Indian Health Service: Division of Diabetes Treatment and Prevention 

Promoting a Healthy Weight in 

Children and Youth

Clinical Strategies 

Recommendations and Best Practices 

Version 4.0

December 2008 

Office of Information Technology (OIT) 

Division of Information Resource Management 

Albuquerque, New Mexico 
Promoting a Healthy Weight in Children and Youth v4.0 

ACKNOWLEDGEMENTS

This document was prepared by Amy Patterson, PhD, with the assistance of the 

following individuals: 

• Tammy Brown, MPH, RD 

• Theresa Cullen, MS, MD 

• Candace Jones, MPH 

• Martin Kileen, MD 

• Kelly R. Moore, MD 

We would also like to acknowledge and express our appreciation to the IHS and tribal 

health professionals who reviewed this document and provided valuable comments: 

• Ann Bullock, MD 

• Cecelia Butler, RD, MS 

• Lori Byron, MD 

• Lisa Griefer, RD 

• Diana Hu, MD 

• Shannon Myers, PNP 

• Susannah Olnes, MD 

• Jane Oski, MD 

• Ann Racehorse 

• Janine Rourke, RN 

• Roy Teramoto, MD 

• Judith Thierry, DO 

• Sara Thomas, RD, MS 

• Quana Winstead, PA-C 

Recommendations and Best Practices Acknowledgements

December 2008 

 i 
Promoting a Healthy Weight in Children and Youth v4.0 

TABLE OF CONTENTS

Clinical Strategies: Summary of Recommendations ....................................................... 1

Introduction: The Epidemic of Childhood Overweight ..................................................... 6

Recommendations .......................................................................................................... 9

Recommendation 1: Body Mass Index (BMI) Assessment................................... 9

Provide BMI Screening and Assessment for All Children through Age 18. 9

Strategies................................................................................................. 10

Resources................................................................................................ 11

Recommendation 2: Breastfeeding .................................................................... 11

Promote Exclusive Breastfeeding for Infants ........................................... 11

Breastfeeding Promotion Strategies ........................................................ 12

Breastfeeding Resources......................................................................... 15

Recommendation 3: Patient Health Education ................................................... 15

Implementation of Universal Patient Health Education ............................ 15

Strategies................................................................................................. 17

Resources................................................................................................ 19

Recommendation 4: Counseling and Referrals .................................................. 19

Patients Already Overweight or Obese.................................................... 19

Strategies................................................................................................. 20

Resources................................................................................................ 21

Recommendation 5: Community Education ....................................................... 21

Promote and Advocate Healthful Eating .................................................. 21

Strategies................................................................................................. 21

Community Education Resources............................................................ 23

Best Practices Benchmarks .......................................................................................... 24

AAP/AAFP.......................................................................................................... 24

Institute of Medicine (IOM) ................................................................................. 24

United States Preventive Services Task Force (USPSTF) Recommendation .... 25

CRS and GPRA: Childhood Weight Control and Breastfeeding Measures ................... 27

Childhood Weight Control Measure (GPRA) ...................................................... 27

Breastfeeding Measure ...................................................................................... 28

Resource and Contact Information................................................................................ 30

Community Resource Directory.......................................................................... 30

Appendix A: References for Selected Research ........................................................... 31

Childhood Weight Control Research .................................................................. 31

Reports, Guides, and Policy Statements ............................................................ 36

Breastfeeding References .................................................................................. 38

Co-Morbidities References ................................................................................. 40

Recommendations and Best Practices Table of Contents 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Table of Contents 

December 2008 

 iii

Obesity and Social Determinants of Health References..................................... 42

Appendix B: Resources................................................................................................. 43

BMI and Childhood Weight Control .................................................................... 43

Breastfeeding ..................................................................................................... 44

Appendix C: IHS Report to Congress: Obesity Prevention and Control for American 

Indians and Alaska Natives April 2001 ............................................................... 46

Recommendation 1 ............................................................................................ 46

Recommendation 2 ............................................................................................ 46

Recommendation 3 ............................................................................................ 46

Recommendation 4 ............................................................................................ 46

Recommendation 5 ............................................................................................ 47

Recommendation 6 ............................................................................................ 47

Recommendation 7 ............................................................................................ 47

Appendix D: IHS Workgroup Report “What Should IHS Do in the Next 2 Years for an 

Obesity/Healthy Weight Initiative? 2005*............................................................ 48

Goal 1 ................................................................................................................. 48

Goal 2 ................................................................................................................. 48

Goal 3 ................................................................................................................. 48

Goal 4 ................................................................................................................. 48

Goal 5 ................................................................................................................. 48

Goal 6 ................................................................................................................. 48

Appendix E: Community Resources Template.............................................................. 49

Appendix F: Listing of Co-Morbidities of Childhood Obesity.......................................... 50

Resources .......................................................................................................... 52

Appendix G: Bottle Feeding .......................................................................................... 53

Bottle Feeding .................................................................................................... 53

Strategies................................................................................................. 53

Bottle Feeding Resources........................................................................ 55

Appendix H: Serving Size Portions ............................................................................... 56

Contact Information....................................................................................................... 57
Promoting a Healthy Weight in Children and Youth v4.0 

Clinical Strategies: Summary of Recommendations 

Provide BMI screening and assessment for all children through age 18 

• Measure height and weight at every well-child appointment for children up to 

age five, and at every appointment for children age five and older. 

• Calculate BMI in patient’s chart and age and sex-specific BMI percentile 

(BMI-for-age) and plot on a growth chart. 

• Track BMI trends for individual patients. 

• Use appropriate “V” codes to document BMI screening and assessment. 

– V85.5X codes are used to document BMI values up to age 18. 

– V85.X codes are used to document BMI values for adults. 

• Educate all providers on the use of BMI-for-age as a tool for identifying 

overweight and obese patients. 

• Use web resources available for training on BMI measurement. 

• Encourage all pediatric health care providers to receive training on child and 

adolescent BMI interpretation. 

Promote exclusive breastfeeding for infants 

• Breastfeeding education: Conduct small group education classes or provide 

individual education during the prenatal visit. Include benefits of 

breastfeeding, prenatal breast care, common problems and how to overcome 

them. 

– Discuss breastfeeding at the first and subsequent prenatal visits. 

– If possible, provide one-on-one counseling for breastfeeding support; this 

has been shown effective in increasing breastfeeding initiation and 

duration rates. 

– Ask “Have you thought about how to feed your baby?” 

– Encourage mothers to initiate breastfeeding within one hour of delivery. 

– Refer to lactation specialist, if available. 

• After delivery: 

– Encourage mothers to “room-in” with their infants. 

– Refer to lactation specialist, if available. 

• Postpartum period: 

– Promote peer support or support and advice on breastfeeding from 

mothers who have breastfed and received training as peer counselors, 

given via home visit or telephone. 

Recommendations and Best Practices Clinical Strategies: Summary of Recommendations 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

– Conduct follow-up appointments with patients; contact postpartum 

mothers to offer help and information on feeding choices. 

– Assist nursing mothers with practical and realistic strategies to promote 

continued breastfeeding even when they are separated from their infants 

by work, school, or other circumstances. 

• Collaborate with Women, Infants, and Children (WIC) programs and other 

programs that have expertise in breastfeeding support. 

• Provide patients with resources for breastfeeding support, including contact 

numbers for national, state, and IHS breastfeeding hotlines. 

• Establish hospital policies to promote breastfeeding; encourage IHS direct 

hospitals to work toward “Baby-Friendly Hospital” designation. 

• Offer breastfeeding education to providers; providers trained in breastfeeding 

interventions have higher rates of breastfeeding among patients whom they 

have educated and encouraged. 

• Establish workplace policies to promote breastfeeding, and disseminate to the 

community as model policies. 

• Designate personnel or programs to ensure supportive equipment needs 

(breast pumps) of breastfeeding mothers are addressed in the community 

through health care facilities, local WIC programs, or local businesses. 

• Use Clinical Reporting System (CRS) to monitor breastfeeding rates for 2, 6, 

9 and 12-month old infants. 

• If parents/caregivers choose to bottle feed, then providers should provide 

appropriate education on feeding in response to hunger cues and avoidance of 

overfeeding. 

Implement universal patient health education regarding healthy eating behavior 

and increased physical activity to prevent and treat childhood overweight. 

• Limit juice and other sugar sweetened drinks to no more than 4 ounces daily 

(2-4 ounces for toddlers), or less than one small cup per day. 

• Replace one can of soda with water every day, with the goal of eventually 

replacing all soda with water. 

• Encourage water as the only in-between meal drink. 

• Eat five (5) servings or helpings of fruits and vegetables a day. (A serving 

equals 1T of fruit or vegetable per year of age up to age six.) 

• Avoid using food as a reward for good behavior. 

Recommendations and Best Practices Clinical Strategies: Summary of Recommendations 

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Promoting a Healthy Weight in Children and Youth v4.0 

• Eat together as a family for meals as much as possible. 

• Discourage TV viewing during mealtimes. 

• Learn about calorie and fat content of foods consumed. 

• Play or get active every day, at least 30-60 minutes every day. 

• Reduce TV and screen time (e.g. video games, computers) to no more than 

two hours every day. 

• Avoid putting TVs in children’s bedrooms. 

• Follow the “5-2-1-0” model. Make sure to do the following every day: 

– 5: Eat 5 servings of fruits and vegetables each day. 

– 2: Limit TV and other screen time to no more than 2 hours a day. 

– 1: Engage in 1 hour of physical activity. 

– 0: Limit sugar-sweetened beverages—none is best. 

Other Strategies 

• Encourage parents to wean infants from the bottle to the cup at or before 12 

months of age. 

• Emphasize to parents that infants should not be offered food other than breast 

milk or infant formula until they can sit with support and have good control of 

the head and neck, at about 4 to 6 months of age. 

• Explain that no nutritional advantage is known, but disadvantages may exist, 

in introducing supplemental foods before their baby is developmentally ready, 

at about 4– 6 months of age. 

• Emphasize that if the infant does not like a new food, he/she should not be 

forced to eat it. The food can be offered at a later time. It may take 15 to 20 

attempts before an infant accepts a particular food. 

• Tell parents children 1 to 3 years of age need 4– 6 servings per day of fruits 

and vegetables as well as smaller serving sizes. See the table in Appendix G: 

Serving Size Portions. 

• Instruct parents to serve children 1 to 2 years of age whole milk. For older 

children, reduced-fat (2 percent), low-fat (1 percent), or fat-free (skim) milk is 

acceptable. 

• Teach the concept of “everyday” and “sometimes” foods. Everyday foods 

come from the food groups on the food guide pyramid. “Sometimes foods” 

are okay to eat but only sometimes or in small amounts, like chips, candy, 

fried foods, and desserts. (See the USDA “My Pyramid” website 

http://www.mypyramid.gov/mypyramid/index.aspx for more information.) 

Recommendations and Best Practices Clinical Strategies: Summary of Recommendations 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

• Encourage parents and children not to skip meals. 

• Serve as a role model for healthful eating and regular physical activity and 

encourage parents and caregivers to serve as role models. 

• Serve as an advocate in your local community, especially schools, to promote 

a healthier environment, including healthier school menus and school vending 

machine policies as well as regular physical activity for all school children.

Encourage parents and caregivers to advocate as well. 

• Advocate for increased outdoor playtime for school-aged children. 

• Record patient education in CRS; use “Cheat Sheets” for data entry. 

For patients who are already overweight or obese, assess for complications and 

co-morbidities, provide counseling, and identify and refer patients to resources 

that promote weight-reduction, weight management, nutrition, and physical 

activity. 

• Assess overweight patients for complications and co-morbidities associated 

with childhood overweight. 

• Provide culturally-competent counseling for children and families to work on 

specific goals for behavior change, which should include: 

– Reducing family intake of sugar sweetened drinks and fast food. 

– Parental monitoring and modeling of positive eating behaviors. 

– Increasing physical activity. 

• When counseling children and families, follow these guidelines: 

– Develop a clear but culturally competent message about your concern for 

the child’s weight and the potential for positive change. 

Note: Cultural competence is the ability of individuals to 

consider ethnic/racial, and cultural aspects in all 

dimensions of their work relative to obesity prevention and 

population health programs and interventions. Cultural 

competence is optimized when programs involve clients or 

recipients in all phases of a program, from planning to 

implementation, monitoring, and evaluation.1

– Avoid using the term “obesity;” use the term “overweight.” 

– Encourage and empathize rather than criticize. 

– Acknowledge patient feelings. 

– Answer questions without showing judgment; e.g. use terms such as 

“healthier food” instead of terms like “bad food.” 

– Promote permanent lifestyle changes, not short-term diets. 

 

Recommendations and Best Practices Clinical Strategies: Summary of Recommendations 

1

 IOM, Progress in Preventing Childhood Obesity: How do we measure up? p.434. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Clinical Strategies: Summary of Recommendations 

December 2008 

 5 

– Urge them to set simple, concrete goals, which lead to a sense of success. 

• Involve family and all caregivers in the treatment process. 

• Use motivational interviewing techniques. 

• Be sensitive to and appreciate the food and nutrition traditions as well as the 

cultural beliefs of the tribe(s) of the service unit towards food and why certain 

foods may be valued. 

• Locate and document appropriate community resources for referrals. 

– Complete Community Resources Template with contact information. See 

Appendix D. 

– Provide training to providers on using community resources. 

• Refer obese and overweight children and their caregivers to Registered 

Dietitians (RDs), if possible. 

• Adopt a team approach — involve all qualified staff, RNs, RDs, health 

educators, physical therapists, wellness staff, and behavioral health specialists. 

Advocate for and promote healthful eating and regular physical activity in the 

larger community. 

Strategies 

• Assess school-based wellness policies in place in your community — 

especially for children in grades K-8. 

• Using the Community Resources Template: 

– Assess school and community resources available as adjuncts to clinical 

resources for overweight and obese children. 

– Assess and advocate for community venues and programs for physical 

activity that can be promoted to children and families. 

• Assess and advocate for increased community availability of healthier food 

choices, and develop culturally competent and realistic recommendations for 

families seeking positive lifestyle changes. 
Promoting a Healthy Weight in Children and Youth v4.0 

Introduction: The Epidemic of Childhood Overweight 

In the past 25 years, the prevalence of overweight among children in the United 

States has steadily increased. Since the 1970s, rates of childhood overweight have 

more than doubled for preschool children aged 2-5 years, and have tripled among 

children aged 6-11 years. Approximately nine million American children over age six 

are overweight. 

BMI 

Body Mass Index, or BMI, is a measure of a person’s weight in relationship to their 

height. In children, BMI typically decreases from birth to about age six and then 

increases steadily until adulthood as a part of normal growth and development. The 

adult cutoffs of 25 for overweight and 30 for obesity are not meaningful in children. 

BMI: Children 

The American Academy of Pediatrics has recently issued guidelines regarding the 

prevention, assessment, and treatment of children who are obese and overweight. 

According to the AAP, children with a BMI at or above the 95 percentile should be 

considered “obese” and children with a BMI at or above 85%, but less than 95%, 

should be considered “overweight”. These terms replace the previous categories of 

“overweight” for children with a BMI at or above the 95 percentile and “at risk of 

overweight” for children with a BMI between the 85-94 percentiles.2

 In 1999-2000, 

the prevalence of obesity (previously defined as overweight) was 10.4% among all 2-

5-year-olds.3 The rates are even higher among preschool-aged children from lowincome households.4

BMI: American Indian and Alaska Native Children 

Rates of overweight among American Indian and Alaska Native (AI/AN) children 

exceed these high national averages. Among American Indian children aged two to 

five, overweight/obesity rates have been reported at 12 to 39 percent.5 A recent study 

conducted by the Aberdeen Area Indian Health Service found that at five years of 

age, 47% of boys and 41% of girls had a BMI at or above the 85 percentile, and 24% 

of the children had a BMI at or above the 95 percentile.6 These higher rates persist 

into later childhood as well. Among AI children ages 6 to 19, the rate of overweight 

December 2008 

 6 

 

2

 Barlow SE, and the Expert Committee, Expert Committee Recommendations Regarding the Prevention, 

Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report Pediatrics 2007 

120:S164-S192. 

3

 Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and Trends in Overweight Among US Children and 

Adolescents, 1999-2000. JAMA 2002;288:1728-1732. 4

 Mei Z, Scanlon KS, Grummer-Strawn LM, Freedman DS, Yip R, Trowbridge FL. Increasing prevalence of 

overweight among US low-income preschool children: the Centers for Disease Control and Prevention Pediatric 

Nutrition Surveillance, 1983 to 1995. Pediatrics 1998;101(1):E12. 5

 Indian Health Service. IHS Report to Congress: Obesity Prevention and Control for American Indians and Alaska 

Natives April 2001; 9. 

Recommendations and Best Practices Introduction: The Epidemic of Childhood Overweight 

6

 Zephier E, Himes JH, Story M, Zhou X. Increasing Prevalences of Overweight and Obesity in Northern Plains 

American Indian Children. Arch Pediatr Adoles Med 2006;160:34-39. 
Promoting a Healthy Weight in Children and Youth v4.0 

and obesity has been estimated at 39%, compared to 15% for all races combined.7 A 

study of schoolchildren in seven American Indian communities found that 28.6% of 

AI children ages 6-11 had a BMI above the 95 percentile.8

Government Performance Results Act (GPRA) 

The Indian Health Service (IHS) created a GPRA measure to assess the rate of 

overweight and obesity among its patient population through the measurement of 

BMI of all active clinical patients. In FY 2006, this measure changed to assessing the 

percentage of children ages 2-5 with a BMI at or above the 95 percentile. This change 

was made in order to assess the scope of the problem of childhood overweight among 

young children in the IHS patient population. Data from the Clinical Reporting 

System (CRS) for FY 2007 show that these rates are quite high, with Area rates 

ranging from 20% to 30%, and an overall national rate of 24%. 

Results of Childhood Overweight 

Children who are overweight tend to show related signs of morbidity, which may 

include elevated blood pressure, cholesterol, triglyceride, and insulin levels.9 In one 

population-based sample, approximately 60 percent of obese children aged five to ten 

had at least one cardiovascular disease (CVD) risk factor, such as elevated total 

cholesterol, triglycerides, insulin, or blood pressure, and 25 percent had two or more 

CVD risk factors.10 Overweight children also are at risk for psychosocial difficulties 

arising from being obese, including shame, self-blame, and low self-esteem, all of 

which may impair academic and social functioning and carry into adulthood.11

One major result of rising childhood overweight rates is the growing prevalence of 

type 2 diabetes among children. In some populations, type 2 diabetes is now the 

dominant form of diabetes in children and adolescents.12 For children born in the 

United States in 2000, the lifetime risk of being diagnosed with type 2 diabetes at 

some point in their lives has been estimated at 30 percent for boys and 40 percent for 

girls, if rates of overweight stabilize. The estimated lifetime risk for developing type 2 

diabetes is even higher among some ethnic minority groups (including AI/ANs) at 

birth and at all ages.13 In case reports from the 1990s, type 2 diabetes accounted for 

December 2008 

 7 

 

7

 Story M, Evans M, Fabsitz RR, Clay TE, Holy Rock B, Broussard B. The epidemic of obesity in American Indian 

communities and the need for childhood obesity-prevention programs. Am J Clin Nutr 1999;69(4 Suppl):747S-754S. 8

 Caballero B, Himes JH, Lohman T, Davis SM, Stevens J, Evans M, Going S, Pablo J; Pathways Study Research 

Group. Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities. 

Am J Clin Nutr 2003;78(2):308-12. 9

 Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics

1998;101:518-525. 

10 Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors 

among children and adolescents: The Bogalusa Heart Study. Pediatrics 1999;103(6 Pt 1):1175–1182. 11 Schwartz MB, Puhl R. Childhood obesity: A societal problem to solve. Obes Rev 2003;4(1):57–71. 12 Deckelbaum RJ, Williams CL. Childhood obesity: the health issue. Obes Res 2001;9 (Suppl 4):239S-243S. 

Recommendations and Best Practices Introduction: The Epidemic of Childhood Overweight 

13 Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the 

United States. JAMA 2003;290(14):1884–1890. 
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Introduction: The Epidemic of Childhood Overweight 

December 2008 

 8 

cases.

8-45 percent of all new childhood cases of diabetes. Prior to the 1990s, type 2 

diabetes accounted for less than 4% of new 14

Excess weight gain in early childhood also has significant effects on later health, 

including a high risk of being overweight or obese in adulthood, and a higher risk of 

cardiovascular disease and some cancers.15 16

Among adults, obesity is associated with significant health risks, including high blood 

pressure, high cholesterol, asthma, arthritis, coronary heart disease, stroke, colon 

cancer, post-menopausal breast cancer, endometrial cancer, gall bladder disease, and 

sleep apnea. The overweight epidemic among children may also reduce overall adult 

life expectancy because it increases lifetime risk for type 2 diabetes and other serious 

chronic disease conditions.17 This epidemic has the potential to reverse gains that 

have been achieved in reducing mortality rates in the past century. As a result, this 

may be the first generation of Americans to have a shorter life expectancy than their 

parents. 

The epidemic of overweight among children has been recognized as a public health 

crisis. In 2005, the Institute of Medicine published a report on obesity among children 

calling for a broad public health response: “Just as broad-based approaches have been 

used to address other public health concerns — including automobile safety and 

tobacco use — obesity prevention should be public health in action at its broadest and 

most inclusive level.” 

“Prevention of obesity in children and youth should be a 

national public health priority.”18

 

14 Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, Beckles GL, Saaddine J, Gregg 

EW, Williamson DF, Narayan KM. Type 2 diabetes among North American children and adolescents: an 

epidemiologic review and a public health perspective. J Pediatr 2000;136(5):664–672. 15 Pi-Sunyer FX. Health implications of obesity. Am J Clin Nutr 1991;53(6 Suppl):1595S-1603S. 16 Power C, Lake JK, Cole TJ. Measurement and long-term health risks of child and adolescent fatness. Int J Obes 

Relat Metab Disord 1997;21:507-526. 17 Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA

2002;289(2):187–193; Narayan et al 2003. 

18 IOM, Preventing Childhood Obesity: Health in the Balance. 2005. 
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations 

The Indian Health Service (IHS) has a GPRA measure targeting childhood 

overweight and obesity. The annual goal is to reduce the percentage of children ages 

2-5 with a BMI at or above the 95 percentile. 

The IHS will adopt a multi-faceted approach to fighting childhood overweight, with 

the ultimate goal of reducing the overall rate of children with a BMI at or above the 

95 percentile in the active user population from the 2007 rate of 24%. 

Although obesity is difficult to treat and data on effective ways to prevent and treat 

overweight in AI/AN communities are limited, providers may still adopt the “best 

available” evidence. The following five recommendations are based on the best 

available clinical evidence regarding the prevention and treatment of childhood 

overweight. 

Recommendation 1: Body Mass Index (BMI) Assessment 

Provide BMI screening and assessment for all children through age 18. 

Recommendation 2: Breastfeeding 

Promote exclusive breastfeeding for infants. 

Recommendation 3: Patient Health Education 

Implement universal patient health education regarding healthy eating behavior and 

increased physical activity to prevent and treat childhood overweight. 

Recommendation 4: Counseling and referrals 

For patients who are already overweight or obese, assess for complications and comorbidities, provide counseling, and identify and refer patients to resources that 

promote weight-reduction, weight management, nutrition, and physical activity. 

Recommendation 5: Community Education 

Advocate for and promote healthful eating and regular physical activity in the larger 

community. 

Recommendation 1: Body Mass Index (BMI) Assessment 

Provide BMI Screening and Assessment for All Children through Age 18 

The American Academy of Pediatrics (AAP), along with most other recommending 

bodies, endorse universal screening using body mass index (BMI) and use of agespecific BMI percentiles to identify overweight and obese children. 

Recommendations and Best Practices Recommendations 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

BMI is interpreted differently for children than adults. Also called “BMI-for-age,” 

this measurement is plotted on gender-specific growth charts and evaluated according 

to the following criteria: 

• Underweight: BMI-for-age < 5 percentile 

• Normal: BMI-for-age 5th to < 85 percentile 

• Overweight: BMI-for-age 85 percentile to < 95 percentile 

• Obese: BMI-for-age > 95 percentile19

During early childhood, BMI typically decreases from birth until about age six years 

and then increases steadily until adulthood as part of normal growth and 

development. The adult cutoffs of 25 for overweight and 30 for obesity therefore are 

not meaningful in children 

The CDC has charts available (see “resources” below) to plot BMI-for-age for 

children, age 2-20. Infants under age two should be measured for length; providers 

should use the sex appropriate “weight-for-length” CDC charts, which cover children 

from birth to 36 months. At age 24 months and older, if the child can stand unassisted 

and follow directions, stature should be measured and plotted on the BMI-for-age 

chart for children (2 to 20 years). 

Strategies 

• Measure height and weight at every well-child appointment for children up to 

age five, and at every appointment for children age five and older. 

• Calculate BMI in patient’s chart and age and sex-specific BMI percentile 

(BMI-for-age) and plot on a growth chart. 

• Track BMI trends for individual patients. 

• Use appropriate “V” codes to document BMI screening and assessment. 

– V85.5X codes are used to document BMI values up to age 18 

– V85.X codes are used to document BMI values for adults 

• Educate all providers on the use of BMI-for-age as a tool for identifying 

overweight, obese, and at-risk patients. 

• Use web resources available for training on BMI measurement. 

• Encourage all pediatric health care providers to receive training on child and 

adolescent BMI interpretation. 

 

Recommendations and Best Practices Recommendations 

19 Barlow SE, and the Expert Committee, Expert Committee Recommendations Regarding the Prevention, 

Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report Pediatrics 2007 

120:S164-S192. 

December 2008 

 10
Promoting a Healthy Weight in Children and Youth v4.0 

Resources 

CDC (Centers for Disease Control): BMI for age charts: 

http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm

CDC training modules for using growth charts: 

http://www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/

WIC (Women, Infant, and Children) Website (BMI growth charts): 

http://www.nal.usda.gov/wicworks/Learning_Center/WIC_growthcharts.html

WHO (World Health Organization) Growth Charts: 

http://www.who.int/childgrowth/en/

American Dietetic Association certificate training course on Childhood and 

Adolescent weight management: 

http://www.cdrnet.org/wtmgmt/childhood.htm

The Indian Health Service pediatric height and weight study website has training 

tools, including: 

• Training guide for measuring BMI in children and adolescents 

• Online training test 

• Continuing education unit module 

http://www.ihs.gov/medicalprograms/anthropometrics/

*Additional resources can be found in Appendix B: Resources in this 

document.http://www.ihs.gov/medicalprograms/anthropometrics/

Recommendation 2: Breastfeeding 

Promote Exclusive Breastfeeding for Infants 

Numerous studies have shown a positive association between breastfeeding and lower 

rates of overweight among children. A number of studies show that the prevalence of 

overweight in childhood is lower among young children (3-6 years of age) who were 

breastfed compared to children who were never breastfed.20 The protective effect also 

seems to persist into older childhood. One study found that among older children 

(ages 9-14) the risk of becoming overweight was lower for children who were 

 

Recommendations and Best Practices Recommendations 

20 Armstrong J, Reilly J; Child Health Information Team. Breastfeeding and lowering the risk of childhood obesity. 

Lancet 2002;359:2003–2004; Gillman MW, Rifas-Shiman SL, Camargo CA, Berkey CS, Frazier AL, Rockett HR, 

Field AE, Coldiz GA. Risk of overweight among adolescents who were breastfed as infants. JAMA 

2001;285(19):2461–2467; Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant 

breastfeeding and overweight in young children. JAMA 2001;285(19):2453–2460; Von Kries R, Koletzko B, 

Sauerwalk T, von Mutius E, Barnette D, Grunert V, von Voos H. Breast feeding and obesity: cross sectional study. 

BMJ 1999;319:147–150. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

exclusively or mostly breastfed when compared to children who were fed mostly 

formula. It also found that older children who were breastfed at least seven months 

were also 20 percent less likely to be overweight than children who were breastfed for 

at least three months.21 A recent study also suggests that there is a dose-dependent 

effect on overweight; for each month of breastfeeding, there was an associated 4% 

decrease in the risk of the child becoming overweight.22

Note: Breastfeeding promotion is a prevention-based 

intervention that has the greatest potential to reduce rates of 

overweight among young children. 

Breastfed infants also have lower rates of asthma and diabetes. Research suggests that 

exclusive breastfeeding for at least the first four months may be preventive for asthma 

and other allergies in children who are susceptible to environmental influences that 

trigger the onset of the disease.23 Breastfeeding has also been correlated with a lower 

prevalence of type 2 diabetes in adult Indians. One study found that both nonpregnant and pregnant breastfed Pima Indians studied had lower plasma glucose 

concentrations at ages 20-24 years.24

The Healthy People 2010 objective is to have at least 75 percent of mothers 

breastfeeding during the early postpartum period, and 50 and 25 percent breastfeeding 

at six months and one year, respectively. In 1998, 64 percent of mothers breastfed 

their infants during the early postpartum period. 29 and 16 percent of mothers 

breastfed their infants at six months and one year, respectively.25 In 2007, two new 

objectives on exclusive breastfeeding were added to Healthy People 2010. The new 

objectives are to increase the proportion of mothers who exclusively breastfeed their 

infants through age 3 months to 60% and through age 6 months to 25%. Rates for 

exclusive breastfeeding through ages 3 months and 6 months among infants born in 

2004 were 30% and 11%, respectively.26

Breastfeeding Promotion Strategies 

Breastfeeding Education 

• Conduct small group education classes or provide individual education during 

the prenatal visit. Include benefits of breastfeeding, prenatal breast care, 

common problems and how to overcome them. 

 

21 Gillman et al 2001. 

22 Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: A metaanalysis. Am J Epidemiol 2005;162(5):397-403. 23 Bjorksten B, Kjellman N-IM. Perinatal environmental factors influencing the development of allergy. Clin Exper 

Allergy 1990;20 Suppl(3):3-8. 24 Pettitt DJ, Roumain J, Hanson R, et al. Lower glucose in pregnant and nonpregnant Pima Indians who were breast 

fed as infants. Diabetologia 1995;38 (suppl 1):A61. 25 Healthy People 2010. 

Recommendations and Best Practices Recommendations 

26 CDC. Breastfeeding Trends and Updated National Health Objectives for Exclusive Breastfeeding - United States, 

Birth Years 2000-2004. MMWR 2007;56(30):760-763 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

– Discuss breastfeeding at the first and subsequent prenatal visits. 

– If possible, provide one-on-one counseling for breastfeeding support; this 

has been shown effective in increasing breastfeeding initiation and 

duration rates. 

– Ask “Have you thought about how to feed your baby?” 

– Encourage mothers to initiate breastfeeding within one hour of delivery. 

– Refer to lactation specialist, if available. 

• After delivery: 

– Encourage mothers to “room-in” with their infants. 

– Refer to lactation specialist, if available. 

• Postpartum period: 

– Promote peer support, or support and advice on breastfeeding from 

mothers who have breastfed and received training as peer counselors, 

given via home visit or telephone. 

– Conduct follow-up appointments with patients; contact postpartum 

mothers to offer help and information on feeding choices. 

– Assist nursing mothers with practical and realistic strategies to promote 

continued breastfeeding even when they are separated from their infants 

by work, school, or other circumstances. 

• Collaborate with WIC programs and other programs that have expertise in 

breastfeeding support. 

• Provide patients with resources for breastfeeding support, including contact 

numbers for national, state, and IHS breastfeeding hotlines. 

• Establish hospital policies to promote breastfeeding; encourage IHS direct 

hospitals to work toward “Baby-Friendly Hospital” designation. 

• Offer breastfeeding education to providers; providers trained in breastfeeding 

interventions have higher rates of breastfeeding among patients whom they 

have educated and encouraged.27

• Establish workplace policies to promote breastfeeding, and disseminate to the 

community as model policies. 

• Designate personnel or programs to ensure supportive equipment needs 

(breast pumps) of breastfeeding mothers are addressed in the community 

through health care facilities, local WIC programs, or local businesses. 

• Use Clinical Reporting System (CRS) to monitor breastfeeding rates for 2, 6, 

9 and 12-month old infants. 

December 2008 

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27 Humenick SS, Hill PD, Spiegelberg PL. Breastfeeding and health professional encouragement. 

Recommendations and Best Practices Recommendations 

J Hum Lact 1998;14(4):305-310. 
Promoting a Healthy Weight in Children and Youth v4.0 

According to the Centers for Disease Control and Prevention (CDC), the combination 

of breastfeeding education, peer support and policy changes in the hospital and 

workplace positively impact breastfeeding incidence and duration rates. 

Breastfeeding education was reported to be effective in increasing rates in women 

from different income and ethnic groups, while peer support programs were 

particularly effective among low-income women.28

The World Health Organization (WHO) promotes “Ten Steps to Successful 

Breastfeeding”: a list of hospital and maternity care policies and practices that can be 

adapted to clinical settings. These ten steps are part of the Baby-Friendly Hospital 

Initiative. 

WHO “Ten Steps to Successful Breastfeeding” 

1. Have a written breastfeeding policy that is routinely communicated to all health 

care staff. 

2. Train all health care staff in skills necessary to implement this policy. 

3. Inform all pregnant women about the benefits and management of breastfeeding. 

4. Help mothers initiate breastfeeding within one hour of birth. 

5. Show mothers how to breastfeed, and how to maintain lactation even if they should 

be separated from their infants. 

6. Give newborn infants no food and drink other than breast milk, unless medically 

indicated. 

7. Practice rooming-in; allow mothers and infants to remain together– 24 hours a day. 

8. Encourage unrestricted breastfeeding (on demand). 

9. Give no artificial teats or pacifiers (also called dummies or soothers) to 

breastfeeding infants. 

Note: Several studies have shown that pacifier use has a 

protective effect on the incidence of SIDS.29 The American 

Academy of Pediatrics recommends the use of pacifiers 

when placing infants to sleep for the first year of life, but 

delaying this practice until one month of age in breastfed 

infants.30 

 

28 CDC Resource Guide for Nutrition and Physical Activity Interventions to Prevent Obesity and other Chronic 

Diseases http://www.cdc.gov/nccdphp/dnpa/ 29 Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A metaanalysis. Pediatrics 2005;147:32-7. 

Recommendations and Best Practices Recommendations 

30 Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, 

Children and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics, p. 280. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

10. Foster the establishment of breast-feeding support groups and refer mothers to 

them on discharge from the hospital or clinic.31

Breastfeeding Resources 

IHS Maternal and Child Health Breastfeeding Home Page: 

http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm

Indian Health Service Division of Diabetes Best Practices on Breastfeeding: 

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBPList

IHS Breastfeeding Patient Health Education Protocols: 

http://www.ihs.gov/NonMedicalPrograms/HealthEd/Pepctopics/bf_2007.pdf

*Additional breastfeeding resources can be found in Appendix E: Community 

Resources Template in this document. Resources and recommendations for parents 

who choose to bottle feed can be found in Appendix G: Bottle Feeding, in this 

document. 

Recommendation 3: Patient Health Education 

Implementation of Universal Patient Health Education 

Implement universal patient health education regarding healthy eating behavior and 

increased physical activity to prevent and treat childhood overweight. Three 

behavioral factors most commonly associated with overweight among children are as 

follows: 

• Long hours of television viewing 

• Consumption of sweetened drinks (e.g. soda) 

• Consumption of fast food 

One study tracking children over a 19 month period found that each additional 

serving of a sugar-sweetened beverage consumed daily was associated with a 60% 

increase in the risk of being overweight after controlling for other potentially 

confounding variables.32 Excessive sweetened drink consumption (>12 oz/day) 

among children ages 6-13 years old is associated with lower milk consumption, lower 

protein and calcium intake, higher daily energy intake, and greater weight gain.33

National cross-sectional surveys have shown a positive association between the 

 

31 World Health Organization Ten Steps to Successful Breastfeeding. 

http://www.euro.who.int/nutrition/Infant/20020808_1; also http://www.unicef.org/newsline/tenstps.htm 32 Ludwig DS, Peterson KE, Gortmaker SL. Relation between drinks and childhood obesity: a prospective, 

observational analysis Lancet 2001;357(9255):505-508. 

Recommendations and Best Practices Recommendations 

33 Mrdjenovic G. Nutritional and energetic consequences of sweetened drink consumption in 6 to 13-year-old 

children. J Pediatrics 2003;142(6):604-610. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Recommendations 

December 2008 

 16

 

number of hours children watch television and prevalence of overweight.34 The 2001 

Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity

recommended that children watch no more than two hours of television a day.35

For AI/AN children, these environmental and behavioral factors appear to be a 

significant contributor to childhood overweight. As the 2001 IHS Report to Congress: 

Obesity Prevention and Control for American Indians and Alaska Natives stated, 

“most AI/AN populations developed obesity only in the past few generations, a 

change probably related to the relative abundance of modern foods, accompanied by 

relatively rapid changes from an active to a sedentary lifestyle.” It also notes that 

“...the recent proliferation of fast-food restaurants and convenience food stores on 

and near reservations also encourages the consumption of foods high in fat and 

sugar.”36

One study documented that Navajo adolescents consumed sugared carbonated 

beverages at more than twice the national average.37 Another study found one group 

of overweight AI/AN children consumed 402 more calories per day than children 

who were not overweight.38 Other researchers assessed physical activity in Pima and 

Caucasian children, and found that Pima children spent more time watching television 

and were less involved in sports than Caucasian children.39

An understanding of social determinants of health may also help to explain and 

provide solutions for the epidemic of childhood overweight in AI/AN communities. 

AI/AN children and their families experience many social, economic, and health 

disparities and are more likely to live in environments with insufficient 

encouragement and reinforcement for health-promoting behaviors. 

The recent IOM report: Progress in Preventing Childhood Obesity: How Do We 

Measure Up? points to the need for a broader understanding of systemic disadvantage 

in reaching high-risk populations, including AI/ANs.

34 Crespo CJ, Smit E, Troiano RP, Bartlet SJ, Macera CA, Andersen RE. Television watching, energy intake, and 

obesity in US children: results from the Third National Health and Nutrition Examination Survey, 1988–1994. Arch 

Pediatr Adoles Med 2001;155(3):360–365; Dennison BA, Erb TA, Jenkins PL. Television viewing and television in 

bedroom associated with overweight risk among low-income preschool children. Pediatrics 2002;109(6):1028–35. 35 Surgeon General’s Call to Action http://www.surgeongeneral.gov/topics/obesity/ 36 IHS Report to Congress 2001. 

37 Gilbert TJ, Percy CA, Sugarman JR, Benson L, Percy C. Obesity among Navajo adolescents. Relationship to 

dietary intake and blood pressure. Am J Dis Child 1992;146:289-95. 38 Harvey-Berino J, Wellman A, Hood V, Rourke J, Secker-Walker R. Preventing obesity in American Indian 

children: when to begin. J Am Diet Assoc 2000;100:564-6. 39 Fontvieille AM, Kriska A, Ravussin E. Decreased physical activity in Pima Indian compared with Caucasian 

children. Int J Obes Relat Metab Disord 1993;17:445-52. 
Promoting a Healthy Weight in Children and Youth v4.0 

Note: Helping at-risk children and youth balance their 

energy intakes and their energy expenditures requires an 

understanding of the complex and interacting influences of 

the social, economic, and built environments and the 

adverse environmental conditions that low-income and 

racially/ethnically diverse populations encounter as they 

regularly attempt to obtain affordable foods, beverages, and 

meals that contribute to a healthful diet.40

Strategies 

For children, the role of parents and caregivers is particularly important. Family and 

parental involvement is critical.41

Encourage all families to do the following: 

• Limit juice and other sweetened drinks to no more than 4 ounces daily (2-4 

ounces for toddlers), or less than one small cup per day. 

• Replace one can of soda with water every day, with the goal of eventually 

replacing all soda with water. 

• Encourage water as the only in-between meal drink. 

• Eat five servings or helpings of fruits and vegetables a day. (A serving equals 

1T of fruit or vegetable per year of age up to age 6.) 

• Avoid using food as a reward for good behavior. 

• Eat meals together as a family whenever possible. 

• Discourage TV viewing during mealtimes. 

• Learn about calorie and fat content of foods consumed. 

• Play or get active every day, at least 30-60 minutes every day. 

• Reduce TV and screen time (e.g. video games, computers) to no more than 2 

hours every day. 

• Avoid putting TVs in children’s bedrooms. 

• Follow the “5-2-1-0” model. Make sure to do the following every day: 

– 5: Eat 5 servings of fruits and vegetables each day. 

– 2: Limit TV and other screen time to no more than 2 hours a day. 

– 1: Engage in 1 hour of physical activity. 

– 0: Limit sugar-sweetened beverages—none is best. 

 

40 IOM, Progress in Preventing Childhood Obesity: How do we measure up? p.75. 

Recommendations and Best Practices Recommendations 

41 Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. The Maternal and 

Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human 

Services. Pediatrics 1998;102:E29. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Other Strategies for Providers 

• Encourage parents to wean infants from the bottle to the cup at or before 12 

months of age. 

• Emphasize to parents that infants should not be offered food other than breast 

milk or infant formula until they can sit with support and have good control of 

the head and neck, at about 4 to 6 months. 

• Explain that no nutritional advantage is known, but disadvantages may exist, 

in introducing supplemental foods before their baby is developmentally ready, 

at about 4 to 6 months.42 

• Emphasize that if the infant does not like a new food, she should not be forced 

to eat it. The food can be offered at a later time. It may take 15 to 20 attempts 

before an infant accepts a particular food.43

• Tell parents children 1 to 3 years of age need 4– 6 servings per day of fruits 

and vegetables as well as smaller serving sizes. See the table in Appendix H: 

Serving Size Portions. 

• Instruct parents to serve children 1 to 2 years of age whole milk. For older 

children, reduced-fat (2 percent), low-fat (1 percent), or fat-free (skim) milk is 

acceptable.44

• Teach the concept of “everyday” and “sometimes” foods. Everyday foods 

come from the food groups on the food guide pyramid. “Sometimes foods” 

are okay to eat but only sometimes or in small amounts, like chips, candy, 

fried foods, and desserts. 

• Encourage parents and children not to skip meals. 

• Serve as a role model for healthful eating and regular physical activity and 

encourage parents and other caregivers to serve as role models.45

• Serve as an advocate in your community, especially schools, to promote a 

healthier environment, including healthier school menus and school vending 

machine policies as well as regular physical activity for all school children. 

Encourage parents and caregivers to advocate as well. 

• Advocate for increased outdoor playtime for school-aged children. 

• Record patient education in CRS; use “Cheat Sheets” for data entry. 

December 2008 

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42 Kleinman RE, ed. Pediatric Nutrition Handbook, 4th ed. Elk Grove Village, IL: American Academy of 

Pediatrics; 1998. 

43 Satter E. Your Child’s Weight: Helping Without Harming, Birth through Adolescence. Kelcy Press; 2005. 44 Kleinman RE, ed. Pediatric Nutrition Handbook, 4th ed. Elk Grove Village, IL: American Academy of 

Pediatrics, 1998. 

Recommendations and Best Practices Recommendations 

45 IOM, Preventing Childhood Obesity: Health in the Balance, p. 223. 
Promoting a Healthy Weight in Children and Youth v4.0 

Resources 

USDA “My Pyramid for Kids” website 

http://www.mypyramid.gov/kids/ 

USDA “My Pyramid” website 

http://www.mypyramid.gov/mypyramid/index.aspx

State of Alaska WIC Program 

http://www.hss.state.ak.us/dpa/programs/nutri/WIC/WICEducation.htm

Gerber Web site 

http://www.gerber.com/feedingplan

Bright Futures materials on nutrition and physical activity 

http://www.brightfutures.org/nutrition/index.html

http://www.brightfutures.org/physicalactivity/pdf/

We Can! Web site 

http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan

* Additional Resources can be found in Appendix B: Resources in this document 

Recommendation 4: Counseling and Referrals 

Patients Already Overweight or Obese 

For patients who are already overweight or obese, assess for complications and comorbidities, provide counseling, and identify and refer patients to resources that 

promote weight-reduction, weight management, nutrition, and physical activity. 

Behavior change is the mainstay of obesity treatment. A study of successful weightcontrol strategies concluded that “providers who can use counseling techniques to 

motivate families, guide parents in consistent limit setting and reinforcement

techniques, and identify and address family conflicts that interfere with change will 

likely be most successful in helping families.”46 Providers are encouraged to seek 

additional training to increase their proficiency in behavioral counseling. 

Providers should identify resources in their communities that can assist children and 

families in combating overweight. Examples of such resources are community health 

programs and Women, Infants and Children’s (WIC) nutrition programs available 

through state agencies. This document provides a template for providers to use to 

document the resources available to facilities and their patients. (See Appendix B: 

Resources) 

 

Recommendations and Best Practices Recommendations 

46 Barlow S, Dietz W. Management of Child and Adolescent Obesity: Summary and Recommendations Based on 

Reports From Pediatricians, Pediatric Nurse Practitioners, and Registered Dietitians. Pediatrics 2002;110(1):236-

238. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Strategies 

• Assess overweight patients for complications and co-morbidities associated 

with childhood overweight. 

• Provide culturally-competent counseling for children and families to work on 

specific goals for behavior change. 

Note: Cultural competence is the ability of individuals to 

consider ethnic/racial, and cultural aspects in all 

dimensions of their work relative to obesity prevention and 

population health programs and interventions. Cultural 

competence is optimized when programs involve clients or 

recipients in all phases of a program, from planning to 

implementation, monitoring, and evaluation. 

Goals for behavior change should include the following: 

– Reducing family intake of sugar sweetened drinks and fast food. 

– Parental monitoring and modeling of positive eating behaviors. 

– Increasing physical activity. 

• When counseling children and families: 

– Develop a clear but culturally competent message about your concern for 

the child’s weight and the potential for positive change. 

– Avoid using the term “obesity;” use the term “overweight.” 

– Encourage and empathize rather than criticize. 

– Acknowledge patient feelings. 

– Answer questions without showing judgment; e.g. use terms like 

“healthier food” instead of terms like “bad food.” 

– Promote permanent lifestyle changes, not short-term diets. 

– Urge them to set simple, concrete goals, which lead to sense of success. 

• Involve family and all caregivers in the treatment process. 

• Use motivational interviewing techniques. 

• Learn more about the attitudes of the tribe(s) of the service unit towards food 

and why certain foods may be valued. 

• Locate and document appropriate community resources for referrals. 

– Complete Community Resources Template with contact information. (See 

Appendix E) 

– Provide training to providers on using community resources. 

• Refer obese and overweight children and their caregivers to Registered 

Dietitians (RDs) if possible. 

• Adopt a team approach—involve all qualified staff, RNs, RDs, health 

educators, physical therapists, wellness staff, and behavioral health specialists. 

Recommendations and Best Practices Recommendations 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Resources 

• Community Resources Template (See Appendix E) 

Recommendation 5: Community Education 

Promote and Advocate Healthful Eating 

Advocate for and promote healthful eating and regular physical activity in the 

larger community. 

The epidemic of childhood obesity is not only a Native American issue, but a national 

and international issue as well. The children we serve live in communities in the 

United States that are influenced by media, marketing, and other external factors that 

influence their choices on a daily basis. While our clinical focus is individual and 

family change, communities can support and enhance these positive changes. 

Strategies 

• Assess school-based wellness policies in place in your community - especially 

for children in grades K-8. 

• Using the community resource form: 

– Assess school and community resources available as adjuncts to clinical 

resources for overweight and obese children. 

– Assess and advocate for community venues and programs for physical 

activity that can be promoted to children and families. 

• Assess and advocate for increased community availability of healthier food 

choices, and develop culturally competent and realistic recommendations for 

families seeking positive lifestyle changes. 

Other Strategies 

• Increase choices of healthier foods in the lunch room, vending machines, in 

school stores, in academic incentives, rewards and fund-raising. 

• Create FOOD-FREE ZONES within walking distance of schools. 

• Minimize food advertising and teach media literacy to help kids and parents 

become informed consumers. 

• Prohibit schools from displaying advertisements promoting junk foods, 

including those on vending machines. 

• Require a closed campus during lunch in elementary and middle schools. 

• Prohibit schools from using junk food coupons as a reward for students. 

• Require school food service managers to be well trained in food preparation 

techniques to provide school meals that are lower in saturated fat, sodium, and 

Recommendations and Best Practices Recommendations 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

sugar and to offer healthy food choices that include lean meats, fruits, 

vegetables, whole grains and low-fat or non-fat dairy foods. 

• Require the classroom, the school dining room, and other school activities to 

provide clear and consistent messages that explain and reinforce healthy 

eating and physical activity habits. 

• Encourage PTA/PTO, student groups and clubs to choose activities and 

fundraisers that do not focus on food. 

• Encourage PTA/PTO to coordinate one health-related event per year that 

includes parents and teachers. 

• Encourage the use of locally-grown produce in schools. 

• Work with schools in helping students participate in at least 60 minutes of 

moderate intensity physical activity most days of the week. 

• Work with school systems to help address issues related to time available, 

space and facilities available for physical activity and physical education. 

• Explore relationships with sporting goods companies and the Sporting Goods 

Association to provide sports equipment packages at discounted rates that 

enable schools to increase the amount and range of physical activity available 

to students. 

• Secure in-kind donations of sports equipment for schools with limited 

resources. 

• Encourage schools, K– 12, to have certified physical education specialists. 

• Increase the percentage of students who walk, wheel or ride a bike for 

transportation. 

• Encourage parents, students and school employees to participate in a Walk to 

School day. 

• Have a mile walking track with a goal for each student to walk at least one 

mile per week. 

• Encourage the availability of biking lanes on reservation roads. 

• Make sure bike racks are accessible on school campuses. 

• Provide access to intramural interscholastic sports programs and other 

physical clubs, programs and lessons: in-school and after-school. 

• Allow after-school use of school facilities and community centers for physical 

fitness activities. 

Recommendations and Best Practices Recommendations 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Recommendations 

December 2008 

 23

Community Education Resources 

CDC Division of Adolescent and School Health key strategies to prevent obesity at 

schools Web site: http://www.cdc.gov/healthyyouth/keystrategies/index.htm

CDC Healthy Youth and schools Web site: 

http://www.cdc.gov/HealthyYouth/index.htm

IHS Best Practice for Indian Health Diabetes Programs on School Health: 

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBPList

National Diabetes Education Program’s American Indian/Alaska Native Work 

Group’s Youth Campaign: Move It!: 

http://ndep.nih.gov/diabetes/AIAN/moveit.htm

U.S. Department of Agriculture Team Nutrition Changing the Scene– Improving the 

School Nutrition Environment toolkit: 

http://teamnutrition.usda.gov/Resources/changing.html
Promoting a Healthy Weight in Children and Youth v4.0 

Best Practices Benchmarks 

AAP/AAFP 

The American Academy of Pediatrics (AAP) and the American Academy of Family 

Physicians (AAFP) endorse universal screening using body mass index (BMI) and 

use of BMI growth curves to identify obese and overweight children. 

Institute of Medicine (IOM) 

Preventing Childhood Obesity: Health in the Balance 2005 

The IOM committee argued that although the clinical evidence for the effectiveness 

of obesity reduction programs is limited, the epidemic of childhood obesity is a 

problem that requires immediate intervention with the best available methods: 

“Because the obesity epidemic is a serious public health problem calling for 

immediate reductions in obesity prevalence and in its health and social consequences, 

the committee believed strongly that actions should be based on the best available 

evidence—as opposed to waiting for the best possible evidence. However, there is an 

obligation to accumulate appropriate evidence not only to justify a course of action 

but to assess whether it has made a difference.” 

Recommendation: Health Care 

“Pediatricians, family physicians, nurses, and other clinicians should engage in the 

prevention of childhood obesity. Health-care professional organizations, insurers, and 

accrediting groups should support individual and population-based obesity prevention 

efforts. 

Implementation of Recommendation 

• Health care professionals should routinely track body mass index, offer 

relevant evidence-based counseling and guidance, serve as role models, and 

provide leadership in their communities for obesity prevention efforts. 

• Professional organizations should disseminate evidence-based clinical 

guidance and establish programs on obesity prevention. 

• Training programs and certifying entities should require obesity prevention 

knowledge and skills in their curricula and examinations. 

• Insurers and accrediting organizations should provide incentives for 

maintaining healthy body weight and include screening and obesity preventive 

services in routine clinical practice and quality assessment measures.” 

Recommendation: Home 

“Parents (defined broadly to include primary caregivers) have a profound influence 

on their children by fostering certain values and attitudes, by rewarding or reinforcing 

specific behaviors, and by serving as role models. A child’s health and well-being are 

thus enhanced by a home environment with engaged and skillful parenting that 

Recommendations and Best Practices Best Practices Benchmarks 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

models, values, and encourages healthful eating habits and a physically active 

lifestyle. Parents play a fundamental role as household policy makers. They make 

daily decisions on recreational opportunities, food availability at home, and children’s 

allowances; they determine the setting for foods eaten in the home; and they 

implement countless other rules and policies that influence the extent to which 

various members of the family engage in healthful eating and physical activity. Older 

children and youth, meanwhile, have responsibilities to be aware of their own eating 

habits and activity patterns and to engage in health-promoting behaviors. Parents 

should promote healthful eating behaviors and regular physical activity for their 

children. 

Implementation of Recommendation 

• Choose exclusive breastfeeding as the method for feeding infants for the first 

four to six months of life. 

• Provide healthful food and beverage choices for children by carefully 

considering nutrient quality and energy density. 

• Assist and educate children in making healthful decisions regarding types of 

foods and beverages to consume, how often, and in what portion size. 

• Encourage and support regular physical activity. 

• Limit children’s television viewing and other recreational screen time to less 

than two hours per day. 

• Discuss weight status with their child’s health-care provider and monitor ageand gender-specific BMI percentile. 

• Serve as positive role models for their children regarding eating and physicalactivity behaviors.” 

United States Preventive Services Task Force (USPSTF) 

Recommendation 

“The USPSTF concludes that the evidence is insufficient to recommend for or against 

routine screening for overweight in children and adolescents as a means to prevent 

adverse health outcomes.” 

Rating: I Recommendation 

Rationale: Approximately 15 percent of children and adolescents aged 6-19 years are 

overweight and are at risk for diabetes, elevated blood lipids, increased blood 

pressure and their sequelae, as well as slipped capital femoral epiphysis, 

steatohepatitis, sleep apnea, and psychosocial problems. The USPSTF found fair 

evidence that body mass index (BMI) is a reasonable measure for identifying children 

and adolescents who are overweight or are at risk for becoming overweight. There is 

fair evidence that overweight adolescents and children aged eight years and older are 

at increased risk for becoming obese adults. The USPSTF found insufficient evidence 

for the effectiveness of behavioral counseling or other preventive interventions with 

Recommendations and Best Practices Best Practices Benchmarks 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Best Practices Benchmarks 

December 2008 

 26

overweight children and adolescents that can be conducted in primary care settings or 

to which primary care clinicians can make referrals. There is insufficient evidence to 

ascertain the magnitude of the potential harms of screening or prevention and 

treatment interventions. The USPSTF was, therefore, unable to determine the balance 

between potential benefits and harms for the routine screening of children and 

adolescents for overweight. These ratings are available online at: 

http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#irec

However, the USPSTF also attached a commentary in which it mentions the 

following: 

“The USPSTF adheres strongly to a policy of making recommendations (either for or 

against delivery of preventive services) only in the presence of sufficient evidence of 

adequate quality. The USPSTF cannot make a recommendation for or against 

screening even for a practice that may be supported by expert consensus or less 

rigorous evidence. It is important to note that the USPSTF did not recommend that 

primary care clinicians not weigh and measure children or ignore parental concerns 

about weight.” 
Promoting a Healthy Weight in Children and Youth v4.0 

CRS and GPRA: Childhood Weight Control and 

Breastfeeding Measures 

Childhood Weight Control Measure (GPRA) 

Denominator: GPRA: Active Clinical Patients 2-5 for whom a BMI could be 

calculated, broken out by age groups. 

Numerators 

1. Patients with BMI 85-94%. 

2. GPRA: Patients with a BMI 95% and up. 

3. Patients with a BMI ≥ 85%. 

Definitions 

1. Age: All patients who are between the ages of two and five at the beginning of the 

Report Period and who do not turn age six during the Report Period are included in 

this measure. Age in the age groups is calculated based on the date of the most 

current BMI found. For example, a patient may be two at the beginning of the time 

period but is three at the time of the most current BMI found. That patient will fall 

into the Age 3 group. 

2. BMI: CRS looks for the most recent BMI in the Report Period. CRS calculates 

BMI at the time the report is run, using NHANES II. A height and weight must be 

taken on the same day any time during the Report Period. The BMI values for this 

measure are reported differently than in Obesity Assessment since this age group is 

children ages 2-5, whose BMI values are age-dependent. The BMI values are 

categorized as Overweight for patients with a BMI between 85-94% and Obese for 

patients with a BMI of 95%. Patients whose BMI either is greater or less than the 

Data Check Limit range will not be included in the report counts for Overweight or 

Obese. The following table provides an example of BMI Standard Reference Data. 

BMI STANDARD REFERENCE DATA 

 BMI BMI 

Low-High >= >= Data Check Limits 

Ages Sex (Overwt.) (Obese) BMI > BMI < 

----------------------------------------------------------------------------- 

2-2 Male 17.7 18.7 36.8 7.2 

 Female 17.5 18.6 37.0 7.1 

3-3 Male 17.1 18.0 35.6 7.1 

 Female 17.0 18.1 35.4 6.8 

4-4 Male 16.8 17.8 36.2 7.0 

 Female 16.7 18.1 36.0 6.9 

5-5 Male 16.9 18.1 36.0 6.9 

 Female 16.9 18.5 39.2 6.8 

Recommendations and Best Practices CRS and GPRA 

December 2008 

 27
Promoting a Healthy Weight in Children and Youth v4.0 

Performance Measure Description: In FY 2009, this measure is eliminated as an 

annual measure and is changed to a long term measure and has no annual target. 

Patient List: Patients ages 2-5 with current BMI. 

Breastfeeding Measure 

Note: Breastfeeding rates are calculated by CRS but as of 

FY 2007 breastfeeding is not a GPRA measure. 

Denominator 

Active Clinical patients who are 45-394 days old. 

Numerators 

1. Patients who have been screened for infant feeding choice. 

A. Patients who, at the age of two months (45-89 days) old, were either exclusively 

or mostly breastfed. 

B. Patients who, at the age of six months (165-209 days) old, were either 

exclusively or mostly breastfed. 

C. Patients who, at the age of nine months (255-299 days) old, were either 

exclusively or mostly breastfed. 

D. Patients who, at the age of one year (350-425 days), were either exclusively or 

mostly breastfed. 

Definitions 

Infant Feeding Choice: The documented feeding choice from the file V Infant 

Feeding Choice that is closest to the exact age that is being assessed will be used. For 

example, if a patient was assessed at 45 days old as 1⁄2 breastfed and 1⁄2 formula and 

assessed again at 65 days old as mostly breastfed, the mostly breastfed value will be 

used since it is closer to the exact age of 2 months (i.e. 60 days). Another example is 

a patient who was assessed at 67 days as mostly breastfed and again at 80 days as 

mostly formula. In this case, the 67 days value of mostly breastfed will be used. 

The other exact ages are 180 days for 6 months, 270 days for 9 months, and 365 days 

for 1 year. In order to be included in the age-specific screening numerators, the 

patient must have been screened at the specific age range. For example, if a patient 

was screened at 6 months and was exclusively breastfeeding but was not screened at 2 

months, then the patient will only be counted in the 6 months numerator. Another 

documented as exclusively breastfed at 60 days old, but changed to 1⁄2 breastfed and 

1⁄2 formula fed at 80 days old, the exclusively breastfed value will be used. 

Recommendations and Best Practices CRS and GPRA 

December 2008 

 28
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices CRS and GPRA 

December 2008 

 29

Measure Description: Establish the baseline rate of infants aged 45-89 days old who 

are either exclusively or mostly breastfed during the Report Period. 

Breastfeeding Only (Exclusively Breastfed): Formula supplementing fewer than 2 

times per week.

Mostly breastfed: Formula supplementing 3 or more times per week, but otherwise 

mostly breastfeeding. 

Patient List: Patients 45-394 days old, with infant feeding choice value, if any. 
Promoting a Healthy Weight in Children and Youth v4.0 

Resource and Contact Information 

Community Resource Directory 

This directory can also be found in Appendix E for more convenient printing.

NUTRITION EDUCATION

Hospital

Classes offered: 

Clinic:

Medical Center 

Individual training: 

 Meal planning 

Group classes: 

WIC SERVICES 

LOCAL WIC Office:

Other WIC OFFICES 1-800-800-1850

Spanish

Other 

DIET 

Weight Management (Group Health 

Patients) 

Weight Talk (telephonic counseling) 

Shapedown

TOPS (Take Off Pounds Sensibly) 

 www.tops.org

Weight Watchers 1-800-651-6000 

 www.weightwatchers.com

COUNSELING 

Dr. 

Dr. 

GROUP SUPPORT 

Hospital

Free day and evening meetings 

Other Group Support

EXERCISE/RECREATIONAL CLUBS 

 Fitness Club

 Address 

 Gold’s Gym

 Address 

 Jazzercise

 Address 

 Pool 

 Address 

 YMCA

 Address 

 Fitness

 Address 

OTHER 

 Resource

 Address 

 Resource

 Address 

 Resource

 Address 

COMMUNITY HEALTH RESOURCES 

 Resource 

 Address 

 Memorial Hospital

 Address 

RESOURCES-WEB SITES 

www.familydoctor.org Family doctor education 

www.eatright.org The American Dietetic Association 

www.jdrf.org Juvenile Diabetes Research Foundation 

www.cdc.gov Centers for Disease Control Public 

Health Resource

www.ghc.org My Group Health patient website

Recommendations and Best Practices Resource and Contact Information 

December 2008 

 30
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix A: References for Selected Research 

Childhood Weight Control Research 

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Barlow SE, Dietz WH. Management of child and adolescent obesity: Summary and 

recommendations based on reports from pediatricians, pediatric nurse practitioners 

and registered dietitians. Pediatrics 2002;110:236-238. 

Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee 

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www.pediatrics.org/cgi/content/full/102/3/e29

Berg-Smith SM, Steven VJ, Brown KM, Van Horn L, Gernhofer N, Peters E., et al. A 

brief motivational intervention to improve dietary adherence in adolescents. Health 

Education Research Theory & Practices 1999;14:399-410. 

Berkey CS, Rockett HR, Gillman MJ. One-year changes in activity and inactivity 

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Pediatrics 2003;111:836-843. 

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sibutramine for the treatment of adolescent obesity: a randomized controlled trial. 

JAMA 2003;289(14):1805-12. 

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1704 schoolchildren from 7 American Indian communities. Am J Clin Nutr 2003; 

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Health and Nutrition Examination Survey, 1988–1994. Arch Pediatr Adolesc Med 

2001; 155(3):360–365. 

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Promoting a Healthy Weight in Children and Youth v4.0 

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treatment, then and now: twenty-five years of pediatric obesity treatment. Health 

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Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due 

to obesity. JAMA 2003;289(2):187–193. 

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cardiovascular risk factors among children and adolescents: The Bogalusa Heart 

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childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa 

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Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in 

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Reports, Guides, and Policy Statements 

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Committee, Expert Committee Recommendations Regarding the Prevention, 

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Summary Report Pediatrics 2007 120: S164-S192 

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of maternity services. Geneva: World Health Organization, 1989. 

Von Kries R, Koletzko B, Sauerwalk T, von Mutius E, Barnette D, Grunert V, von 

Voos H. Breast feeding and obesity: cross sectional study. BMJ 1999;319:147–150. 

Co-Morbidities References 

Balen AH, Conway OS, Kalesas G, et al. Polycystic ovary syndrome: the spectrum of 

the disorder in 1741 patients. Hum Reprod 1995;10:2107-11. 

Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee 

recommendations [The Maternal and Child Health Bureau, Health Resources and 

Services Administration and the Department of Health and Human Services]. 

Pediatrics 1998; 102:e29. 

Bereneson GS, Srinivasan SR, Bao W. Newman WP III, Racy RE, Wattigney WA. 

Association between multiple cardiovascular risk factors and atherosclerosis in 

children and young adults. The Bogalusa Heart Study. N Engl J Med 1998;350:2362-

2374. 

Boxer GH, Bauer AM, Miller BD: Obesity-hypoventilation in childhood. J Am Acad 

Child Adolesc Psychiatry 1988:37:552-8. 

Bringer J, Lefebvre P, Bouler F, et al. Body composition and regional fat distribution 

in polycystic ovarian syndrome. Relationship to hormonal and metabolic profiles. 

Ann NY Acad Sci 1993;637:115-23. 

Crichlow RW, Seltzer MH, Jannetta PJ. Cholecystitis in adolescents. Dig Dis

1972;17:868-72. 

Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson 

TN, Scott BJ, St. Jeor S, Williams, C. Overweight in children and adolescents: 

pathophysiology, consequences, prevention, and treatment. Circulation 2005; 

111(15):1999-2012. 

Dietz WH. Health consequences of obesity in youth: childhood predictors of adult 

disease. Pediatrics 1998 Mar;101(3 Pt 2):518-25. 

Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (tibia vara): another 

skeletal disorder associated with childhood obesity. J Pediatr 1982;101:735-7. 

Recommendations and Best Practices Appendix A: References for Research 

December 2008 

 40 
Promoting a Healthy Weight in Children and Youth v4.0 

Eissa MA, Gunner KB. Evaluation and management of obesity in children and 

adolescents. J Pediatr Health Care 2004;18:35-8. 

Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of 

childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa 

Heart Study. Pediatrics 2001;108:712-718. 

Gidding BS, Leibel RL, Daniels S, Rosenblum M, Van Horn L, Marx OR. 

Understanding obesity in youth. A statement for healthcare professionals from the 

Committee on Atherosclerosis and Hypertension in the Young of the Council on 

Cardiovascular Disease in the Young and Nutrition Committee, American Heart 

Association, Writing Group. Circulation 1996;94:3383-7. 

Isnard P, Michel G, Frelut ML, Vila G, Falissard B, Naja W, Navarro J, MourenSimeoni MC. Binge eating and psychopathology in severely obese adolescents. Int J 

Eat Disord 2003;34:253-243. 

Kelsey JL, Acheson RM, Keggi KJ. The body build of patients with slipped femoral 

capital epiphysis. Am J Dis Child 1972;124:276-281. 

Kinugasa A, Tsunamoto K, Furukawa N, et al. Fatty liver and its fibrous changes 

found in simple obesity of children. J Pediatr Gastroenterol Nutri 1984;3:408-414. 

Lauer RM, Clarker WR. Childhood risk factors for high adult blood pressure: the 

Muscatine study. Pediatrics 1989;84:633-641. 

Lauer RM, Connor WE, Leaverton PE, et al. Coronary heart disease risk factors in 

school children: the Muscatine Study. J Pediatr 1975;86:697-706. 

Lauer RM, Lee J, Clarke WR. Factors affecting the relationship between childhood 

and adult cholesterol levels: the Muscatine Study. Pediatrics 1988;82:309-318. 

Mallory GB Jr., Fiser DH, Jackson R. Sleep-associated breathing disorders in 

morbidly obese children and adolescents. J Pediatr 1989;115:892-7. 

Pinhas-Hamiel O, Dolan LM, Daniels SR, Szandiford D, Khoury PR, Zeither P. 

Increased incidence of non-insulin dependent diabetes mellitus among adolescents. J 

Pediatr 1996;128:608-15. 

Plourde G. Preventing and managing pediatric obesity: Recommendations for family 

physicians. Can Fam Physician 2006;52:322-8. 

Reid AC, Teasdale GM, Matheson MS, Teasdale EM: Serial ventricular volume 

measurements: further insights into the aetiology and pathogenesis of benign 

intracranial hypertension. J Neurol Neurosurg Psychiatry 1981;44:636-40. 

Recommendations and Best Practices Appendix A: References for Research 

December 2008 

 41 
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Appendix A: References for Research 

December 2008 

 42 

Richards GE, Cavallo A, Meyer WJ III, et al. Obesity, acanthosis nigricans, insulin 

resistance, and hyperandrogenemia: pediatric perspective and natural history. J 

Pediatr 1985;107:893-897. 

Silvestri JM, Weese-Mayer DE, Bass MT, Kenny AS, Hauptman SA, Pearsall SM. 

Polysomnography in obese children with a history of sleep-associated breathing 

disorders. Pediatr Pulmonol 1993;16:124-9. 

Sorenson KH. Slipped upper femoral epiphysis. Acta Orthop Scand 1968;39:499-517. 

Starr CR, Smith JM, Cradock MM, Pihoke C. Characteristics of youth-onset 

noninsulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus at 

diagnosis. Pediatrics 1997;100:84-91. 

Strauss RS, Barlow SE, Dietz WH. Prevalence of abnormal serum aminotransferase 

values in overweight and obese adolescents. J Pediatr 2000;136:727-33. 

Weisberg LA, Chutorian AM. Pseudotumor cerebri of childhood. Am J Dis Child

1977;131:1243-48. 

Obesity and Social Determinants of Health References 

Corvalan C, Dangour AD, Uauy R. Need to address all forms of childhood 

malnutrition with a common agenda. Arch Dis Child 2008; 93: 361-362. 

Friel S, Chopra M, Satcher D. Unequal weight: equity oriented policy responses to 

the global obesity epidemic. BMJ 2007 Dec 15;335(7632):1241-3. 

Gordon-Larsen P, Adair L, Popkin BM. The relationship between ethnicity, 

socioeconomic factors, and overweight: the National Longitudinal Study of 

Adolescent Health. Obes Res 2003;11 :121–129. 

Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the built 

environment underlies key health disparities in physical activity and obesity. 

Pediatrics 2006; 117: 417 - 424. 

Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet 

linked with noncommunicable diseases. Am J Clin Nutr 2006; 84: 289 - 298. 
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix B: Resources 

BMI and Childhood Weight Control 

IHS AI/AN Pediatric Height and Weight Study website 

http://www.ihs.gov/medicalprograms/anthropometrics/index.cfm

IHS Health Promotion and Disease Prevention Programs, Focus Area: Obesity 

http://www.ihs.gov/NonMedicalPrograms/HPDP/index.cfm?module=focus&option=

obesity&newquery=1

Action for Healthy Kids 

www.actionforhealthykids.org/

America on the Move 

http://aom.americaonthemove.org/site/c.hiJRK0PFJpH/b.1310797/k.BF62/Home.htm

Blubber Buster (site on overweight in children, including information for parents) 

http://www.blubberbuster.com

CDC: 5 A Day Fruits and Vegetables 

http://www.cdc.gov/nccdphp/dnpa/5ADay/index.htm

CDC: BMI for children and teens, 2008 

http://www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-age.htm

CDC: Defining overweight and obesity. 2008

http://www.cdc.gov/nccdphp/dnpa/obesity/defining.htm

CDC: Growth Charts: http://www.cdc.gov/growthcharts/

CDC: CATCH for Improved Physical Activity and Diet in Elementary School (Univ. 

Texas) 

http://www.cdc.gov/prc/tested-interventions/adoptable-interventions/catch-improvedphysical-activity-diet-elementary-school.htm

CDC: Physical Activity: http://www.cdc.gov/nccdphp/dnpa/physical/index.htm

CDC: Planet Health for Obesity Reduction in School Children (Harvard University) 

http://www.cdc.gov/prc/selected-interventions/adoptable-interventions/planet-healthobesity-reduction-school-children.htm

CDC: Resource Guide for Nutrition and Physical Activity Interventions to Prevent 

Obesity and Other Chronic Diseases 

http://www.cdc.gov/nccdphp/dnpa/pdf/guidance_document_3_2003.pdf

Recommendations and Best Practices Appendix B: Resources 

December 2008 

 43
Promoting a Healthy Weight in Children and Youth v4.0 

Envision New Mexico (Initiative for Child Healthcare Quality) 

http://www.envisionnm.org/ Provider toolkits, posters, references, and information on 

community outreach pilot projects. Also includes information on the “Get More 

Energy” project. 

Includes provider flipchart on “General Treatment Principles”: 

http://www.envisionnm.org/files/flipchart/flipchart3a.pdf

Kids on the Block Program on Combating Childhood Obesity and Overweight 

http://www.kotb.com/kob2.htg/obesity.htm

NICHQ (National Initiative for Children’s Healthcare Quality) Join their Childhood 

Obesity Action Network to gain access to their Implementation Guide’s resources and 

tools 

http://www.nichq.org/NICHQ/Programs/ConferencesAndTraining/ChildhoodObesity

ActionNetwork.htm

NIH Aim for a Healthy Weight 

http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm

Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 

http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm

http://www.surgeongeneral.gov/topics/obesity/

University of California, Agriculture and Natural Resources. Children and Weight: 

What Communities Can Do. Publication 3422 

http://www.cnr.berkeley.edu/cwh/resources/childrenandweight.shtml

WHO Child Growth Standards 

http://www.who.int/childgrowth/en/

WIN: Weight-Control Information Network (NIDDK) “Helping your overweight 

child” 

http://win.niddk.nih.gov/publications/over_child.htm

Breastfeeding 

American Academy of Pediatrics 

http://www.aap.org/healthtopics/breastfeeding.cfm

CDC: Breastfeeding Promotion and Support 

http://www.cdc.gov/breastfeeding

http://www.cdc.gov/breastfeeding/resources/guide.htm

HHS Blueprint for action on breastfeeding (2000) 

http://www.cdc.gov/breastfeeding/pdf/bluprntbk2.pdf

Recommendations and Best Practices Appendix B: Resources 

December 2008 

 44
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Appendix B: Resources 

December 2008 

 45

Indian Health Service Breastfeeding Page 

http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm

Indian Health Service Division of Diabetes Best Practices on Breastfeeding 

http://www.ihs.gov/MedicalPrograms/Diabetes/index.cfm?module=toolsBPList 

LaLeche League 

http://www.llli.org/nb.html

National Women’s Health Information Center 

http://www.4woman.gov/breastfeeding/index.cfm?page=home

UNICEF Baby-Friendly Hospital Initiative 

http://www.unicef.org/programme/breastfeeding/baby.htm

WIC Breastfeeding Promotion 

http://www.fns.usda.gov/wic/Breastfeeding/breastfeedingmainpage.HTM

WHO (World Health Organization): 

WHO: Exclusive Breastfeeding Information 

http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/

WHO: The optimal duration of exclusive breastfeeding. A systematic review

http://www.who.int/nutrition/publications/optimal_duration_of_exc_bfeeding_report_

eng.pdf

WHO: Evidence for the ten steps to successful breastfeeding 

http://www.who.int/nutrition/publications/evidence_ten_step_eng.pdf

WHO: Breastfeeding Counseling: A Training Course 

http://www.who.int/child_adolescent_health/documents/who_cdr_93_3/en/
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix C: IHS Report to Congress: Obesity 

Prevention and Control for American Indians 

and Alaska Natives April 2001 

Seven recommendations, as described within this section, were proposed by IHS to 

address the obesity epidemic. 

Recommendation 1 

Work collaboratively with Tribal governments to: 

Address obesity prevention and treatment in AI/AN children and adults. 

Enable Tribal governments, communities, and tribal members to take ownership of 

health and obesity interventions, including the development, implementation, and 

evaluation of obesity treatment and prevention, and weight loss maintenance 

programs. 

Develop cross-program initiatives including non-Native services and populations, at 

the national, state, regional, and tribal community levels to reach AI/AN. 

Recommendation 2 

Develop a “Healthy Weight and Physical Activity Program for American Indians and 

Alaska Natives” to potentially plan, implement, and evaluate obesity prevention and 

control programs in AI/AN communities. 

Recommendation 3 

Work with other government agencies and departments to potentially develop 

interventions to reduce obesity among AI/AN communities. 

Recommendation 4 

Maintain or increase health care provider expertise and access to quality nutrition 

services. 

Train health care professionals and community health workers about obesity 

prevention and management. 

Maintain efforts to recruit and retain registered dietitians to work with AI/AN people. 

Maintain or increase current level of access to nutrition services for the AI/AN. 

Recommendations and Best Practices Appendix C: IHS Report to Congress 

December 2008 

 46
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Appendix C: IHS Report to Congress 

December 2008 

 47

Recommendation 5 

Support or encourage the implementation of “best practices” regarding obesity 

prevention and management in AI/AN communities in order to: 

• Identify and disseminate a kit of research-based best practices. 

• Select and build upon the successful components of the Pathways Study, 

Diabetes Prevention Program (DPP), National Diabetes Education Program, 

Weight Information Network (WIN) and other effective NIH, CDC, or other 

programs. 

Recommendation 6 

Support clinical behavioral research and evaluation of public health approaches 

conducted in partnership with tribes by NIH, CDC, and IHS to prevent and treat 

obesity in AI/AN populations. 

Recommendation 7 

Develop a more detailed plan to address the obesity epidemic in AI/AN populations. 
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix D: IHS Workgroup Report “What Should IHS 

Do in the Next 2 Years for an Obesity/Healthy 

Weight Initiative? 2005* 

Six goals were proposed by IHS to address the obesity epidemic to achieve the 

overall goal: Reduce overweight and obesity in American Indians and Alaska 

Natives by eliminating health disparities related to healthy eating and physical 

activity in a culturally respectful way. 

Goal 1 

Enhance and create accurate useable data. 

Goal 2 

Transform policy into action. 

Goal 3 

Partner with Tribes to build and maximize community capacity. 

Goal 4 

Create a new organizational workforce model to improve access to quality nutrition 

and physical activity services. 

Goal 5 

Enhance integrated quality care systems. 

Goal 6 

Leverage and strengthen partnerships to mobilize and maximize resources. 

*For a copy of the entire report, contact Jean Charles-Azure, IHS Principal Nutrition 

Consultant Jean.Charles-Azure@ihs.gov

*Indian Health Obesity Strategic Plan Workgroup met in April 2008 as a first step in 

updating the plan with tribal consultation to address needs in 2008 and beyond with 

Tribal consultation. 

Recommendations and Best Practices Appendix D: IHS Workgroup Report 

December 2008 

 48
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix E: Community Resources Template 

The following list of community resources can be completed, printed, and provided to 

local patients. 

NUTRITION EDUCATION 

Hospital

Classes offered: 

Clinic:

Medical Center 

Individual training: 

 Meal planning 

Group classes: 

WIC SERVICES 

LOCAL WIC Office:

Other WIC OFFICES 1-800-800-1850

Spanish

Other 

DIET 

Weight Management (Group Health 

Patients) 

Weight Talk (telephonic counseling) 

Shapedown

TOPS (Take Off Pounds Sensibly) 

 www.tops.org

Weight Watchers 1-800-651-6000 

 www.weightwatchers.com

COUNSELING 

Dr. 

Dr. 

GROUP SUPPORT 

Hospital

Free day and evening meetings 

Other Group Support

EXERCISE/RECREATIONAL CLUBS 

 Fitness Club

 Address 

 Gold’s Gym

 Address 

 Jazzercise

 Address 

 Pool 

 Address 

 YMCA

 Address 

 Fitness

 Address 

OTHER 

 Resource

 Address 

 Resource

 Address 

 Resource

 Address 

COMMUNITY HEALTH RESOURCES 

 Resource 

 Address 

 Memorial Hospital

 Address 

RESOURCES-WEB SITES 

www.familydoctor.org Family doctor education 

www.eatright.org The American Dietetic Association 

www.jdrf.org Juvenile Diabetes Research Foundation 

www.cdc.gov Centers for Disease Control Public Health 

Resource 

www.ghc.org My Group Health patient website 

Recommendations and Best Practices Resource and Contact Information 

December 2008 

 49
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix F: Listing of Co-Morbidities of Childhood 

Obesity 

Childhood overweight is associated with a higher prevalence of risk factors for 

adverse health outcomes, such as insulin resistance, elevated blood lipids, increased 

blood pressure, and glucose intolerance and diabetes. Other health consequences 

include liver disease, gallbladder problems, sleep apnea, and psychiatric and 

psychological abnormalities. 

Approaches for the medical evaluation of children or adolescents who are overweight 

are available. A few are mentioned here: 

• The Maternal and Child Health Bureau, Health Resources and Services 

Administration, and the Department of Health and Human Services Expert 

Committee Recommendations on Obesity Evaluation and Treatment 

published in Pediatrics in 1998 47

• American Heart Association Scientific Statement: Overweight in Children and 

Adolescents: Pathophysiology, Consequences, Prevention, and Treatment 48

• Guidelines adapted for use in the Department of Pediatrics at the University of 

Texas-Houston Health Science Center 49

• Recommendations for family physicians in the official journal of the College 

of Family Physicians of Canada 50

Recommendation 4 directs clinicians to assess children and youth who are already 

overweight or obese for complications and co-morbidities. An abbreviated listing of 

these complications and co-morbidities is provided here. Clinicians are referred to the 

above publications or the list of references for more information. 

December 2008 

 50

 

47 Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations [The Maternal and 

Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human 

Services]. Pediatrics 1998;102:e29. 48 Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TN, Scott BJ, St. Jeor S, 

Williams C. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. 

Circulation 2005;111(15):1999-2012. 49 Eissa MA, Gunner KB. Evaluation and management of obesity in children and adolescents. J Pediatr Health Care 

2004;18:35-8. 

50 Plourde G. Preventing and managing pediatric obesity: Recommendations for family physicians. Can Fam 

Physician 2006;52:322-8. 

Recommendations and Best Practices Appendix F: Listing of Co-Morbidities 
Promoting a Healthy Weight in Children and Youth v4.0 

Co-Morbidities and Complications 

Social stigmatization, poor self-image, depression, and discrimination51 

Eating disorders52 

Sleep apnea and obesity hypoventilation syndrome53 

Pseudotumor cerebri54 

Dyslipidemia and accelerated atherosclerosis55 

Hypertension56

Polycystic ovary syndrome57 

Type 2 diabetes58 

Slipped capital femoral epiphyses, Blount’s disease (tibia vara) 59 

December 2008 

 51

 

51 Gidding BS, Leibel RL, Daniels S, Rosenblum M, Van Horn L, Marx OR. Understanding obesity in youth. A 

statement for healthcare professionals from the Committee on Atherosclerosis and Hypertension in the Young of the 

Council on Cardiovascular Disease in the Young and Nutrition Committee, American Heart Association, Writing 

Group. Circulation 1996;94:3383-7; Dietz WH. Health consequences of obesity in youth: childhood predictors of 

adult disease. Pediatrics 1998 Mar;101(3 Pt 2):518-25. Review. 52 Isnard P, Michel G, Frelut ML, Vila G, Falissard B, Naja W, Navarro J, Mouren-Simeoni MC. Binge eating and 

psychopathology in severely obese adolescents. Int J Eat Disord 2003;34:253-243. 53 Boxer GH, Bauer AM, Miller BD: Obesity-hypoventilation in childhood. J Am Acad Child Adolesc Psychiatry 

1988:37:552-8; Mallory GB Jr. Fiser DH, Jackson R. Sleep-associated breathing disorders in morbidly obese 

children and adolescents. J Pediatr 1989;115:892-7; Silvestri JM, Weese-Mayer DE, Bass MT, Kenny AS, 

Hauptman SA, Pearsall SM: Polysomnography in obese children with a history of sleep-associated breathing 

disorders. Pediatr Pulmonol 1993; 16:124-9. 54 Weisberg LA, Chutorian AM. Pseudotumor cerebri of childhood. Am J Dis Child, 1977;131:1243-48; Reid AC, 

Teasdale GM, Matheson MS, Teasdale EM: Serial ventricular volume measurements: further insights into the 

aetiology and pathogenesis of benign intracranial hypertension. J Neurol Neurosurg Psychiatry 1981;44:636-40. 55 Lauer RM, Lee J, Clarke WR. Factors affecting the relationship between childhood and adult cholesterol levels: 

the Muscatine Study. Pediatrics 1988:82:309-318; Bereneson GS, Srinivasan SR, Bao W. Newman WP III, Racy 

RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and 

young adults. The Bogalusa Heart Study. N Engl J Med 1998;350:2362-2374; 56 Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood obesity to coronary 

heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics 2001;108:712-718; Lauer RM, Connor 

WE, Leaverton PE, et al. Coronary heart disease risk factors in school children: the Muscatine Study. J Pediatr

1975;86:697-706; Lauer RM, Clarker WR. Childhood risk factors for high adult blood pressure: the Muscatine 

study. Pediatrics 1989;84:633-641. 57Balen AH, Conway OS, Kalesas G, et al. Polycystic ovary syndrome: the spectrum of the disorder in 1741 

patients. Hum Reprod 1995;10:2107-11; Bringer J, Lefebvre P, Bouler F, et al. Body composition and regional fat 

distribution in polycystic ovarian syndrome. Relationship to hormonal and metabolic profiles. Ann NY Acad Sci

1993;637:115-23. Richards GE, Cavallo A, Meyer WJ III, et al. Obesity, acanthosis nigricans, insulin resistance, and 

hyperandrogenemia: pediatric perspective and natural history. J Pediatr 1985;107:893-897. 58 Pinhas-Hamiel O, Dolan LM, Daniels SR, Szandiford D, Khoury PR, Zeither P. Increased incidence of noninsulin dependent diabetes mellitus among adolescents. J Pediatr 1996;128:608-15; Starr CR, Smith JM, Cradock 

MM, Pihoke C. Characteristics of youth-onset noninsulin-dependent diabetes mellitus and insulin-dependent 

diabetes mellitus at diagnosis. Pediatrics 1997;100:84-91. 

Recommendations and Best Practices Appendix F: Listing of Co-Morbidities 

59 Dietz WH Jr, Gross WL, Kirkpatrick JA Jr. Blount disease (tibia vara): another skeletal disorder associated with 

childhood obesity. J Pediatr 1982;101:735-7; Sorenson KH. Slipped upper femoral epiphysis. Acta Orthop Scand 

1968;39:499-517; Kelsey JL, Acheson RM, Keggi KJ. The body build of patients with slipped femoral capital 

epiphysis. Am J Dis Child 1972;124:276-281. 
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Appendix F: Listing of Co-Morbidities 

December 2008 

 52

Nonalcoholic steatoheptatis 60

Cholelithiasis 61 

Resources 

National Association of Pediatric Nurse Practitioners’ HEATSM (Healthy Eating and 

Activity Together) Guideline and Resource Kit 

http://www.napnap.org/index.cfm?page=198&sec=220&ssec=486

American Academy of Pediatrics Bright Futures Guidelines for Health Supervision of 

Infants, Children, and Adolescents– Third Edition 

http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html

http://www.brightfutures.org/bf2/pdf/

 

60 Kinugasa A, Tsunamoto K, Furukawa N, et al. Fatty liver and its fibrous changes found in simple obesity of 

children. J Pediatr Gastroenterol Nutri 1984;3:408-414; Strauss RS, Barlow SE, Dietz WH. Prevalence of abnormal 

serum aminotransferase values in overweight and obese adolescents. J Pediatr 2000;136:727-33. 61 Crichlow RW, Seltzer MH, Jannetta PJ. Cholecystitis in adolescents. Dig Dis 1972;17:868-72. 
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix G: Bottle Feeding 

If parents/caregivers choose to bottle feed, then providers should provide 

appropriate education on feeding in response to hunger cues and avoidance of 

overfeeding. 

Bottle Feeding 

Formula feeding, unlike breastfeeding, has not been found to be protective against 

childhood obesity.62 Some researchers have proposed that formula-fed infants may be 

likely to consume more than needed for satiety, and that this overfeeding may be a 

potential contributor to childhood obesity.63 Additionally, the uniform composition of 

formula is unlike that of breast milk, and does not provide the infant with the same 

hormonal or metabolic cues that may regulate intake.64 The combination of the 

metabolic impact of human hormones found in breast milk, the early learned eating 

behaviors associated with breastfeeding, as well as the early weight gain patterns 

unique to breastfed infants, may all be protective against obesity. Formula-fed infants 

do not enjoy the same protective factors, especially compared to infants who are 

exclusively breastfed for several months. However, any amount of breastfeeding is 

beneficial, and all mothers should be encouraged to initiate breastfeeding and 

continue as long as possible, even after returning to school and/or work. 

The third edition of Bright Futures: Guidelines for Health Supervision of Infants,

Children and Adolescents promotes the following: 

“Exclusive breastfeeding, and avoidance of overfeeding if the parent’s bottle feed 

their infants, is recommended to ensure adequate growth that is not excessive.”65

Strategies 

• Instruct parents that any amount of breastfeeding is beneficial for their child; 

and that even babies that are mostly formula fed can benefit from breast milk, 

if mothers are willing to nurse part-time or express their milk using a breast 

pump. 

December 2008 

 53

 

62 Dewey KG. Is breastfeeding protective against child obesity? J Hum Lact 2003;19(1):9-18. IOM, Preventing 

Childhood Obesity: Health in the Balance. 2005. 63 Bergman KE, Bergmann RL, von Kries R, Bohm O, Richter R, Dudenhauen JW, Wahn U. Early determinants of 

childhood overweight and adiposity in a birth cohort study: Role of breastfeeding. Int J Obes Relat Metab Disord

2003;27(2):162-172; Dewey, 2003; Lederman SA, Akabas S, Moore BJ, Bentley ME, Devaney B, Gillman MW, 

Kramer MS, Menalla JA, Ness A, Wardle J. Summary of the presentations at the Conference on Preventing 

Childhood Obesity, December 8, 2003. Pediatrics 2004;114:1146-1173. 64 Lederman et al. 2004. 

Recommendations and Best Practices Appendix G: Bottle Feeding 

65 Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, 

Children and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics. 
Promoting a Healthy Weight in Children and Youth v4.0 

• If mothers are unable or unwilling to breastfeed, or can only breastfeed parttime, recommend the use of iron-fortified formula as a substitute for breast 

milk for full-term infants during the first year of life. 

• Instruct parents/caregivers not to add cereal or other foods to formula, unless 

under specific instruction from a health professional. 

• Instruct parents/caregivers to hold their baby close, in a semi-upright position, 

and to look into their baby’s eyes during bottle feeding. 

• Counsel parents to avoid propping the bottle or letting their baby feed alone. 

This will minimize the risk of choking, ear infections, and early childhood 

caries.66

• Counsel parents to check for causes if infant is crying more than usual or 

seems to want to eat all the time (uncomfortable feeding position, formula 

prepared incorrectly, bottle nipple too firm or hole too big, unheeded hunger 

cues, distracting feeding environment). 

• Provide useful guidelines for serving sizes based on age for formula fed 

infants. 

– While parents should be instructed to feed their baby until she seems full, 

the following guide may be helpful: 

▫ A month old may drink 1-2 ounces every 2-3 hours 

▫ 1-2 month old may drink 2-3 ounces every 2-3 hours 

▫ 2-3 month old may drink 4-5 ounces every 3-4 hours 

▫ 3-4 month old may drink 5-6 ounces every 3-4 hours 67

– The third edition of Bright Futures: Guidelines for Health Supervision of 

Infants, Children and Adolescents provides the following guidelines on 

total daily amounts of formula by age: 

▫ A newborn at the 50 percentile with appropriate growth may drink 

an average of 20 oz of formula per day with the amount of formula 

ranging from 16 to 24 oz per day. 

▫ The usual 24 hour amount for a 2-month-old infant is about 26 to 

28 ounces with a range of 21 to 32 ounces. 

▫ A 4-month-old may drink an average of 31 oz of formula per day 

without solid foods with a range of 26 to 36 oz per day. 

▫ Infants six months and older may drink 24 to 32 oz of formula per 

day, but larger male infants (6 months old, 90 percentile for eight) 

December 2008 

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66 Tully SB, Bar-Haim Y, Bradley RL. Abnormal tympanography after supine bottle feeding. J Pediatr 1995; 

126(6):S105-11; Hagan et al. 2008. 

Recommendations and Best Practices Appendix G: Bottle Feeding 

67 Alaska WIC Program http://www.hss.state.ak.us/dpa/programs/nutri/WIC/Participants/WICFAQbottlefeeding.htm
Promoting a Healthy Weight in Children and Youth v4.0 

Recommendations and Best Practices Appendix G: Bottle Feeding 

December 2008 

 55

may drink as much as 42 oz of formula per day, in addition to solid 

foods.68

• Provide parent/caregiver education on correct formula preparation, 

appropriate storage of prepared formula, and other important food safety 

information on formula feeding, including heating of formula and cleaning 

bottles and nipples. 

• Encourage parents and caregivers to wean infants from the bottle to the cup at 

or before 12 months of age. 

• Collaborate with WIC and other programs that have expertise in bottle 

feeding. 

Other Strategies 

• Instruct parents to feed their baby when he is hungry. Signs of hunger include

hand-to-mouth activity, rooting, facial grimaces, fussing sounds, and crying. 

Ask parents how they know if their baby is hungry. 

• Instruct parents to feed their baby until he seems full. Signs of fullness are 

turning his head away from the nipple, showing interest in things other than 

eating, and closing his mouth. Ask parents how they know if their baby has 

had enough to eat. 

• Warn parents against encouraging their baby to finish a bottle when she has 

demonstrated that she is full by turning her head away from the nipple, closing 

her mouth, or showing interest in things other than eating. 

• Let parents/caregivers know that babies often have a strong urge to suck, 

unrelated to hunger, and this urge can often be satisfied with a pacifier or 

thumb. 

Bottle Feeding Resources 

IHS Child health education protocols—see newborn nutrition section: 

http://www.ihs.gov/NonMedicalPrograms/HealthEd/Pepctopics/chn_2007.pdf

State of Alaska WIC Program Bottle Feeding FAQ:

http://www.hss.state.ak.us/dpa/programs/nutri/WIC/Participants/WICFAQbottlefeeding.htm

American Academy of Pediatrics Bright Futures Guidelines for Health Supervision of 

Infants, Children, and Adolescents– Third Edition: 

http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html

http://www.brightfutures.org/bf2/pdf/

 

68 Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, 

Children and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics. 
Promoting a Healthy Weight in Children and Youth v4.0 

Appendix H: Serving Size Portions 

Age 1–3 

year olds 

4–6 

year olds 

7–12 

year olds 

Teens

Fruits & Vegetables 

Fruit: Vitamin C rich source daily; 

Vitamin A source 3-4 per wk 

Cooked or canned 

Fresh 

Juice 

Servings 

Vegetables: Vitamin C rich source 

daily; Vitamin A source 3-4 per wk 

Cooked 

Raw 

Servings 

1/4 c 

1/2 piece 

2–4 oz juice 

2–3 

1–3 tbsp 

Few pieces 

2–3 

1⁄4–1⁄2 c 

1⁄2–1 small 

4 oz juice 

2–3 

4–6 tbsp 

Few pieces 

2–3 

1⁄4–1⁄2 c 

1 medium 

4 oz juice 

2–3 

1/2 c 

Several pieces 

2–3 

1/2 c 

1 medium 

4 oz juice 

2–3 

1/2 c 

1 cup 

2–3 

Dairy 

Milk 

Cheese 

Yogurt 

Servings 

4 oz 

1⁄2 oz (1-inch cube) 

1⁄3 c 

2–3 

4–6 oz 

1⁄2–3⁄4 oz 

1⁄2 c 

3–4 

4–8 oz 

3⁄4–1 oz 

1 c 

3–4 

4–8 oz 

1 oz 

1 c 

3–4 

Legumes 

Nuts 

Servings per day 

2 tbsp cooked 

Not recommended 

for this age group 

2 

4–5 tbsp cooked 

4 tbsp peanut butter

2 

1⁄2 c cooked 

4 tbsp peanut 

butter 

3–4 

1⁄2 c cooked 

4 tbsp peanut 

butter 

3–4 

Grain products 

Bread 

Rice, pasta cooked 

Cereal, dry 

Cereal, cooked 

Crackers 

Servings per day 

1⁄2–1 slice 

4 tbsp 

1⁄4–1⁄2 c 

1⁄4–1⁄2 c 

1–2 

3–4 

1 slice 

1⁄2 c 

1 c 

1⁄2 c 

5 

3–4 

1 slice 

1⁄2 c 

1 c 

1⁄2–1 c 

5 

4–5 

1 slice 

1⁄2 c 

1 c 

1⁄2–1 c 

5 

4–5 

Adapted from Samour PQ, King K. Handbook of Pediatric Nutrition. Sudbury, MA: 

Jones and Bartlett; 2005. 

*Each day, a child between ages 1 and 3 needs about 40 calories for every inch of 

height. The amount varies with the child’s build and activity level.69

 

Recommendations and Best Practices Appendix H: Serving Size Portions 

69 Dietz WH, Stern L, eds. 1999. Guide to Your Child’s Nutrition: Making Peace at the Table and Building Healthy 

Eating Habits for Life. New York, NY: Random House, p. 41. 

December 2008 

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Promoting a Healthy Weight in Children and Youth v4.0 

Contact Information 

If you have any questions or comments regarding this distribution, please contact the 

following: 

Name: Amy Patterson, PhD 

Phone: (916) 930-3981 ext 320 

Email: Amy.Patterson@ihs.gov

Name: Theresa Cullen, MD, MS 

Email: Theresa.Cullen@ihs.gov

Recommendations and Best Practices Contact Information 

December 2008

 57