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Practical Application of the Nutrition Recommendations

for the Prevention and Treatment of Obesity in Pediatric Primary Care

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EDUCATIONAL OBJECTIVES

1. Identify the nutrition recommendations for the prevention and treatment of childhood overweight and obesity. 2. Discuss the best use of behavioral strategies to implement changes in nutrition and feeding behaviors. 3. Dene the major challenges to adhering to nutrition recommendations and provide strategies to address these challenges. Elizabeth Prout Parks, MD, is a Fellow in Nutrition, The Childrens Hospital of Philadelphia. Shiriki Kumanyika, PhD, MPH, is with the University of Pennsylvania School of Medicine. Nicolas Stettler, MD, MSCE, is with the The Childrens Hospital of Philadelphia, and University of Pennsylvania School of Medicine. Address correspondence to: Elizabeth Prout Parks, MD, The Childrens Hospital of Philadelphia, 3535 Market St., Ste. 1587, Philadelphia, PA 19104; or fax: 215-5900604; or e-mail proute@email.chop.edu. Dr. Prout has disclosed no relevant nancial relationships. doi: 10.3928/00904481-20100223-05

hildhood obesity is epidemic and has tripled over the past 3 decades, making the need for effective prevention and treatment strategies of paramount importance.1 Major targets for prevention and treatment of childhood obesity include nutrition and feeding be-

haviors, physical activity, and sedentary behavior.2 Recommendations for physical activity and sedentary behavior have been reviewed elsewhere in this series.3,4 This article focuses on the nutrition recommendations for the prevention and treatment of childhood overweight and obesity.

Elizabeth Prout Parks, MD; Shiriki Kumanyika, PhD, MPH; and Nicolas Stettler, MD, MSCE

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NUTRITION RECOMMENDATIONS The nutrition recommendations for the prevention of childhood overweight are equivalent to those for normal growth and development for healthy children and adolescents. The Dietary Guidelines for Americans 2005 provides recommendations for healthy nutrition,2 and the American Heart Association (AHA) provides guidelines for the prevention of cardiovascular disease in adults and children.5 Additionally, in 2005, the American Medical Association (AMA), in collaboration with the Health Resources and Services Administration and the Centers for Disease Control and Prevention (CDC), convened an Expert Committee charged with providing recommendations regarding the assessment, prevention, and treatment of childhood obesity.6 The new recommendations were based on current evidence, as well as clinical expertise when evidence did not exist.6 The sixth edition of the American Academy of Pediatrics (AAP) Pediatric Nutrition Handbook also provides guidelines regarding age-appropriate portion sizes and daily recommended amounts of specic food groups based on the Dietary Guidelines and MyPyramid.gov recommendations for a sedentary child.5,8 Additionally, for specic food and beverage portion sizes based on age, height, weight, and activity level of children, parents can be referred to www.mypyramid. gov. AHA nutrition guidelines, the Dietary Guidelines for Americans 2005, and the Expert Committee nutrition recommendations for the prevention of childhood obesity are highly congruent and have, therefore, been combined in the Sidebar (see page 149). Evaluation of whether families are adhering to these dietary and feeding guidelines listed in the Sidebar should be included during every well-child visit.6 NUTRITION AND FEEDING RECOMMENDATIONS FOR THE PREVENTION OF OBESITY Obesity prevention is a priority for overweight children (BMI 85th percentile and < 95th percentile) and of children of obese parents. The recommendations focus on specic behaviors, some of which are added to the guidelines for children in the general population. The goal of therapy is to maintain weight as the child grows in height for younger children or to facilitate slow weight loss in adolescents (1 lb/mo).6 and fruits daily. Remind families that frozen and canned vegetables (without added sauces, salt or sugar) can be used in addition to fresh. Parents should serve vegetables and fruits with meals and for snacks. Children should consume no more than two fruits per day; make the rest vegetables (see www.MyPyramid. gov).5,6 Fruits and vegetables are high in ber and are thought to displace high energy-dense (high sugar or high fat) foods in the diet.6 Additionally fruits and vegetables contain vitamins, minerals, and phytochemicals thought to be helpful in lowering blood pressure and preventing other chronic diseases.2,13 Fruit juices do not have the same benecial effects as intact fruit because juice has concentrated calories similar to sugar sweetened beverages and lacks the ber and many other important nutrients. Limit the consumption of sugarsweetened beverages (SSB). SSB are a major source of energy intake in adolescents.14 SSB have been strongly linked to an increased BMI.16 SSB add calories without inducing satiety.15 Encourage families to remove SSB, including soda, sports drinks, and juice drinks, from the house.6 Recommend replacement with skim or 1% milk, water, and other non-caloric beverages. Additionally, encourage parents not to drink SSB in front of the children. Prepare more meals at home rather than purchasing restaurant food.6 Meals purchased outside of the home tend to be energy-dense and have large portions.16 Additionally, these meals tend to be consumed with sugar-sweetened beverages.17 Remind parents that meals at home can be simple and quick (eg, soup and sandwich). Eat at the table as a family ve to six times per week with the television turned off. Family meals are associated with lower saturated and trans fat intake, lower intakes of sugar-sweetened beverage consumption, and increased consumption of fruits and vegetables.18 Eat-

Meals purchased outside of the home tend to be energy-dense and have large portions.
Table 1 (see page 150) provides age-specic nutrition and feeding recommendations for obesity prevention during the well-child visit and tips for implementing dietary guidelines. Breastfeed exclusively for 6 months and continue breastfeeding for up to 1 year and beyond.6,7 Prenatal breastfeeding education and lactation support in the hospital, and during the rst 2 weeks postpartum should be provided, especially for mothers who are obese or are at a higher risk for having difculty breastfeeding. As mothers do not see their obstetrician until 6 weeks post-partum, breastfeeding is a pediatric issue.12 Support for the continuation of breastfeeding and plans for returning to work should be discussed during the prenatal visit and the early well-child visits.12 Encourage the consumption of ve or more servings of vegetables

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ing in front of the television is associated with higher energy intakes.19 Consume a healthy breakfast every day. If a child skips breakfast, evaluate the reason. Determine if the child is full from staying up late and eating at night. Evaluate for frequent nighttime awakenings secondary to restless sleep from obstructive sleep apnea. Patients with obstructive sleep apnea who also had night eating were shown to discontinue night eating after the obstructive apnea was treated.20 In older children, negotiate removal of naps and an earlier bedtime. If the reason for skipping breakfast is lack of time, provide quick, healthy, on-the go breakfast ideas, such as those provided by the U.S. Department of Agriculture (USDA) on its Website: www. fns.usda.gov/TN/Resources/EatSmart/ start_smart.pdf. Involve the whole family in lifestyle changes. As opposed to other childhood diseases, where lifestyle changes are an adjunct to a pharmaceutical treatment, the treatment for obesity is the lifestyle change. Additionally, rather than the primary focus of treatment centering on the child with added parental support, a more successful approach is to target the family as a whole.21 In fact, obesity treatment interventions directed toward the parents alone were found to be equally effective as interventions directed toward the family and the child if the child is prepubertal and to be superior to interventions directed toward the child.22 All aspects of the nutrition recommendations whether intended to promote normal growth and development, to prevent diabetes in high-risk children, or to treat childhood obesity should center on the family. Allow the child to self-regulate the quantity of food ingested; parents should avoid overly restrictive feeding behaviors. Parental restriction of childrens food intake during meals is associated with overeating when children are not hungry in between meals.23 Parents should provide well-balanced, portion-controlled meals, but how much of the food that is consumed should be left up to the child.24 Eat a diet rich in calcium. Appropriate calcium intake is important for bone health and is frequently not achieved by children and adolescents. Diets low in calcium have been associated with higher adiposity and with high blood pressure in children,25 although it is not clear whether this association is causal. NUTRITIONAL TREATMENT OF OBESE CHILDREN AND THEIR FAMILIES Obese children (BMI 95th percentile) and overweight children with an obesity-related comorbidity (elevated cholesterol 200 mg/dL, elevated LDL cholesterol > 110 mg/dL, elevated liver enzymes more than twice the upper limit of normal, or a diagnosis of nonalcoholic fatty liver disease [NAFLD], hypertension, obstructive sleep apnea [OSA], impaired glucose tolerance [pre-diabetes], type 2 diabetes, polycystic ovary syndrome) require structured weight management with the goal of weight loss (no more than 2 lb/wk).6 In addition to physical activity and sedentary behavior goals described elsewhere,3,4 this weight loss requires an eating plan with balanced macronutrients and controlled portions. For many children, enforcing portioncontrolled eating of three meals and one to two snacks (depending on the age) will result in weight loss, because this will result in a signicant reduction in calorie intake. Other children will require a specic reduced-calorie eating plan under the guidance of a nutritionist.6 BEHAVIOR MODIFICATION Preliminary studies have shown motivational interviewing to be an effective strategy in pediatric primary care for the management of obesity.26 Motivational interviewing (MI) allows families to evaluate necessary changes

SIDEBAR.

Nutrition Guidelines for Prevention of Obesity and Related Risk Factors

Encourage exclusive breastfeeding up to 6 months and maintenance of breastfeeding up to 12 months and beyond7 Avoid intake of calories in excess to what is recommended for age8 Limit portion sizes Choose a variety of vegetables and fruits each day and limit juice intake Choose from each of the subgroups of vegetables (dark green, orange, legumes, starchy, and all other) Make half of all your grains whole grains, and eat a diet high in ber Eat a diet rich in calcium. Children 2 to 8 years should consume two cups of fat-free milk or low-fat milk per day, and children older than 9 years should consume three cups (or equivalent). Keep total fat calorie intake to between 30% to 35% of all calories in children 2 to 3 years and between 25% to 30% in children 4 to 18 years Make most fats unsaturated fats from sh, nuts, vegetable oils, and soft margarines instead of butter and animal fats Limit the consumption of energy-dense foods Choose and prepare foods with little sugar and caloric sweeteners Limit the consumption of sugar-sweetened beverages Choose and prepare food with little salt and avoid salt from processed foods Eat breakfast daily Limit eating out at restaurants Consume family meals
Recommendations adapted from the Expert Committee Guidelines for the prevention of childhood obesity, The 2005 Dietary Guidelines for Americans, and the AHA Nutrition Recommendations for the Prevention of Cardiovascular Disease

and potential barriers to change, and how to overcome them. In addition, MI allows families to assess their level of condence in making a change and the

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TABLE 1.

Nutrition and Feeding Behaviors Points of Consideration by Age Group for Obesity Prevention
Age
Birth-6 months

Nutrition Recommendations
Breast milk only if possible; vitamin D supplement 400 IU/day for breastfed infants6 Introduce complementary foods; continue breastfeeding; avoid high salt, high fat, and high sugar foods; may introduce no more than 4-6 oz of 100% fruit juice in a cup served during a meal10 May introduce reduced fat milk11*; emphasize no soda or sugar-sweetened beverages; introduce a variety of vegetables and fruits Continue reduced fat milk; 3 meals and 2 snacks- at the table without television in the presence of a parent; Give no more than 6 oz of fruit juice per day Encourage correct portion sizes; see www. mypyramid.gov; 3 meals and 1 snack; give less than 12 oz of 100% fruit juice per day; 2 cups of low-fat milk or equivalent per day; encourage diet with high ber and whole grains 3 cups of low-fat milk or equivalent per day

Feeding Behaviors
Review hunger and satiety cues

6-11 months

Sit in high chair with back support at table with no television

> 12 months-toddler years

Healthy modeling of variety of foods by parents; eat meals at the table; wean bottle by 15 months17**; Parents decide what food and portion size served; toddler decides how much to eat

Preschool

Do not use food as reward or punishment

School age

Eat meals at the table with the television off; keep foods high in fat and sugar out of the house; have a healthy snack ready for afterschool

Adolescence

Watch for emotional eating, night eating, binge and purge behaviors

Adapted from Pediatric Obesity: Prevention, Intervention and Treatment Strategies for Primary Care unless otherwise indicated.8** Prolonged bottle feeding has been associated with increased BMI. Each additional month of bottle feeding past 15 months is associated with a 3% increase in the odds of being in a higher BMI category9 * A Finnish study that followed 1,032 infants from 7 months through age 13 years weaned infants from breast milk to skim milk supplemented with vegetable oil lowered BMI and cholesterol without any adverse effects on growth.10,11

level of importance of the behavioral change. Resources for formal training in motivational interviewing are available in the article by Schwartz (see page 154, and www.motivationalinterviewing.org/clinical/index.html). Even without special training, any provider can incorporate assessment of the stage of readiness to change (pre-contemplation, contemplation, preparation, action, maintenance),27 which is a key element of success in motivational interviewing. The role of the provider is to assess readiness to change and to attempt to motivate the patient to a higher level of change.26 When a family is ready for action, the provider can proceed through the steps for behavioral change listed below.

PRACTICAL STEPS Here are some practical steps for initiating lifestyle nutrition behavior change counseling in the overweight and obese child.6,8 1. Assess the nutrition and feeding behavior of family. 2. Assess readiness for change. 3. Allow child/family to decide which target behaviors they are willing to change. 4. Have the child/family establish specic goals for change. 5. Assess level of importance and condence of the child/family in making the change. 6. Summarize the nutritional behavior change plan and provide self-monitoring tools.

7. 8.

Discuss the role of the parent in behavioral change. Schedule a follow-up visit.

Nutrition Assessment Step 1 is to understand the daily routine and eating habits of the child and family.8,9 One approach is to ask for a 24-hour dietary recall, What did the patient eat and drink in the past 24 hours? Another approach is to ask about regular intake of food (eg, What do you usually eat for lunch?) When reviewing information from the 24-hour recall, important items for consideration in addition to the actual food and portion sizes include the following: Breakfast: yes/no at home/school or both

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Lunch: yes/no from home/school/both or other, presence of lunch sharing Snacks: when/how many-from home, convenience stores, fast-food or other Meals: as a family yes/no, prepared at home or outside of the house, who prepares the meals Feeding behaviors in child: presence of constant hunger, rapid eating, multiple helpings, constant snacking, hiding/sneaking foods, binge eating behaviors, nocturnal eating

is a 7 because she feels she can provide yogurt and fruit for her daughter easily but not a 9, as she is not sure her daughter will eat the yogurt. The level of condence (step 5) for the child is a 7, as she believes she can eat the yogurt and fruit on the way to school and not a 10 because she might forget. The scores help the family to put into words their ability and likelihood of mak-

Case Example Here is an example of a 24-hour recall and initial behavioral intervention for a 12-year-old girl with a BMI at the 97th percentile in a family that is motivated to make changes in behavior (step 2). Skipped breakfast Lunch: slice of cheese pizza, fruit cup, low-fat chocolate milk Home from school at 3:00. Snack: Ramen noodles, bag of chips, juice drink Nap for 1 hour Dinner at 6:30 p.m. cooked by grandmother: rice, stewed chicken, juice 8 p.m.: two scoops of ice cream Bedtime: 10 p.m. Based on this 24-hour recall, there are multiple areas for nutritional intervention to assist in implementing healthy eating behaviors, which include eating breakfast, eliminating the juice drink, increasing vegetable and fruit intake, increasing ber/whole grains in the diet, and eliminating/decreasing high saturated fats and salt in diet. Allow the family to decide on areas they are willing to work on (step 3). The child and her family decided on the behavior of skipping breakfast. She has specically agreed to eat yogurt and fruit for breakfast 5 days a week (step 4). On a scale of 1-10, family rates the importance of making the change to the childs eating breakfast as a 7 (step 5). It is not a 4 because she does not want to stay at her current weight. It is not a 9 because she is rushed in the morning. The level of condence for making the change for Mom

parent(s) their following potential roles in their childs weight management:28 Follow the same healthy eating plan as the child and model healthy eating behaviors. Buy healthy foods and remove highfat, high-sugar snacks and drinks from the house. Reward behavioral changes in the child (trip to the park; book/toy/comic; friend stay overnight). Schedule regular meal times with at least one parent eating with the child at the table. Teach children to eat when hungry and not to snack on food constantly. Monitor behavioral changes for younger children and encourage selfmonitoring in older children. Discourage eating while doing other activities, such as watching television, playing videogames, or doing homework. POPULAR DIETS AND EATING PLANS A review comparing low-fat diets, with low-carbohydrate diets, overall energy restriction diets, low glycemic index, and low glycemic load diets in children, reported that, although lowcarbohydrate, low glycemic index and low glycemic load diets resulted in more rapid weight loss during the rst 6 months, after 22 months, weightloss was equivalent in all groups.29 A dietary plan that has been successful in research studies is the Trafc Light Diet.30 A similar plan sponsored by the National Heart Lung and Blood Institute of the National Institutes of Health is We Can! (Ways to Enhance Childrens Activity and Fitness). We Can! categorizes foods as whoa foods (high sugar, high fat), slow foods (food that you can eat in moderation), and go foods (fruits and vegetables, high ber low-calorie foods). Resources for parents, community partnerships, and practitioners can be downloaded at http://wecan.nhlbi.nih.gov.

Teach children to eat when hungry and not to snack on food constantly.
ing the designated change now and give the provider the ability to help problem-solve ways to increase the familys condence or suggest a simplied behavioral change. Ratings of 4 or less indicate the family is probably not ready to make this change; scores of 7 or more are a strong indication that the family is ready for action.26 The family was given self-monitoring forms to record the days that the child met her goal of eating breakfast and was told to bring the forms with them to her follow-up appointment in 1 month (steps 6 and 7). Follow-up (step 8) is essential to the success of behavioral management. The provider should help families to recognize successes and to support and provide guidance for relapses in behavior. Additionally, it is helpful to discuss with the

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TABLE 2.

Family Challenges for Implementing Nutrition Recommendations

Type of Challenge
Many families do not eat together

Overcoming the Challenges

Agree that one adult will be present for one meal with child/adolescent daily Write down the plan and provide to all caregivers, if possible meet with all caregivers, or any caregiver resistant to plan Give simple, quick recipes Simplied plans, encouragement, and support Refer to community cooking classes Limit, not eliminate, energy dense foods; include motivational interviewing www.fruitsandveggiesmatter.gov/publications/index.html has suggestions for buying vegetables and fruits within restricted budgets Emphasis on health and motivation interviewing Refer for food stamps, WIC program, and food pantries Discuss limiting screen time; include motivational interviewing

Presence of multiple caregivers Frequent meals outside of the home Single -parent families and/or poor family support systems Limited cooking skills Hostile attitudes to healthy dietary patterns

Cost, mood and, convenience drive food choices rather than health Cultural and family beliefs about obesity Food insecurity Media/inuence of advertising

OVERCOMING CHALLENGES FOR IMPLEMENTING NUTRITION RECOMMENDATIONS The following are recommendations for overcoming some of the main feeding behavior challenges in the child or adolescent. Additional family challenges are highlighted in Table 2. Picky Eaters Encourage families to continue to introduce healthy foods and to recognize that children up to 10 years sometimes need up to 15 exposures of a food before accepting that new food.31,32 Hunger Schedule three meals and one to two snacks (dependent on the age) and increase high-ber foods. When children/ adolescents are hungry in between meals and snacks, use distraction rst: direct them to an activity. If they are still hungry, provide low-/zero-calorie foods (eg, sugar-free gelatin, popsicles made with non-caloric beverages).8

Rapid Eater/Multiple Portions Give half of the regular portion on the plate at a time; if the child is still hungry, provide vegetables.8 Shortened Sleep Duration Shortened sleep duration (SSD) is associated with childhood obesity.33 Causes of SSD include obstructive sleep apnea (OSA), night eating syndrome (NES), and television viewing.34 For adults, NES is dened by the consumption of more than 25% of the daily caloric intake after the evening meal and having nighttime awakenings for food at least twice a week for at least 3 months with feelings of distress.35 There is no consistent denition of NES for children. NES is associated with binge eating disorder (BED) dened by binge eating with feelings of loss of control and stress without any weight-reducing behaviors.36 Children with NES or BED should be referred to a psychologist. After medical causes for nocturnal eating have been considered, goals should be

eliminating daytime napping, removing the television from the bedroom, and negotiating an earlier bedtime.8,6 CONCLUSION Childhood obesity is epidemic. The nutrition recommendations for the prevention of childhood overweight are the same recommendations for healthy growth of children and adolescents. These recommendations are implemented with particular attention to supporting or establishing child and family behavior patterns that will avoid excess weight gain. Nutrition guidance in overweight children involves a nutrition assessment of the family, reinforcement of healthy nutrition, goal setting, and monitoring. Nutrition therapy for the obese child involves all of the above, plus a more structured meal plan. It is recommended that a dietitian or a clinician with specialized training in nutrition be consulted for reduced-calorie meal plans in children and adolescents.

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It is important to remember that nutrition is only one component of the prevention and treatment of childhood overweight and obesity. Other components of prevention include reducing sedentary behavior and increasing physical activity. For the complex obese child/adolescent with BMI 99th percentile (standards found on a chart)6 or with multiple comorbidities, a multidisciplinary team, consisting of an obesity specialist, nutritionist, psychologist, social worker, and exercise physiologist, should be assembled.8 The primary care pediatrician plays an important role in encouraging families to develop healthy eating habits by incorporating dietary guidelines into the family lifestyle and monitoring changes. REFERENCES
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Pediatrics. 2007;120(Suppl 4):S254-288. 5. Fogli-Cawley JJ, Dwyer JT, Saltzman E, McCullough ML, Troy LM, Jacques PF . The 2005 Dietary Guidelines for Americans Adherence Index: Development and Application. J Nutr. 2006;136(11):2908-2915. 6. Barlow SE, and Expert Committee. Expert Committee Recommendations regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight 14. and Obesity: Summary Report. Pediatrics. 2007;120(Suppl 4):S164-192. Gartner LM, Morton J, Lawrence RA, et al; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506. Kleinman RE, ed. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009. Hassink S. Pediatric Obesity: Prevention, Intervention, and Treatment Strategies for Primary Care. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics. 2001;107(5)1210-1213. Bonuck K, Kahn R, Schechter C. Is late bottleweaning associated with overweight in young children? Analysis of NHANES III Data. Clin Ped (Phila). 2004;43(6):535-540. Geraghty SR, Riddle SW, Shaikh U. The breastfeeding mother and the pediatrician. J Human Lact. 2008;24(3):335-339. Heimburger D C. Handbook of Clinical Nutrition. 4th ed. Philadelphia, PA: Mosby Elsevier Inc.; 2006. 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(6):e1604-1614. DellaValle, DM, Roe LS, Rolls BJ. Does the Consumption of caloric and non-caloric beverages with a meal affect energy intake? Appetite. 2005:44(2):187-193. Rosenheck R. Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk. 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Comparison of parent-only vs. family-based interventions for overweight children in underserved rural settings:outcomes from Project STORY. Arch Pediatr Adolesc Med. 2008;162(12):1119-1125. 23. Faith MS, Berkowitz RI, Stallings VA, Kerns J, Storey M, Stunkard AJ. Parental feeding attitudes and styles and child body mass index: prospective analysis of a gene-environment interaction. Pediatrics. 2004;114(4):e429. 24. Orlet Fisher J, Rolls NJ, Birch LL. Childrens bite size and intake of an entree are greater with large portions than with ageappropriate or self-selected portions. Am J Clin Nut. 2003;77(5):1164-1170. 25. Moore LL, Bradlee ML, Gao D, Singer MR. Low dairy intake in early childhood predicts excess body fat gain. Obesity (Silver Spring). 2006;14(6):1010-1018. 26. Schwartz RP, Hamre R, Dietz WH, et al. Ofce-based motivational interviewing to prevent childhood obesity: a feasibility study. Arch Ped Adolesc Med. 2007;161(5):495-501. 27. Resnicow K, Davis R, Rollnick S. Motivational interviewing for pediatric obesity: conceptual issues and evidence review. J Amer Diet Assoc. 2006;106(12):2024-2033. 28. Stewart L, Reilly JJ, Hughes AR. Evidencebased behavioral treatment of obesity in children and adolescents. Child Adolesc Psychiatr Clin North Am. 2009;18(1):189-198. 29. Gibson LJ, Peto J, Warren JM, dos Santos Silva I. Lack of evidence on diets for obesity for children: a systematic review. Intl Epidem. 2006;35(6):1544-1552. 30. Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics. 1988;101(3 Supple)):554-570. 31. Wardle J, Herrera ML, Cooke L, Gibson EL. Modifying childrens food preferences: the effects of exposure and reward on acceptance of an unfamiliar vegetable. Eur J Clin Nut. 2003;57(2):341-348. 32. Cooke L. The importance of exposure for healthy eating in childhood: a review. J Hum Nutr Diet. 2007;20(4):294-301. 33. Cappuccio FP, Taggart FM, Kandala NB, et al. 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