Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Definition; epidemiology; and etiology of obesity in children and adolescents

William J Klish, MD
Section Editors
Kathleen J Motil, MD, PhD
Mitchell E Geffner, MD
Deputy Editor
Alison G Hoppin, MD


Obesity has become one of the most important public health problems in the United States and many other resource-rich countries and transitional economies [1-3]. As the prevalence of obesity increased, so did the prevalence of the comorbidities associated with obesity [3]. For this reason, it is imperative that health care providers identify overweight and obese children so that counseling and treatment can be provided.

The definition, epidemiology, and etiology of obesity in children and adolescents will be presented here. Comorbidities of obesity in children and adolescents and the clinical evaluation of the obese child or adolescent are discussed separately. (See "Comorbidities and complications of obesity in children and adolescents" and "Clinical evaluation of the obese child and adolescent".)


The term "obesity" refers to an excess of fat. However, the methods used to directly measure body fat are not available in daily practice. For this reason, obesity usually is assessed by the relationship between weight and height (ie, anthropometrics), which provides an estimate of body fat that is sufficiently accurate for clinical purposes.

The body mass index (BMI) is the accepted standard measure of overweight and obesity for children two years of age and older [4]. BMI provides a guideline for weight in relation to height and is equal to the body weight (in kilograms) divided by the height (in meters) squared (table 1). Other measures of childhood obesity, including weight-for-height (which is particularly useful for the child younger than two years), measures of regional fat distribution (eg, waist circumference and waist-to-hip ratio), and the growth standards developed by the World Health Organization (WHO), are discussed separately. (See "Measurement of body composition in children" and "Measurement of growth in children", section on 'Growth standards'.)

Adults with a BMI between 25 and 30 kg/m2 are considered overweight; those with a BMI ≥30 kg/m2 are considered to be obese. Obesity in adults is subcategorized as class I (BMI ≥30 to 35), class II (BMI ≥35 to 40), and class III (BMI ≥40). Because children grow in height as well as weight, the norms for BMI in children vary with age and sex. In 2000, the National Center for Health Care Statistics and the Centers for Disease Control (CDC) published BMI reference standards for children between the ages of 2 and 20 years (figure 1A-B). BMI percentiles also can be determined using a calculator for boys (calculator 1) and for girls (calculator 2). As children approach adulthood, the 85th and 95th percentiles for BMI are approximately 25 and 30 kg/m2, the thresholds for overweight and obesity in adults, respectively [5].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 07, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA 2001; 286:2845.
  2. Ogden CL, Carroll MD, Lawman HG, et al. Trends in Obesity Prevalence Among Children and Adolescents in the United States, 1988-1994 Through 2013-2014. JAMA 2016; 315:2292.
  3. GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH, et al. Health Effects of Overweight and Obesity in 195 Countries over 25 Years. N Engl J Med 2017; 377:13.
  4. Deurenberg P, Weststrate JA, Seidell JC. Body mass index as a measure of body fatness: age- and sex-specific prediction formulas. Br J Nutr 1991; 65:105.
  5. Baker S, Barlow S, Cochran W, et al. Overweight children and adolescents: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005; 40:533.
  6. Kelly AS, Barlow SE, Rao G, et al. Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association. Circulation 2013; 128:1689.
  7. Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity in US children, 1999-2014. Obesity (Silver Spring) 2016; 24:1116.
  8. Flegal KM, Wei R, Ogden CL, et al. Characterizing extreme values of body mass index-for-age by using the 2000 Centers for Disease Control and Prevention growth charts. Am J Clin Nutr 2009; 90:1314.
  9. Gulati AK, Kaplan DW, Daniels SR. Clinical tracking of severely obese children: a new growth chart. Pediatrics 2012; 130:1136.
  10. Freedman DS, Butte NF, Taveras EM, et al. The Limitations of Transforming Very High Body Mass Indexes into z-Scores among 8.7 Million 2- to 4-Year-Old Children. J Pediatr 2017; 188:50.
  11. Freedman DS, Butte NF, Taveras EM, et al. BMI z-Scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014. Obesity (Silver Spring) 2017; 25:739.
  12. Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr 2007; 150:12.
  13. Skelton JA, Cook SR, Auinger P, et al. Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr 2009; 9:322.
  14. Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120 Suppl 4:S164.
  15. Pan L, Blanck HM, Sherry B, et al. Trends in the prevalence of extreme obesity among US preschool-aged children living in low-income families, 1998-2010. JAMA 2012; 308:2563.
  16. Anderson SE, Whitaker RC. Prevalence of obesity among US preschool children in different racial and ethnic groups. Arch Pediatr Adolesc Med 2009; 163:344.
  17. Centers for Disease Control and Prevention (CDC). Obesity prevalence among low-income, preschool-aged children - United States, 1998-2008. MMWR Morb Mortal Wkly Rep 2009; 58:769.
  18. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 337:869.
  19. Eagle TF, Sheetz A, Gurm R, et al. Understanding childhood obesity in America: linkages between household income, community resources, and children's behaviors. Am Heart J 2012; 163:836.
  20. Neovius M, Linné Y, Barkeling B, Rössner S. Discrepancies between classification systems of childhood obesity. Obes Rev 2004; 5:105.
  21. Wang Y. Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. Int J Epidemiol 2001; 30:1129.
  22. Janssen I, Katzmarzyk PT, Boyce WF, et al. Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes Rev 2005; 6:123.
  23. World Obesity Federation, World Map of Obesity. Available at: http://www.worldobesity.org/aboutobesity/world-map-obesity/?map=children (Accessed on May 05, 2015).
  24. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA 2002; 288:1728.
  25. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311:806.
  26. Centers for Disease Control and Prevention (CDC). Vital signs: obesity among low-income, preschool-aged children--United States, 2008-2011. MMWR Morb Mortal Wkly Rep 2013; 62:629.
  27. Pan L, Freedman DS, Sharma AJ, et al. Trends in Obesity Among Participants Aged 2-4 Years in the Special Supplemental Nutrition Program for Women, Infants, and Children - United States, 2000-2014. MMWR Morb Mortal Wkly Rep 2016; 65:1256.
  28. Kern E, Chan NL, Fleming DW, et al. Declines in student obesity prevalence associated with a prevention initiative - King County, Washington, 2012. MMWR Morb Mortal Wkly Rep 2014; 63:155.
  29. Wen X, Gillman MW, Rifas-Shiman SL, et al. Decreasing prevalence of obesity among young children in Massachusetts from 2004 to 2008. Pediatrics 2012; 129:823.
  30. Centers for Disease Control and Prevention (CDC). Obesity in K-8 students - New York City, 2006-07 to 2010-11 school years. MMWR Morb Mortal Wkly Rep 2011; 60:1673.
  31. Centers for Disease Control and Prevention (CDC). Obesity prevalence among low-income, preschool-aged children--New York City and Los Angeles County, 2003-2011. MMWR Morb Mortal Wkly Rep 2013; 62:17.
  32. Centers for Disease Control and Prevention (CDC). Obesity in K-7 students - Anchorage, Alaska, 2003-04 to 2010-11 school years. MMWR Morb Mortal Wkly Rep 2013; 62:426.
  33. Olds TS, Tomkinson GR, Ferrar KE, Maher CA. Trends in the prevalence of childhood overweight and obesity in Australia between 1985 and 2008. Int J Obes (Lond) 2010; 34:57.
  34. Salanave B, Peneau S, Rolland-Cachera MF, et al. Stabilization of overweight prevalence in French children between 2000 and 2007. Int J Pediatr Obes 2009; 4:66.
  35. Aeberli I, Ammann RS, Knabenhans M, et al. Decrease in the prevalence of paediatric adiposity in Switzerland from 2002 to 2007. Public Health Nutr 2010; 13:806.
  36. Rodd C, Sharma AK. Recent trends in the prevalence of overweight and obesity among Canadian children. CMAJ 2016; 188:E313.
  37. Gluckman P, Nishtar S, Armstrong T. Ending childhood obesity: a multidimensional challenge. Lancet 2015; 385:1048.
  38. World Health Organization. Obesity and overweight, Fact sheet #311. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/ (Accessed on March 26, 2015).
  39. Dietz WH, Robinson TN. Clinical practice. Overweight children and adolescents. N Engl J Med 2005; 352:2100.
  40. Wang G, Dietz WH. Economic burden of obesity in youths aged 6 to 17 years: 1979-1999. Pediatrics 2002; 109:E81.
  41. Guo SS, Roche AF, Chumlea WC, et al. The predictive value of childhood body mass index values for overweight at age 35 y. Am J Clin Nutr 1994; 59:810.
  42. Power C, Lake JK, Cole TJ. Body mass index and height from childhood to adulthood in the 1958 British born cohort. Am J Clin Nutr 1997; 66:1094.
  43. Parsons TJ, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord 1999; 23 Suppl 8:S1.
  44. Reilly JJ, Methven E, McDowell ZC, et al. Health consequences of obesity. Arch Dis Child 2003; 88:748.
  45. Rudolf M. Predicting babies' risk of obesity. Arch Dis Child 2011; 96:995.
  46. 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.
  47. Cunningham SA, Kramer MR, Narayan KM. Incidence of childhood obesity in the United States. N Engl J Med 2014; 370:403.
  48. Mead E, Batterham AM, Atkinson G, Ells LJ. Predicting future weight status from measurements made in early childhood: a novel longitudinal approach applied to Millennium Cohort Study data. Nutr Diabetes 2016; 6:e200.
  49. Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med 2011; 365:1876.
  50. Watts AW, Loth KA, Peterson C, et al. Characteristics of a Favorable Weight Status Change From Adolescence to Young Adulthood. J Adolesc Health 2016; 58:403.
  51. The NS, Suchindran C, North KE, et al. Association of adolescent obesity with risk of severe obesity in adulthood. JAMA 2010; 304:2042.
  52. Garn SM, Cole PE. Do the obese remain obese and the lean remain lean? Am J Public Health 1980; 70:351.
  53. Mellits ED, Cheek DB. The assessment of body water and fatness from infancy to adulthood. Monogr Soc Res Child Dev 1970; 35:12.
  54. Deshmukh-Taskar P, Nicklas TA, Morales M, et al. Tracking of overweight status from childhood to young adulthood: the Bogalusa Heart Study. Eur J Clin Nutr 2006; 60:48.
  55. Herman KM, Craig CL, Gauvin L, Katzmarzyk PT. Tracking of obesity and physical activity from childhood to adulthood: the Physical Activity Longitudinal Study. Int J Pediatr Obes 2009; 4:281.
  56. Patton GC, Coffey C, Carlin JB, et al. Overweight and obesity between adolescence and young adulthood: a 10-year prospective cohort study. J Adolesc Health 2011; 48:275.
  57. Plachta-Danielzik S, Kehden B, Landsberg B, et al. Attributable risks for childhood overweight: evidence for limited effectiveness of prevention. Pediatrics 2012; 130:e865.
  58. Taber DR, Chriqui JF, Powell L, Chaloupka FJ. Association between state laws governing school meal nutrition content and student weight status: implications for new USDA school meal standards. JAMA Pediatr 2013; 167:513.
  59. Anderson SE, Whitaker RC. Household routines and obesity in US preschool-aged children. Pediatrics 2010; 125:420.
  60. Bremer AA, Auinger P, Byrd RS. Relationship between insulin resistance-associated metabolic parameters and anthropometric measurements with sugar-sweetened beverage intake and physical activity levels in US adolescents: findings from the 1999-2004 National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med 2009; 163:328.
  61. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006; 84:274.
  62. Berkey CS, Rockett HR, Field AE, et al. Sugar-added beverages and adolescent weight change. Obes Res 2004; 12:778.
  63. Ebbeling CB, Feldman HA, Osganian SK, et al. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006; 117:673.
  64. Dowda M, Ainsworth BE, Addy CL, et al. Environmental influences, physical activity, and weight status in 8- to 16-year-olds. Arch Pediatr Adolesc Med 2001; 155:711.
  65. Menschik D, Ahmed S, Alexander MH, Blum RW. Adolescent physical activities as predictors of young adult weight. Arch Pediatr Adolesc Med 2008; 162:29.
  66. Levin S, Lowry R, Brown DR, Dietz WH. Physical activity and body mass index among US adolescents: youth risk behavior survey, 1999. Arch Pediatr Adolesc Med 2003; 157:816.
  67. Drake KM, Beach ML, Longacre MR, et al. Influence of sports, physical education, and active commuting to school on adolescent weight status. Pediatrics 2012; 130:e296.
  68. Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev 2011; :CD001871.
  69. Agency for Healthcare Research and Quality (AHRQ). Childhood Obesity Prevention Programs: Comparative Effectiveness Review and Meta-Analysis -- Final Report (No. 115). Available at: http://effectivehealthcare.ahrq.gov/ehc/products/330/1524/obesity-child-report-130610.pdf (Accessed on June 12, 2013).
  70. U.S. Department of Agriculture, Food and Nutrition Service. National School Lunch Program and School Breakfast Program: Nutrition Standards for All Foods sold in School as Required by the Healthy, hunger-Free Kids Act of 2010. Available at: http://www.gpo.gov/fdsys/pkg/FR-2013-06-28/pdf/2013-15249.pdf (Accessed on March 25, 2015).
  71. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at: http://health.gov/dietaryguidelines/2015/guidelines/ (Accessed on January 09, 2016).
  72. American Academy of Pediatrics Committee on School Health. Soft drinks in schools. Pediatrics 2004; 113:152.
  73. Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics 2011; 127:1182.
  74. Council on School Health, Committee on Nutrition. Snacks, sweetened beverages, added sugars, and schools. Pediatrics 2015; 135:575.
  75. Crepinsek MK, Gordon AR, McKinney PM, et al. Meals offered and served in US public schools: do they meet nutrient standards? J Am Diet Assoc 2009; 109:S31.
  76. American Beverage Association. Alliance School Beverage Guidelines: Final Progress Report. Washington, DC: American Beverage Association; March 8, 2010. Available at: https://www.healthiergeneration.org/_asset/qm41p9/SBG-FINAL-PROGRESS-REPORT-March-2010.pdf (Accessed on March 25, 2015).
  77. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr 2013; 98:1084.
  78. DeBoer MD, Scharf RJ, Demmer RT. Sugar-sweetened beverages and weight gain in 2- to 5-year-old children. Pediatrics 2013; 132:413.
  79. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics 2008; 121:e1604.
  80. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med 2012; 367:1407.
  81. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med 2012; 367:1397.
  82. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk of obesity. N Engl J Med 2012; 367:1387.
  83. Farley TA. The role of government in preventing excess calorie consumption: the example of New York City. JAMA 2012; 308:1093.
  84. Elbel B, Cantor J, Mijanovich T. Potential effect of the New York City policy regarding sugared beverages. N Engl J Med 2012; 367:680.
  85. Turner L, Chaloupka FJ. Encouraging trends in student access to competitive beverages in US public elementary schools, 2006-2007 to 2010-2011. Arch Pediatr Adolesc Med 2012; 166:673.
  86. Pomeranz JL, Brownell KD. Portion sizes and beyond--government's legal authority to regulate food-industry practices. N Engl J Med 2012; 367:1383.
  87. Briggs AD, Mytton OT, Kehlbacher A, et al. Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. BMJ 2013; 347:f6189.
  88. Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugar-sweetened beverage consumption, and obesity risk. Pediatrics 2013; 131:14.
  89. Grimes CA, Wright JD, Liu K, et al. Dietary sodium intake is associated with total fluid and sugar-sweetened beverage consumption in US children and adolescents aged 2-18 y: NHANES 2005-2008. Am J Clin Nutr 2013; 98:189.
  90. Dietz WH Jr, Gortmaker SL. Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics 1985; 75:807.
  91. Kaur H, Choi WS, Mayo MS, Harris KJ. Duration of television watching is associated with increased body mass index. J Pediatr 2003; 143:506.
  92. Berkey CS, Rockett HR, Gillman MW, Colditz GA. One-year changes in activity and in inactivity among 10- to 15-year-old boys and girls: relationship to change in body mass index. Pediatrics 2003; 111:836.
  93. Braithwaite I, Stewart AW, Hancox RJ, et al. The worldwide association between television viewing and obesity in children and adolescents: cross sectional study. PLoS One 2013; 8:e74263.
  94. Falbe J, Rosner B, Willett WC, et al. Adiposity and different types of screen time. Pediatrics 2013; 132:e1497.
  95. Gilbert-Diamond D, Li Z, Adachi-Mejia AM, et al. Association of a television in the bedroom with increased adiposity gain in a nationally representative sample of children and adolescents. JAMA Pediatr 2014; 168:427.
  96. Heilmann A, Rouxel P, Fitzsimons E, et al. Longitudinal associations between television in the bedroom and body fatness in a UK cohort study. Int J Obes (Lond) 2017; 41:1503.
  97. Marshall SJ, Biddle SJ, Gorely T, et al. Relationships between media use, body fatness and physical activity in children and youth: a meta-analysis. Int J Obes Relat Metab Disord 2004; 28:1238.
  98. Wake M, Hesketh K, Waters E. Television, computer use and body mass index in Australian primary school children. J Paediatr Child Health 2003; 39:130.
  99. Wahi G, Parkin PC, Beyene J, et al. Effectiveness of interventions aimed at reducing screen time in children: a systematic review and meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 2011; 165:979.
  100. Hancox RJ, Milne BJ, Poulton R. Association between child and adolescent television viewing and adult health: a longitudinal birth cohort study. Lancet 2004; 364:257.
  101. Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass index. J Pediatr 2005; 147:429.
  102. Ludwig DS, Gortmaker SL. Programming obesity in childhood. Lancet 2004; 364:226.
  103. Epstein LH, Roemmich JN, Robinson JL, et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med 2008; 162:239.
  104. Boyland EJ, Harrold JA, Kirkham TC, et al. Food commercials increase preference for energy-dense foods, particularly in children who watch more television. Pediatrics 2011; 128:e93.
  105. Lipsky LM, Iannotti RJ. Associations of television viewing with eating behaviors in the 2009 Health Behaviour in School-aged Children Study. Arch Pediatr Adolesc Med 2012; 166:465.
  106. Epstein LH, Roemmich JN, Paluch RA, Raynor HA. Influence of changes in sedentary behavior on energy and macronutrient intake in youth. Am J Clin Nutr 2005; 81:361.
  107. Stettler N, Signer TM, Suter PM. Electronic games and environmental factors associated with childhood obesity in Switzerland. Obes Res 2004; 12:896.
  108. Kautiainen S, Koivusilta L, Lintonen T, et al. Use of information and communication technology and prevalence of overweight and obesity among adolescents. Int J Obes (Lond) 2005; 29:925.
  109. Bickham DS, Blood EA, Walls CE, et al. Characteristics of screen media use associated with higher BMI in young adolescents. Pediatrics 2013; 131:935.
  110. Dance Dance Revolution Ultramix 3. Konami, Tokyo, Japan www.musicineverydirection.com (Accessed on June 04, 2007).
  111. Lanningham-Foster L, Jensen TB, Foster RC, et al. Energy expenditure of sedentary screen time compared with active screen time for children. Pediatrics 2006; 118:e1831.
  112. Mellecker RR, McManus AM. Energy expenditure and cardiovascular responses to seated and active gaming in children. Arch Pediatr Adolesc Med 2008; 162:886.
  113. Graf DL, Pratt LV, Hester CN, Short KR. Playing active video games increases energy expenditure in children. Pediatrics 2009; 124:534.
  114. Biddiss E, Irwin J. Active video games to promote physical activity in children and youth: a systematic review. Arch Pediatr Adolesc Med 2010; 164:664.
  115. O'Loughlin EK, Dugas EN, Sabiston CM, O'Loughlin JL. Prevalence and correlates of exergaming in youth. Pediatrics 2012; 130:806.
  116. Graves L, Stratton G, Ridgers ND, Cable NT. Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross sectional study. BMJ 2007; 335:1282.
  117. Bailey BW, McInnis K. Energy cost of exergaming: a comparison of the energy cost of 6 forms of exergaming. Arch Pediatr Adolesc Med 2011; 165:597.
  118. Madsen KA, Yen S, Wlasiuk L, et al. Feasibility of a dance videogame to promote weight loss among overweight children and adolescents. Arch Pediatr Adolesc Med 2007; 161:105.
  119. Christison A, Khan HA. Exergaming for health: a community-based pediatric weight management program using active video gaming. Clin Pediatr (Phila) 2012; 51:382.
  120. Trost SG, Sundal D, Foster GD, et al. Effects of a pediatric weight management program with and without active video games a randomized trial. JAMA Pediatr 2014; 168:407.
  121. Chaput JP, Tremblay A. Does short sleep duration favor abdominal adiposity in children? Int J Pediatr Obes 2007; 2:188.
  122. Flint J, Kothare SV, Zihlif M, et al. Association between inadequate sleep and insulin resistance in obese children. J Pediatr 2007; 150:364.
  123. Sekine M, Yamagami T, Handa K, et al. A dose-response relationship between short sleeping hours and childhood obesity: results of the Toyama Birth Cohort Study. Child Care Health Dev 2002; 28:163.
  124. Jiang F, Zhu S, Yan C, et al. Sleep and obesity in preschool children. J Pediatr 2009; 154:814.
  125. Altenburg TM, Chinapaw MJ, van der Knaap ET, et al. Longer sleep--slimmer kids: the ENERGY-project. PLoS One 2013; 8:e59522.
  126. Collings PJ, Ball HL, Santorelli G, et al. Sleep Duration and Adiposity in Early Childhood: Evidence for Bidirectional Associations from the Born in Bradford Study. Sleep 2017; 40.
  127. Bayer O, Rosario AS, Wabitsch M, von Kries R. Sleep duration and obesity in children: is the association dependent on age and choice of the outcome parameter? Sleep 2009; 32:1183.
  128. Cappuccio FP, Taggart FM, Kandala NB, et al. Meta-analysis of short sleep duration and obesity in children and adults. Sleep 2008; 31:619.
  129. Lumeng JC, Somashekar D, Appugliese D, et al. Shorter sleep duration is associated with increased risk for being overweight at ages 9 to 12 years. Pediatrics 2007; 120:1020.
  130. Landhuis CE, Poulton R, Welch D, Hancox RJ. Childhood sleep time and long-term risk for obesity: a 32-year prospective birth cohort study. Pediatrics 2008; 122:955.
  131. Touchette E, Petit D, Tremblay RE, et al. Associations between sleep duration patterns and overweight/obesity at age 6. Sleep 2008; 31:1507.
  132. Carter PJ, Taylor BJ, Williams SM, Taylor RW. Longitudinal analysis of sleep in relation to BMI and body fat in children: the FLAME study. BMJ 2011; 342:d2712.
  133. Araújo J, Severo M, Ramos E. Sleep duration and adiposity during adolescence. Pediatrics 2012; 130:e1146.
  134. Taveras EM, Gillman MW, Peña MM, et al. Chronic sleep curtailment and adiposity. Pediatrics 2014; 133:1013.
  135. Bonuck K, Chervin RD, Howe LD. Sleep-disordered breathing, sleep duration, and childhood overweight: a longitudinal cohort study. J Pediatr 2015; 166:632.
  136. Magee L, Hale L. Longitudinal associations between sleep duration and subsequent weight gain: a systematic review. Sleep Med Rev 2012; 16:231.
  137. Anderson SE, Andridge R, Whitaker RC. Bedtime in Preschool-Aged Children and Risk for Adolescent Obesity. J Pediatr 2016; 176:17.
  138. Wang F, Liu H, Wan Y, et al. Sleep Duration and Overweight/Obesity in Preschool-Aged Children: A Prospective Study of up to 48,922 Children of the Jiaxing Birth Cohort. Sleep 2016; 39:2013.
  139. Hart CN, Carskadon MA, Considine RV, et al. Changes in children's sleep duration on food intake, weight, and leptin. Pediatrics 2013; 132:e1473.
  140. Lesser DJ, Bhatia R, Tran WH, et al. Sleep fragmentation and intermittent hypoxemia are associated with decreased insulin sensitivity in obese adolescent Latino males. Pediatr Res 2012; 72:293.
  141. Koren D, Levitt Katz LE, Brar PC, et al. Sleep architecture and glucose and insulin homeostasis in obese adolescents. Diabetes Care 2011; 34:2442.
  142. Food and Drug Administration, changes to prescribing information for Zyprexa, released 1/4/2010 http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm198402.htm (Accessed on February 01, 2010).
  143. Angelakis E, Armougom F, Million M, Raoult D. The relationship between gut microbiota and weight gain in humans. Future Microbiol 2012; 7:91.
  144. Bäckhed F, Ding H, Wang T, et al. The gut microbiota as an environmental factor that regulates fat storage. Proc Natl Acad Sci U S A 2004; 101:15718.
  145. DiBaise JK, Zhang H, Crowell MD, et al. Gut microbiota and its possible relationship with obesity. Mayo Clin Proc 2008; 83:460.
  146. Kalliomäki M, Collado MC, Salminen S, Isolauri E. Early differences in fecal microbiota composition in children may predict overweight. Am J Clin Nutr 2008; 87:534.
  147. Jess T. Microbiota, antibiotics, and obesity. N Engl J Med 2014; 371:2526.
  148. Ridaura VK, Faith JJ, Rey FE, et al. Gut microbiota from twins discordant for obesity modulate metabolism in mice. Science 2013; 341:1241214.
  149. Cho I, Yamanishi S, Cox L, et al. Antibiotics in early life alter the murine colonic microbiome and adiposity. Nature 2012; 488:621.
  150. Cox LM, Yamanishi S, Sohn J, et al. Altering the intestinal microbiota during a critical developmental window has lasting metabolic consequences. Cell 2014; 158:705.
  151. Trasande L, Blustein J, Liu M, et al. Infant antibiotic exposures and early-life body mass. Int J Obes (Lond) 2013; 37:16.
  152. Ajslev TA, Andersen CS, Gamborg M, et al. Childhood overweight after establishment of the gut microbiota: the role of delivery mode, pre-pregnancy weight and early administration of antibiotics. Int J Obes (Lond) 2011; 35:522.
  153. Saari A, Virta LJ, Sankilampi U, et al. Antibiotic exposure in infancy and risk of being overweight in the first 24 months of life. Pediatrics 2015; 135:617.
  154. Dogra S, Sakwinska O, Soh SE, et al. Dynamics of infant gut microbiota are influenced by delivery mode and gestational duration and are associated with subsequent adiposity. MBio 2015; 6.
  155. Schwartz BS, Pollak J, Bailey-Davis L, et al. Antibiotic use and childhood body mass index trajectory. Int J Obes (Lond) 2016; 40:615.
  156. Gerber JS, Bryan M, Ross RK, et al. Antibiotic Exposure During the First 6 Months of Life and Weight Gain During Childhood. JAMA 2016; 315:1258.
  157. Liou AP, Paziuk M, Luevano JM Jr, et al. Conserved shifts in the gut microbiota due to gastric bypass reduce host weight and adiposity. Sci Transl Med 2013; 5:178ra41.
  158. Cho YM. A gut feeling to cure diabetes: potential mechanisms of diabetes remission after bariatric surgery. Diabetes Metab J 2014; 38:406.
  159. Tremaroli V, Karlsson F, Werling M, et al. Roux-en-Y Gastric Bypass and Vertical Banded Gastroplasty Induce Long-Term Changes on the Human Gut Microbiome Contributing to Fat Mass Regulation. Cell Metab 2015; 22:228.
  160. Suárez-Zamorano N, Fabbiano S, Chevalier C, et al. Microbiota depletion promotes browning of white adipose tissue and reduces obesity. Nat Med 2015; 21:1497.
  161. Turnbaugh PJ, Ley RE, Mahowald MA, et al. An obesity-associated gut microbiome with increased capacity for energy harvest. Nature 2006; 444:1027.
  162. Warner M, Wesselink A, Harley KG, et al. Prenatal exposure to dichlorodiphenyltrichloroethane and obesity at 9 years of age in the CHAMACOS study cohort. Am J Epidemiol 2014; 179:1312.
  163. Schecter A, Malik N, Haffner D, et al. Bisphenol A (BPA) in U.S. food. Environ Sci Technol 2010; 44:9425.
  164. Calafat AM, Ye X, Wong LY, et al. Exposure of the U.S. population to bisphenol A and 4-tertiary-octylphenol: 2003-2004. Environ Health Perspect 2008; 116:39.
  165. Takai Y, Tsutsumi O, Ikezuki Y, et al. Preimplantation exposure to bisphenol A advances postnatal development. Reprod Toxicol 2001; 15:71.
  166. Somm E, Schwitzgebel VM, Toulotte A, et al. Perinatal exposure to bisphenol a alters early adipogenesis in the rat. Environ Health Perspect 2009; 117:1549.
  167. Vom Saal FS, Nagel SC, Coe BL, et al. The estrogenic endocrine disrupting chemical bisphenol A (BPA) and obesity. Mol Cell Endocrinol 2012; 354:74.
  168. Carwile JL, Michels KB. Urinary bisphenol A and obesity: NHANES 2003-2006. Environ Res 2011; 111:825.
  169. Lang IA, Galloway TS, Scarlett A, et al. Association of urinary bisphenol A concentration with medical disorders and laboratory abnormalities in adults. JAMA 2008; 300:1303.
  170. Melzer D, Osborne NJ, Henley WE, et al. Urinary bisphenol A concentration and risk of future coronary artery disease in apparently healthy men and women. Circulation 2012; 125:1482.
  171. Trasande L, Attina TM, Blustein J. Association between urinary bisphenol A concentration and obesity prevalence in children and adolescents. JAMA 2012; 308:1113.
  172. Silventoinen K, Jelenkovic A, Sund R, et al. Genetic and environmental effects on body mass index from infancy to the onset of adulthood: an individual-based pooled analysis of 45 twin cohorts participating in the COllaborative project of Development of Anthropometrical measures in Twins (CODATwins) study. Am J Clin Nutr 2016; 104:371.
  173. Speiser PW, Rudolf MC, Anhalt H, et al. Childhood obesity. J Clin Endocrinol Metab 2005; 90:1871.
  174. Reinehr T, Hinney A, de Sousa G, et al. Definable somatic disorders in overweight children and adolescents. J Pediatr 2007; 150:618.
  175. Vaisse C, Clement K, Durand E, et al. Melanocortin-4 receptor mutations are a frequent and heterogeneous cause of morbid obesity. J Clin Invest 2000; 106:253.
  176. Dubern B, Bisbis S, Talbaoui H, et al. Homozygous null mutation of the melanocortin-4 receptor and severe early-onset obesity. J Pediatr 2007; 150:613.
  177. Vollbach H, Brandt S, Lahr G, et al. Prevalence and phenotypic characterization of MC4R variants in a large pediatric cohort. Int J Obes (Lond) 2017; 41:13.
  178. Farooqi IS, O'Rahilly S. 20 years of leptin: human disorders of leptin action. J Endocrinol 2014; 223:T63.
  179. Farooqi IS, Wangensteen T, Collins S, et al. Clinical and molecular genetic spectrum of congenital deficiency of the leptin receptor. N Engl J Med 2007; 356:237.
  180. Ozsu E, Ceylaner S, Onay H. Early-onset severe obesity due to complete deletion of the leptin gene in a boy. J Pediatr Endocrinol Metab 2017; 30:1227.
  181. Leibel RL, Chua SC, Rosenbaum M. Obesity. In: The Metabolic and Molecular Bases of Inherited Disease, 8th ed, Scriver CR, Beaudet AL, Sly WS, Valle D (Eds), McGraw-Hill, New York 2001. p.3965.
  182. Pediatric Obesity. In: Pediatric Nutrition Handbook, 6th ed, Kleinman R (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.733.
  183. Bougnères P, Pantalone L, Linglart A, et al. Endocrine manifestations of the rapid-onset obesity with hypoventilation, hypothalamic, autonomic dysregulation, and neural tumor syndrome in childhood. J Clin Endocrinol Metab 2008; 93:3971.
  184. Ize-Ludlow D, Gray JA, Sperling MA, et al. Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation presenting in childhood. Pediatrics 2007; 120:e179.
  185. Mantzoros CS, Rifas-Shiman SL, Williams CJ, et al. Cord blood leptin and adiponectin as predictors of adiposity in children at 3 years of age: a prospective cohort study. Pediatrics 2009; 123:682.
  186. Gillman MW, Ludwig DS. How early should obesity prevention start? N Engl J Med 2013; 369:2173.
  187. Chiavaroli V, Giannini C, D'Adamo E, et al. Insulin resistance and oxidative stress in children born small and large for gestational age. Pediatrics 2009; 124:695.
  188. Renom Espineira A, Fernandes-Rosa FL, Bueno AC, et al. Postnatal growth and cardiometabolic profile in young adults born large for gestational age. Clin Endocrinol (Oxf) 2011; 75:335.
  189. Efstathiou SP, Skeva II, Zorbala E, et al. Metabolic syndrome in adolescence: can it be predicted from natal and parental profile? The Prediction of Metabolic Syndrome in Adolescence (PREMA) study. Circulation 2012; 125:902.
  190. Wang G, Divall S, Radovick S, et al. Preterm birth and random plasma insulin levels at birth and in early childhood. JAMA 2014; 311:587.
  191. Huxley R, Owen CG, Whincup PH, et al. Is birth weight a risk factor for ischemic heart disease in later life? Am J Clin Nutr 2007; 85:1244.
  192. Barker DJ, Winter PD, Osmond C, et al. Weight in infancy and death from ischaemic heart disease. Lancet 1989; 2:577.
  193. Li Y, Ley SH, Tobias DK, et al. Birth weight and later life adherence to unhealthy lifestyles in predicting type 2 diabetes: prospective cohort study. BMJ 2015; 351:h3672.
  194. Wang N, Wang X, Han B, et al. Is Exposure to Famine in Childhood and Economic Development in Adulthood Associated With Diabetes? J Clin Endocrinol Metab 2015; 100:4514.
  195. Fernandez-Twinn DS, Ozanne SE. Mechanisms by which poor early growth programs type-2 diabetes, obesity and the metabolic syndrome. Physiol Behav 2006; 88:234.
  196. Plagemann A. Perinatal nutrition and hormone-dependent programming of food intake. Horm Res 2006; 65 Suppl 3:83.
  197. van Abeelen AF, Veenendaal MV, Painter RC, et al. Survival effects of prenatal famine exposure. Am J Clin Nutr 2012; 95:179.
  198. Ravelli AC, van Der Meulen JH, Osmond C, et al. Obesity at the age of 50 y in men and women exposed to famine prenatally. Am J Clin Nutr 1999; 70:811.
  199. Roseboom TJ, van der Meulen JH, Osmond C, et al. Plasma lipid profiles in adults after prenatal exposure to the Dutch famine. Am J Clin Nutr 2000; 72:1101.
  200. Roseboom T, de Rooij S, Painter R. The Dutch famine and its long-term consequences for adult health. Early Hum Dev 2006; 82:485.
  201. Ravelli AC, van der Meulen JH, Michels RP, et al. Glucose tolerance in adults after prenatal exposure to famine. Lancet 1998; 351:173.
  202. de Rooij SR, Painter RC, Roseboom TJ, et al. Glucose tolerance at age 58 and the decline of glucose tolerance in comparison with age 50 in people prenatally exposed to the Dutch famine. Diabetologia 2006; 49:637.
  203. Ludwig DS, Currie J. The association between pregnancy weight gain and birthweight: a within-family comparison. Lancet 2010; 376:984.
  204. Deierlein AL, Siega-Riz AM, Adair LS, Herring AH. Effects of pre-pregnancy body mass index and gestational weight gain on infant anthropometric outcomes. J Pediatr 2011; 158:221.
  205. Castillo H, Santos IS, Matijasevich A. Relationship between maternal pre-pregnancy body mass index, gestational weight gain and childhood fatness at 6-7 years by air displacement plethysmography. Matern Child Nutr 2015; 11:606.
  206. Lau EY, Liu J, Archer E, et al. Maternal weight gain in pregnancy and risk of obesity among offspring: a systematic review. J Obes 2014; 2014:524939.
  207. Sridhar SB, Darbinian J, Ehrlich SF, et al. Maternal gestational weight gain and offspring risk for childhood overweight or obesity. Am J Obstet Gynecol 2014; 211:259.e1.
  208. Richmond RC, Timpson NJ, Felix JF, et al. Using Genetic Variation to Explore the Causal Effect of Maternal Pregnancy Adiposity on Future Offspring Adiposity: A Mendelian Randomisation Study. PLoS Med 2017; 14:e1002221.
  209. Gillman MW, Rifas-Shiman SL, Fernandez-Barres S, et al. Beverage Intake During Pregnancy and Childhood Adiposity. Pediatrics 2017; 140.
  210. Kral JG, Biron S, Simard S, et al. Large maternal weight loss from obesity surgery prevents transmission of obesity to children who were followed for 2 to 18 years. Pediatrics 2006; 118:e1644.
  211. Davey Smith G, Steer C, Leary S, Ness A. Is there an intrauterine influence on obesity? Evidence from parent child associations in the Avon Longitudinal Study of Parents and Children (ALSPAC). Arch Dis Child 2007; 92:876.
  212. Azad MB, Sharma AK, de Souza RJ, et al. Association Between Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index. JAMA Pediatr 2016; 170:662.
  213. Lawlor DA, Lichtenstein P, Långström N. Association of maternal diabetes mellitus in pregnancy with offspring adiposity into early adulthood: sibling study in a prospective cohort of 280,866 men from 248,293 families. Circulation 2011; 123:258.
  214. Davis EF, Lazdam M, Lewandowski AJ, et al. Cardiovascular risk factors in children and young adults born to preeclamptic pregnancies: a systematic review. Pediatrics 2012; 129:e1552.
  215. Washburn L, Nixon P, Russell G, et al. Adiposity in adolescent offspring born prematurely to mothers with preeclampsia. J Pediatr 2013; 162:912.
  216. Seidman DS, Laor A, Gale R, et al. Pre-eclampsia and offspring's blood pressure, cognitive ability and physical development at 17-years-of-age. Br J Obstet Gynaecol 1991; 98:1009.
  217. Ogland B, Vatten LJ, Romundstad PR, et al. Pubertal anthropometry in sons and daughters of women with preeclamptic or normotensive pregnancies. Arch Dis Child 2009; 94:855.
  218. Ong KK, Northstone K, Wells JC, et al. Earlier mother's age at menarche predicts rapid infancy growth and childhood obesity. PLoS Med 2007; 4:e132.
  219. Fraser A, Tilling K, Macdonald-Wallis C, et al. Association of maternal weight gain in pregnancy with offspring obesity and metabolic and vascular traits in childhood. Circulation 2010; 121:2557.
  220. Taveras EM, Rifas-Shiman SL, Sherry B, et al. Crossing growth percentiles in infancy and risk of obesity in childhood. Arch Pediatr Adolesc Med 2011; 165:993.
  221. Smego A, Woo JG, Klein J, et al. High Body Mass Index in Infancy May Predict Severe Obesity in Early Childhood. J Pediatr 2017; 183:87.
  222. Leunissen RW, Kerkhof GF, Stijnen T, Hokken-Koelega A. Timing and tempo of first-year rapid growth in relation to cardiovascular and metabolic risk profile in early adulthood. JAMA 2009; 301:2234.
  223. Monteiro PO, Victora CG. Rapid growth in infancy and childhood and obesity in later life--a systematic review. Obes Rev 2005; 6:143.
  224. Ong KK, Loos RJ. Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions. Acta Paediatr 2006; 95:904.
  225. Owen CG, Martin RM, Whincup PH, et al. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 2005; 115:1367.
  226. Baird J, Fisher D, Lucas P, et al. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005; 331:929.
  227. Belfort MB, Rifas-Shiman SL, Rich-Edwards J, et al. Size at birth, infant growth, and blood pressure at three years of age. J Pediatr 2007; 151:670.
  228. Shehadeh N, Weitzer-Kish H, Shamir R, et al. Impact of early postnatal weight gain and feeding patterns on body mass index in adolescence. J Pediatr Endocrinol Metab 2008; 21:9.
  229. Gardner DS, Hosking J, Metcalf BS, et al. Contribution of early weight gain to childhood overweight and metabolic health: a longitudinal study (EarlyBird 36). Pediatrics 2009; 123:e67.
  230. Skilton MR, Marks GB, Ayer JG, et al. Weight gain in infancy and vascular risk factors in later childhood. Pediatrics 2013; 131:e1821.
  231. Koletzko B, von Kries R, Closa R, et al. Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial. Am J Clin Nutr 2009; 89:1836.
  232. Weber M, Grote V, Closa-Monasterolo R, et al. Lower protein content in infant formula reduces BMI and obesity risk at school age: follow-up of a randomized trial. Am J Clin Nutr 2014; 99:1041.
  233. Pimpin L, Jebb S, Johnson L, et al. Dietary protein intake is associated with body mass index and weight up to 5 y of age in a prospective cohort of twins. Am J Clin Nutr 2016; 103:389.
  234. Butte NF, Wong WW, Hopkinson JM, et al. Infant feeding mode affects early growth and body composition. Pediatrics 2000; 106:1355.
  235. Yeung MY. Postnatal growth, neurodevelopment and altered adiposity after preterm birth--from a clinical nutrition perspective. Acta Paediatr 2006; 95:909.
  236. Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. BMJ 1998; 317:1481.
  237. Thureen PJ. The neonatologist's dilemma: catch-up growth or beneficial undernutrition in very low birth weight infants-what are optimal growth rates? J Pediatr Gastroenterol Nutr 2007; 45 Suppl 3:S152.
  238. Kerkhof GF, Willemsen RH, Leunissen RW, et al. Health profile of young adults born preterm: negative effects of rapid weight gain in early life. J Clin Endocrinol Metab 2012; 97:4498.