Synopsis Of Handbook Of Pediatric Obesity, Combating Child Obesity And 3 Journal Articles

HST6335 Public Health Strategies

HST6335 Public Health Strategies

Handbook of Pediatric Obesity: Etiology, Pathophysiology, and Prevention

Book 1: Handbook of Pediatric Obesity: Etiology, Pathophysiology, and Prevention

In this book, the authors discuss about the Epidemiology, Pathophysiology and Prevention of Pediatric Obesity. The authors points out that obesity and overweight issues are is very common among children and adolescents in USA and other developed countries, considering this, it can be expected that in the next few decades, the number of obesity cases will go even further up. The prevalence of childhood or pediatric obesity is also seemed to be higher among African Americans and Hispanics than in the white population. Engaging in physical activities have been suggested as effective strategy to alleviate the obesity risk and of its related diseases. This book also identifies the consequences of pediatric and childhood obesity, listing diseases/ dysfunctions like: Hypertension, Resistance to Insulin (and type 2 diabetes), Asthma, Eating disorders, Social discrimination and low self esteem, A reduced quality of life, heart disease, cancer (breast cancer, ovarian cancer, polycystic ovarian syndrome (Goran and Southern 2016).

The book contains different case studies based on childhood obesity. Highlights are made upon the risk factors, family history, and genetic predisposition related to childhood obesity. They have also listed the possible medical problems that arise from childhood obesity like benign intercranial hypertension, slipped femoral epiphysis, Obesity hypoventilation syndrome, sleep apnea and snoring, disease of the gall bladder, varicose veins, hypertension, and hypercholesterolemia. The authors have also discussed the the preventative measures to reduce the risk of such diseases, and clarified several basic facts about obesity and childhood obesity like overweight children have overweight parents, overweight children tends to grow to obese adults, Obese children have higher prevalence of health problems, obese children have lower life expectancy, Obese children tend to lead a more sedentary life and fast food can cause obesity (Heaton Harris 2009).

This journal article studies the relation between beverage intake with body fat composition among preschoolers (3-5 years) and adolescents (15-17 years) in Framingham’s Children Study. It was indicated by the study that risks of obesity and overweight can be reduced by a regular consumption of healthy food like milk and vegetable juice. The study also aims to clarify the effect of sugar sweetened beverages (in moderate amounts) particularly, on obesity, because of contradicting results of other studies and found no associated risk with obesity, which were consistent with results from another study- Project EAT. The authors points out that consumption of fruit juice between ages 24 to 72 months do not increase risk of obesity (Hasnain et al. 2014).

Combating Child Obesity

This journal article studies the association of Heart Rate Variability (HRV) and the success of intervention technique for obesity, like dieting. The study showed a negative relation between Heart Rate Variability and body mass, and is consistent with other studies that have shown an inverse relation between HRV and impulse control, which explains relation of HRV with success of dieting as an intervention method (that depends on impulse control). This shows that children with lower LF/HF in HRV are more prone to be successful in long term weight management. In addition, the authors point out that exercise, diet change and stress reduction can alter the HRV, and therefore improve the success of intervention strategies (like dieting) (Taylor et al. 2017).

In this journal, the authors studies the upward trend in in the rise of obesity cases in Europe (with a 10% variation in proportion between different countries), to identify differences in risk factors and protection factors prevalent in different European countries. The journal utilizes a multi dimensional approach in explaining the the role of different factors to weight gain, like social influence, food production, food consumption, individual psychology, individual activity, and biology. The article also points to the higher prevalence of obesity in United Kingdom, as per World Health Organization study in 2014. The study highlights how environmental variants in different geographic locations can have differential outcomes in obesity treatment and prevalence of obesity.

This journal article conducts a systematic study of the epidemiology, etiology, co morbidities, and evaluation, intervention and treatment methods in relation to childhood obesity. The article explains the differences between overweight, obesity and severe obesity, showng that socioeconomic, racial and ethnic as well as genetic and hereditary factors underlying these differences. The authors points out that environmental factors (like psychosocial and emotional distress, eating disorders, birth size, catch up growth, exposure to antibiotics, gut micro biota, breastfeeding status, consumption of sugar sweetened beverage and fast food, sedentary lifestyle and time spent watching television are some of the factors that influences obesity. Genetic factors have been identified to account for 30-50% of the reported adiposity. Other factors like endocrine disorders, poor sleep quality, medications (like glucocorticoids, antipsychotics and antiepileptic drugs) and hypothalamic lesions have also been discussed (Kumar and Kelly. 2017).

This journal article compares obesity and overweight problems with lifestyle problems like a sedentary lifestyle and a lack of physical activity. In is shown by the studies that a Moderate to Vigorous Physical Activity (MVPA) can decrease the chances of developing childhood obesity, and is independent of the sedentary time spent by the children. This highlights the risk of physical inactivity and sedentary lifestyle with the incidence of obesity in children. It is also recommended in the journal that an increased physical activity of at least 20 minutes can help to manage obesity and reduce weight among the children. This shows that intervention for obesity should also aim to alter risky lifestyle behaviour and increase the amount of physical activity to be effective with minimum associated risks.

Beverage Intake in Early Childhood and Change in Body Fat from Preschool to Adolescence

This web page published by the Department of Health, UK Government discusses the plan of action to manage and control childhood obesity. Key action plans, in the form of policy changes and administrative interventions have been identified, that can help to reduce the prevalence of obesity in the UK. Actions include: introduction of levy on the soft drinks producers and importers (not consumers) in order to encourage reduction of sugar in their products; program led by Public Health England to cut the sugar content by 20% (by the year 2020) in food specifically targeted to babies and young children; Supporting healthy innovations in food products that supports healthy lifestyle; updating the nutrient profile model to develop a new framework; ensuring that healthy options are available in public sectors like hospitals or leisure centers (having healthy choice of available food); continued providence of healthy food to underprivileged families; encouraging the children to be involved in one hour of physical; activity daily; improving quality sport and physical activity programs in schools; implementing rating schemes in primary schools, that will encourage efforts in obesity prevention, and healthy eating and physical activity in the schoolchildren; ensuring healthy food in schools and encourage clearer and unambiguous labeling of products by manufacturers.

This news article reports that there are 124 million obese children worldwide as of October, 2017, with a quick rise in the United Kingdom (where 10% of children are reported to be obese). The research and analysis was conducted by International NCD Risk Factor Collaboration, funded by Wellcome Trust and AstraZaneca Young Health Programme, published on The Guardian and BBC, and used data from 200 countries to compare trends from 1975 to 2016. The results show that from 1975 to 2016, obesity in girls rose from 0.7% to 5.6%, and for boys from 0.9% to 7.8% (with a current estimate of 50 million girls and 74 million boys). It also showed that areas with highest incidence of childhood obesity are: Polynesia and Micronesia, followed by high income English speaking countries like UK, North America, Australia and New Zealand (with UK ranking 73^rd among the 200 countries in the prevalence of childhood obesity (Nhs.uk. 2017).

It is an “interactive database” that contains data regarding the health status and behaviors of Americans that is classified as per the states, using clickable charts, maps and tables. The database covers issues like obesity, physical activity, breast feeding status, along with health related behaviour and policy data. The interactive database allows the visage of information both country wise as well as state wise, and the data can also be arranged as per age, sex, ethnicity, and race. This allows an understanding of common trends associated with the disease, and therefore monitoring of the current situation.

Cardiac autonomic regulation as a predictor for childhood obesity intervention success

This database provides access to national and sub-national audits on issues like underweight, overweight, obesity that is classified as per the country of prevalence, year of study, and gender. The database is also interactive, linking maps, tables graphs and documents that can be downloaded. Tracking the body mass index (BMI) can provide a useful information regarding trends in obesity, regionally, and therefore understand any underlying patterns. The database was implemented as a part of WHO Expert Consultation on Obesity: Preventing and Managing the Global Epidemic (June 1997). The data is reported in a standardized format using BMI cut off points recommended by WHO, so that the results can be compared internationally. This database is useful as a global surveillance tool that allows monitoring of nutrition and its status. The database also integrates Dietary Energy Supply

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Website: https://www.worldobesity.org/

The World Obesity Federation is an association of professionals from medical, scientific and research communities from more than fifty obesity organizations. They form a worldwide community of organizations whose aim is to fight obesity. Their mission is to lead and drive worldwide campaigns and efforts to treat obesity, prevent it or reduce the disease burden of it. It increases awareness and understanding of the disease via journals and events and medical/clinical data. It is also involved in World Obesity Policy and Prevention and World Obesity Clinical Care. Their website provides access to up to date news on Obesity, and an integrated library or articles and journals for research and education.

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WHO Regional Office for Europe

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Website: https://www.who.int

The World Health Organization or WHO is a part of the United Nations, that studies health and health issues globally. WHO regularly monitors the epidemiology of Obesity, as with any other health issue, and helps in educating people and strives to reduce the burden of disease associated with obesity, and for people to live healthy lives. The updated factsheet allows an accurate monitoring of the disease, which is pivotal to enable policy changes. WHO has made the eradication of childhood obesity an important mission. Valuable information like recommendations and action plans that can be undertaken to fight obesity is outlined on their site. It also mentions the health risks, and disease burden of obesity. This can be an effective educational tool for people, where they can learn about the disease and its prevention strategies.

Variations in the Prevalence of Obesity among European Countries, and a Consideration of Possible Causes

Figure 1: Prevalence of Childhood Obesity in UK from 2006 to 2015; source: (National Health Statistics, Government of UK 2017).

The table compares the prevalence of obesity in 6^th year school children compared to reception year. For the reception year one in five were estimated to suffer from obesity, while the obesity rate dropped from 10% in 2006 to 9% in 2015. For 6^th graders, the prevalence of obesity is much higher (one out of three), and the rate of obesity also went up from 17% in 2006 to 20% by 2015.

Reference: National Health Statistics, Government of UK. (2017). Statistics on Obesity, Physical Activity and Diet. [online] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613532/obes-phys-acti-diet-eng-2017-rep.pdf [Accessed 14 Dec. 2017].

 

Figure 2: Prevalence of Obesity by Ethnicity; source: (National Health Statistics, Government of UK 2017).

The table compares the incidence of obesity based on ethnicities between 6^th year and reception year schoolchildren. For the reception year, prevalence of obesity ranges from 15% for Black or Black British children and 7% for Chinese children, while 29% of Black or Black British children suffered from obesity. For 6^th graders, the obesity rates have shown a higher incidence among all ethnicities (Black or Black British children- 29% and Chinese children 17%). The number of obese cases among Black or Black British children was also considerable high (49%).

Reference: National Health Statistics, Government of UK. (2017). Statistics on Obesity, Physical Activity and Diet. [online] Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613532/obes-phys-acti-diet-eng-2017-rep.pdf [Accessed 14 Dec. 2017].

Figure 3: Table showing the relation between childhood obesity and physical activity; source: (National Health Statistics, Government of UK 2017).

The table shows the proportion of boys and girls in school who meeting the physical activity guidelines, and proportion of students who were sedentary for six or more hours at a stretch. It shows an increase in the number of students who achieved the physical activity guidelines (for boys it improved from 21% in 2012 to 23% by 2015, and for girls from 16% in 2012 to 20% by 2015). The data also shows that the sedentary time spent at weekdays and weekends by schoolchildren increased with age.

Figure 4: Table showing the fruit and vegetable consumption by children; source: (National Health Statistics, Government of UK 2017).

The figure shows the servings of fruits and vegetables consumed everyday, the number of portions with deprivation levels and number of servings based on ethnic groups. It shows that 52% of 15 year olds consume five or more portions of fruits and vegetables per day, with 58% from least deprived areas, and 48% from most deprived, showing a relevance of access to healthy food. The table also shows that only 50% of black children ate fruits and vegetables compared to 60% for Chinese children.

Review of Childhood Obesity

What is Childhood Obesity?

Obesity literally means having an excessive amount of body fat. Being obese is different from being overweight, as weight of the body can be contributed by bones, muscles and water content of the body, apart from the fat. However both being obese and overweight implies a body weight above the healthy limit of body mass index. Obesity usually occurs when the calorie consumption exceeds calorie usage, and this difference varies between person to person depending upon several factors like genetic characteristics, overconsumption, eating foods with high fat or calorific content, and a sedentary lifestyle (Medlineplus.gov).

As per Centers of Disease Control (CDC, 2017); Body Mass Index (BMI) can be used to determine obesity and overweight. A Body Mass Index above 85^th but below 95^th percentiles is termed as being overweight, while a score above 95^th percentile is considered obese for children and teenagers of same sex and age. The BMI that is applicable for children and teens are specific to age and sex, unlike the BMI index used for adults, due to the variable body composition between male and female children and with age, which is why BMI should be expressed in relation to children of the same age and sex (Cdc.gov 2017).

Figure 5: Table showing the classification of Obesity, Overweight, Normal Weight, and Underweight based on BMI; source: (Cdc.gov 2017).

Figure 6: BMI for age percentile chart for boys between 2 to 20 years of age; source: (Cdc.gov 2017).

Figure 7: BMI for age percentile chart for boys between 2 to 20 years of age; source: (Cdc.gov 2017).

The aim of the report is to understand the risk factors and health risks associated with childhood obesity, and possible preventative or precautionary measures to address and lower the risks associated with it. This might be useful in planning effective intervention strategies in the future.

According to Childhood Obesity Foundation (2017), the risk of developing childhood obesity increases due to several independent factors that has a complicated inter-relation to each other, which are made even more complicated due to different policies affecting the healthcare system across different sectors (Childhood Obesity Foundation 2017). These factors include:

• A decreased amount of daily physical activity, and an increased sedentary lifestyle.
• Consumption of food or beverage, high in sugar or fat content (like candies, fast food, baked food and soda pop).
• Unhealthy environment, that does not promote healthy eating and physical activities.
• Spending an increased amount of screen time (watching television, or playing video games).
• Eating disorders or stress eating
• Family history of obesity, and priority of healthy eating and physical activity in the family.
• Economic status of the family, and consequent access to resources needed for healthy diet choice and active living.
• Exposure to aggressive advertising campaigns that promotes unhealthy food and beverages to children.
• Lack of education about healthy diet choices (in parents or children).
• Lack of access to healthy food.
• Genetic predisposition, like Prader Willi syndrome or Cushing’s syndrome.

Anderson and Butcher (2006) have pointed out that an increase in childhood obesity cases increased since 1980’s, correlated to a significant change in the environment of the child, which might have influenced the growth in childhood obesity rates. Factors like availability and easy access to food and beverage, dense with sugar or fat content to children at school, and marketing campaigns increasingly targeted this age group for promoting unhealthy food or beverages. There was also an increased consumption of soda pop, fast food, precooked meals among children and their parents, owing to the increasingly competitive and busy schedule. Other factors like reduction in physical activity also occurred as more and more children started travelling to school in cars, instead of bicycles (owing to their safety concerns). The busy schedule of the parents also reduced their time involved with the children to engage in physical activities, all of which contributed to an increased sedentary and on screen time spent by the children (as well as their parents). They further point out that the obesity rate have risen due to the disproportionate increase in energy intake compared to the energy expenditure (which drastically decreased), causing an energy misbalance.

Figure 8: Diagram showing the interrelation between different factors that can contribute to obesity; source: (Blundell et al. 2017).

Studies by Bailey at al. (2014) have shown that exposure of infants to broad spectrum antibiotics can significantly increase the likelihood of developing obesity, later in their lives. While McFarlane et al. (2017) indicated a relation between obesity and a lack of sleep caused due to sleep deprivation or sleep disorders. This was supported by the findings by Broussard and (Cauter 2016) who pointed those disturbances in circadian rhythm of the body being related to a higher risk of developing obesity.

Dev et al (2013) have identified 22 different risk factors that can contribute to obesity, including ethnicity, gender, duration of night time sleep, time spent watching television per day, Eating meals while watching television, watching television before going to bed, breastfeeding duration, family status (single parent/ two parent family), maternal education status, BMI of parent(s), family history of obesity, nutrition knowledge of the parent(s), WIC participation, diet intake by child, fat content in milk, sugary beverage consumption, feeding practice of the parents.

Studies by the World Health Organization (2017) show that Childhood Obesity can increase the risk for cardiovascular disease, diabetes, Musculo skeletal disorders and even cancer. Such risks are harder to pre-screen since the symptoms only appears much later in the lives of the affected children (WHO | Why does childhood overweight and obesity matter?. 2017). Similar observations were also made by the Centers of Disease Control and Prevention (US) that highlights the following immediate risks of childhood obesity:

• Hypertension, hypercholesterolemia, and Cardio Vascular Disease
• Tolerance to glucose, insulin resistance and type 2 diabetes
• Respiratory dysfunction like Asthma, Obstructive Sleep Apnea
• Musculoskeletal dysfunction and joint problems/pain
• Fatty liver, gall stone, heartburn.

Additional long term risks of childhood obesity have also been identified as psychological problems (like depression, anxiety, and eating disorders), a reduced or lack of self esteem and quality of life, and social stigmatization and discrimination of obese children. Additionally, obesity in children also increases the chances of obesity later in life, and a higher propensity (and risk factor) of developing the diseases related to obesity compared to normal weight children who became obese later in life (Centers for Disease Control and Prevention 2017). Such findings are also supported by Heaton-Harris (2009). Studies by Bell et al. (2014) have shown that childhood obesity can further cause an increased risk of renal diseases like renal failure and chronic renal dysfunction later on, in adulthood. Rodriguez-Hernandez et al. (2013) argues that an innate immune response on the adipose tissues in the body (especially in obese individuals) causes a systemic inflammation and chronic metabolic dysfunction that underlies obesity in adults and children. Even metabolically healthy obese individuals (that is obese individuals with no metabolic syndrome or dysfunction) are still prone to type 2 diabetes (Bell et al. 2014).

Studies by Pandita et al (2016) identified several risks associated with Childhood obesity, as shown in the table below:

Acute	Type 2 diabetes
	Hypertension
	Hyperlipidemia
	Precocious puberty
	Ovarian hyperandrogenism
	Gynecomastia
	Cholecystitis
	Pancreatitis
	Pseudotumor cerebri
	Fatty liver
	Renal disease (focal glomerulosclerosis)
Orthopaedic Disorders	Slipped capital femoral epiphysis
	Tibia vara
	Blount disease
Liver and gall bladder dysfunction	Elevated transaminases
	Cholecystitis
Physical and psychological	Depression
	Eating disorders
	Social isolation
	Sleep disorders
Cardiovascular and endocrine	Hyperinsulinism and insulin resistance
	Hypercholesterolemia
	Hypertriglyceridemia
	Low levels of high-density lipoprotein
	Hypertension
	Polycystic ovary syndrome
	Coronary artery disease
	Left ventricular hypertrophy
Cancer	Colorectal carcinoma
Long-term	Ischemic heart disease
	Short life span
	Stroke
	Sudden death

Figure 5: Table showing the complications associated with childhood obesity; source (Pandita et al. 2016).

Joint report by WHO and UNICEF (2015) shows that Europe has the highest number of overweight children below the age of 5 years, and that childhood obesity to be more common among high income and upper middle income groups, compared to lower middle to low income groups. The data also shows a sharp rise in the number of obesity cases among children in several countries in Africa, where childhood obesity nearly became twice since 1990 (5.4 million to 10.3 million), and points out the the prevalence of childhood obesity to be more in low and middle income countries than high income countries. Additional key facts were also reported by WHO as shown in the figure below:

Figure 9: WHO fact sheet on Childhood Obesity (2017); source: (World Health Organization 2017).

Reports by NHS (as discussed on Part A) show an increase in childhood obesity in the UK, amounting to 124 million children suffering from it, as of 2016. It also suggested an increase risk of childhood obesity in high income countries, which contradicts the studies by WHO (Nhs.uk. 2017). The studies also shows that the number of obesity in UK being lesser than United States, Mexico, Hungary, Australia and New Zealand. The statistical data analyzed in part A, also shows that obesity among school children increased from reception year to year 6, with most of the increase being from the most deprived areas. Also, the prevalence was found to be disproportionate between different ethnicities, with Black English children showing the highest risk among other ethnic groups. Even the perception of the parents were studied for obesity, which showed that mothers tend to be less perceptible to identify if their child was obese, compared to fathers; and that the amount of time spent sedentarily seemed to rise with the age of the child. All of which points towards an increased risk of obesity.

Childhood obesity is largely preventable and implementing preventative and precautionary measures. Several authors have pointed out that an increased physical activity or physical excercise can alleviate the risks of childhood obesity (Goran et al. 2016; Heaton-Harris 2009; Keane et al. 2017; Tan et al. 2017). New York Health has suggested that promoting healthy lifestyle by the providence of healthy food and snacks, promoting physical exercise and education on nutrition for the parents. They have provided the following recommendations for parents to encourage healthy lifestyle in their children and lower the risk of obesity:

• Focusing on good health, rather than a weight goal, and emphasizing on the goodness of being involved in regular physical exercise and opting for healthy diet choices, instead of fixating on weight of the children.
• Focusing on the family instead of only the obese children.
• Setting up times for meals and snacks, having meals with the family, and selecting healthy food for the children.
• Providing sensible portions in servings, to prevent overconsumption (Health.ny.gov. 2017).

Similar recommendation are also made by the American Heart Organization (2017), highlighting the importance of healthy eating habits, avoiding calorie rich food, promoting physical activity and discouraging sedentary lifestyle. It also adds that success of intervention programs can occur only when the parents are also involved for the dietary treatment, existence of social support in the dietary intervention strategies, and prescribing regular activity routines. Is should also be emphasized that weight loss by lifestyle modification is a slow process, however can provide better protection against childhood obesity and its risks (Heart.org. 2017).

Suburg et al. (2015) discussed the characteristics of effective interventions as the ones that target a change in the behaviour of parents that will encourage an active monitoring of the children’s health and physical activity status. Weight loss programs that included the parents and children also have shown to be more effective than programs that involved only the kids.

Emphasis has also been given on prenatal and early childhood on the growth and development of the children. Involvement of the primary care pediatricians, clinics and health centers during the initial couple of years of the child’s life can promote healthy lifestyle and behaviour in both children and their parents. In addition the physicians can also act as role models, champions of the cause, educators and advocates for child’s health, which will expand their current role to include education and advocacy (Vine et al. 2013). However, Showell et al. (2013) warned that the efficacy of home based intervention strategies are questionable, and further studies have to be done under such settings to fully understand if they are effective. Utilization of technological advancements (like mobile and wireless) can also promotion of  healthy choice of food and engagement with physical activity among children (Turner et al. 2015).

Hoelscher et al. (2013) suggested primary, secondary and tertiary intervention strategies to fight obesity in children, as shown by the diagrams below:

Figure 7: Primary, Secondary and Tertiary intervention for childhood obesity, compared to staged approach; source: (Hoelscher et al. 2013).

Figure 8: Summary of recommendations for primary intervention; source: (Hoelscher et al. 2013).

With an overview of the various significant hazards associated with obesity and childhood and pediatric obesity related to lifestyle and preventable causes, it seems valid that an increased effort must be given to eradicate this preventable source of morbidity and mortality seen globally. As Pandita et al. (2016) points out that “prevention is better than cure” when it comes to childhood obesity. The preventative measure can be primordial (that aims to maintain a normal BMI through the life of the child), primary (aimed to prevent obesity in overweight children), and secondary (treating obesity to reverse the condition or reduce the co morbidities). The measures can be implemented at different stages of a child’s life: Perinatal, Infancy, Preschool, Childhood and Adolescence.

Chirban (2011) points towards the study by CDC that predicted that by 2050, more than 30% of the population will be suffering from diabetes, which can be attributed to an alarming rise of obesity seen worldwide. This will also lead to a significant economic burden, due to treatment costs as well as due to loss of employment and manpower

Given the higher efficacy of preventative measures of obesity, it can therefore be suggested that only with an increased involvement of the government, authorities and the public, and with more revenues for further studies on this disease, the burden of the disease can be lowered significantly and effectively, and help the children live a healthier life.

References:

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Bell, J.A., Kivimaki, M. and Hamer, M., 2014. Metabolically healthy obesity and risk of incident type 2 diabetes: a meta?analysis of prospective cohort studies. Obesity reviews, 15(6), pp.504-515.

Blundell, J.E., Baker, J.L., Boyland, E., Blaak, E., Charzewska, J., de Henauw, S., Frühbeck, G., Gonzalez-Gross, M., Hebebrand, J., Holm, L. and Kriaucioniene, V., 2017. Variations in the Prevalence of Obesity Among European Countries, and a Consideration of Possible Causes. Obesity Facts, 10(1), pp.25-37.

Broussard, J.L. and Van Cauter, E., 2016. Disturbances of sleep and circadian rhythms: novel risk factors for obesity. Current Opinion in Endocrinology, Diabetes and Obesity, 23(5), pp.353-359.

Carey, F.R., Khang, Y.H., Hendriks, A.M., Reifsnider, E., Walsh, A.D. and Douglas, F., 2016. Advances in Childhood Obesity. Advances in Childhood Obesity, p.311.

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