric
obesity in the US (some
comparisons with France)
• How my research informs
clinical practice and the
reverse
• What I do as a pediatrician
to help stop the epidemic
• Exchange ideas with each
other and give each other
tips
The prevalence of childhood obesity
and its health consequences
•In the 1990s-reports that the
health consequences of obesity
appear in childhood as well as
adulthood years. (Dietz WH, Pediatrics,
1998)
•Now, in 2012, 32% of US
children and adolescents are
overweight or obese (Ogden, et al,
JAMA, 2012)
Obesity (not including overweight) prevalence in adults
Overweight and obesity
prevalence in children
11-14%
32%
After a short stay in a gallery in America, this
is what happened to Michelangelo’s David…
Road Map for Today
Influences on Obesity:
Demographics, cultural practices
Parental eating attitudes/feeding
practices/societal weight attitudes
copyright Eliana Perrin, 2011
Television
Girls meeting physical activity recommendations in the
USA
Boys meeting physical activity recommendations
in the USA
Pass the popcorn: obesity in children’s movies


Watched top 4 grossing PG and G movies per year, 2005-2009total 20
Coded for healthy and unhealthy food and exercise messages
that match AAP statement on family obesity prevention
 65% of segments showing food show food of too big portions
 80% of segments showing food, show unhealthy snacks
 55% of beverages shown are sugar-sweetened beverages
 75% of movies show obesity related stigma
Why do we care?
What can we do?
Possible research and intervention
focus areas
DOCTOR’S OFFICE
BUILT ENVIRONMENT
BIOLOGY/GENETICS
CORPORATIONS/POLICY
SCHOOLS/DAY
CARE
COMMUNITY/
CULTURAL
Primary care prevention in the doctor’s office
involves at least a pediatric care provider and a
patient (parent/child or family)
My research attempts to understand both perspectives.
In the USA, this is now a national focus
Primary Care Providers’ Problem
• “Healthy People 2010” charged primary care
providers with task of helping to stop the
epidemic.
• Diagnosis of and screening for overweight
considered one of the 1st steps.
• Multiple studies show physicians under-diagnose
overweight and obesity in both adults and
children. (McArtor RE, et al, 1992; Denen ME, et al, 1993; Eck LH, et al
1994; Stafford RS, et al, 2000, Jain, et al, 2001; Jeffery, et al, 2005; Huang, et
al, 2007; Benson, et al, Pediatrics, 2009)
Primary Care Providers’ Plight
• Much expected to do with limited time:
BP, toilet training, temper tantrums, discipline, school, ADHD,
vision and hearing, immunizations, anemia, lead screening, TB
screening, cholesterol, sexuality and STD prevention, injury
prevention, violence prevention, sleep positioning, and sleep
disturbances, to say nothing of the physical exam, chronic
problems, etc.
Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice:
pediatricians and American Academy of Pediatrics policy statements.
Pediatrics. Oct 2006;118(4):e964-978.
• Even obesity screening is complicated…
Screening for overweight always
involves determining weight for height
Stop-light Color-Coded vs. standard
BMI chart
“Visual impression”- how good is it?
“Visual impression”- how good is it?
BMI ~98th Obese
th
BMI ~93rd Overweight BMI ~12 Healthy
Obese
Age 2, 95th
BMI=19.2
Age 4, 98th
BMI=18.5
Age 6, >99th
BMI=23
Age 12, >99th
BMI=29.8
So from what I have shown you, we know
that pediatricians probably under-diagnose
obesity because their visual impression is not
accurate.
My early research confirmed this, and my
later research has tried to overcome it. Both
are informed by clinical perspective.
Allow me to share some study findings with
you.
BMI vs. Height and Weight Study
(Journal of Pediatrics, 2004)
CONCLUSIONS:
• BMI charting more effectively demonstrated that a
hypothetical child was overweight and prompted greater
concern about her than did height and weight charting
together.
• Yet BMI charting, recommended by the CDC in 2000, was
rarely being used.
IMPLICATIONS:
• Pediatricians had unique opportunities to prevent obesity,
but not without detecting concerning weight trends.
• Further efforts were needed to help pediatricians adopt this
useful tool.
Self-Efficacy Survey Study
(Ambulatory Pediatrics, 2005)
CONCLUSIONS:
• Pediatricians don’t feel effective in their treatment/prevention
of obesity but feel they could be potentially more effective.
• Pediatricians identify environmental barriers as the most
frequently encountered but have low self-efficacy that’s most
associated with practice-based barriers
• Desired many resources including better counseling tools and
better ways of communicating weight status to parents.
IMPLICATIONS:
• Interventions in office-based setting  increase self-efficacy 
increase counseling.
• We need better ways to discuss weight status with parents and
motivate them toward healthy behavioral change
Barriers & facilitators of using BMI –
pediatrician focus group study
(Flower, Perrin, et al, Ambulatory Pediatrics, 2007)
CONCLUSIONS:
• There are many systems barriers to using BMI but it can be a
useful diagnostic and even counseling tool.
IMPLICATIONS:
• Practice-level changes such as incorporating BMI into office
systems and electronic medical records may be needed to
support pediatric primary care providers in using BMI routinely.
• More research on whether parents understand the concept of
BMI or it serves as a communication tool
Pediatrician Weight Self-Perception
Study (Obesity Research, 2005)
CONCLUSIONS:
• Nearly half of overweight pediatricians did not classify
themselves as such and misperception of overweight was worse
than in non-doctor US samples.
• Those identifying themselves as “thin” & those identifying
themselves as “overweight” reported more difficulty counseling
regardless of actual weight status.
IMPLICATIONS:
• Physicians’ weight self-perceptions may be one barrier to
appropriate screening and counseling.
In my CLINCAL experience,
this is what happens
If child is healthy weight, parent thinks child is SKINNY,
and typically is trying to actively get the child to GAIN
weight
If the child is overweight, parents think the child is at a
healthy weight, and is certainly not changing their
dietary or PA behaviors.
Both groups of parents need education about the
child’s weight status and the appropriate
recommendations.
The parent perspective
• Do parents know when their children are too heavy?
• Do parents understand the concept of BMI? What would help
parents understand?
• What do parents find sensitive and motivating with respect to
recommendations? What is their advice for doctors?
• What health effects are there of obesity at young ages and as
predictors for the future that parents might find motivating?
The parent perspectiveinterviews
Be sensitive in our language
On what a doctor should say:
“Okay we're a little bit concerned, he looks
like he's bigger than most kids his age or
something of that sort, then it would've
probably been okay, but I don't know, the
‘obese’ word, I, I don't like it.”
Get to know our patients and make
tailored and realistic recommendations:
“You have to look at your socioeconomic stuff … You know you
have to bring all of that in before you can sit down and make
these high hat recommendations like you should take your
child to the park more often. Well we don’t have a park in the
inner city, not one that is not run by the gangs. Basically you
are not allowed to play in the park in this neighborhood. So in
order to make the recommendations that the doctors are
wanting to make, they are going to need more personal
information and they are going to need a way to get it without
offending people. We live on $459 a month and my disability
check. Forty fifty nine a month for three people. It is not
feasible to recommend fresh vegetables when I can get ‘threefor-a-dollar’ cans, and the cans with the dents for a quarter.
And that is the reality. You need to find out who you are
talking to.”
Others say, “Tell us more about health than
weight!”
“I would listen to advice on how, you know, I
can make them healthier, not help them lose
weight, 'cause I don't want to help (them lose
weight).”
So we have spent a lot of time trying to providing families
with evidence-based, brief, targeted counseling to
improve diet and physical activity
Culturally Appropriate Handouts
What to do as a pediatrician?
Why intervene so early in life?
(preliminary work at our 4 GreenLight sites)
• How many 4 month olds in our clinics are
getting juice / sugary drinks in the bottle??
– 2 out of every 3 babies!
• What % of babies are introduced to solids
before 4 months of age?
– 1 out of every 5 babies!
• What % of 4 month old babies are fed
“whenever they cry?”
– 1 out of every 5 babies!
Key element is prevention
For prenatal and newborn visits:
• Encourage breastfeeding; teach parents infant hunger cues
& to feed by cue not by the clock; discourage bottle
propping
• For visits with babies and toddlers:
• Discussion as there is a transition to solids- time to focus on
the whole family eating together & on healthy foods- fruits
and vegetables, whole grains, lean meats, cooking styles,
appropriate portion sizes
• Beverage counseling- milk as meal-time beverage and water
for thirst quenching. Discourage sweet tea, soda, lemonade,
JUICE
Encourage physical activity
Encourage activity for mom and dad while mom is
pregnant- walking is wonderful & good to get into
healthy family habits
Tummy time is great for babies as is exploration play
Outside activity/ getting out of the stroller important for
toddlers!
My current prevention study
Over 850 babies are
enrolled at 2 months
of age and followed
until they are age 2.
Doctors learn how to
prevent obesity with
parents
Older children
Starting at age 2: screen BMI
•
•
•
•
•
•
Don’t force kids to finish plates; keep
portion size the size of a child’s fist
Replace whole milk w/ lower fat milk
Limit “screen” time & eating in front of
the television!
Limit junk food and soda
Encourage active play
Substitute water and skim milk for juice,
lemonade, sweet tea, and soda.
If child is overweight?
If BMI is overweight or obese (≥85% for age) or
trending upward:
• Follow advice from previous slide
• Advise parents and child of weight status:
show them the BMI chart, talk about future
problems related to overweight
• Protect self-esteem (make our discussion
about health as much as possible)
• Arrange follow-up visit (schedule a lot of time)
Toolkit Study
• Improvements from baseline to 3 months:
– < 3 servings of fruits or vegetables (45%->33%)
– 1 or fewer sugary drinks (30% -> 50%)
– 1 or fewer unhealthy snacks (53%-> 73%)
– Skim or 1% milk (12%-> 25%)
– 2 or fewer hours screen time (49%-> 67%)
Weight perceptions
• At baseline, 100% of parents of healthy
weight children correctly perceived their
child's weight; only 56.5% of parents of
overweight children did (p < .001, t test).
• At 3-month follow-up, 74.1% of parents of
overweight children had an accurate
perception of their child's weight, a
statistically significant improvement from
baseline (p < .05, t test).
Conclusions of my research
and clinical work
• Parents and doctors do not visualize early concerning weight
trajectories
• Providers would benefit from tools that help their selfefficacy, screening, and ways to motivate families to adopt
healthy lifestyles.
• Color-coded BMI charts may help doctors communicate
weight status, particularly to those of lower literacy.
• Parents would appreciate sensitive, yet straightforward,
tailored communication from providers who know them well.
Thank you. I’d like to especially acknowledge
many local mentors and collaborators:
Cynthia Bulik, PhD
Alice Ammerman, RD, DrPH
Peggy Bentley, PhD
Michael Steiner, MD
Asheley Skinner, PhD
Arlene Chung, MD, MPH, MHA
Suzanne Lazorick, MD, MPH
Julie Jacobson Vann, RN, PhD
Russell Rothman, MD, MPP
Shonna Yin, MD, MPH
Lee Sanders, MD, MPH
Anna Maria Fernando-Hernandez, PhD
FUNDING SOURCES:
NIH/NICHD R01 HD059794
NIH/NICHD 5 K23 HD051817
UNC CTSA UL1RR025747
Time Trends in Parental Report of Having Been Told Their
Overweight/Obese Child was Overweight/Obese
100.0
90.0
80.0
70.0
60.0
50.0
Very obese (p=0.020)
40.0
Obese (p=0.753)
30.0
Overweight (p<0.001)
20.0
10.0
0.0
All (p<0.001)