WIC 113 Obese (Children 2-5 Years of Age)

Obesity for children 2-5 years of age is defined as follows:

*The cut off is based on standing height measurements. Therefore, recumbent length measurements may not be used to determine this risk. See Clarification for more information.

The rapid rise in the prevalence of obesity in children and adolescents is one of the most important public health issues in the United States today. The National Health and Nutrition Examination Survey (NHANES) from the mid-1960s to the early 2000s document a significant increase in obesity among children from preschool age through adolescence. These trends parallel a concurrent increase in obesity among adults, suggesting that fundamental shifts occurring in dietary and/or physical activity behaviors are having an adverse effect on overall energy balance (3).

The causes of increased obesity rates in the United States are complex. Both genetic make-up and environmental factors contribute to the obesity risk. Important contributors include a large and growing abundance of calorically dense foods and an increased sedentary lifestyle for all ages. Although obesity tends to run in families, a genetic predisposition does not inevitably result in obesity. Environmental and behavioral factors can influence the development of obesity in genetically at-risk people (3).

BMI is a measure of body weight adjusted for height. While not a direct measure of body fatness, BMI is a useful screening tool to assess adiposity (3). Children >2 years of age, with a BMI-for-age >85th and <95th percentile are considered overweight and those at or above the 95th percentile, obese (4). Research on BMI and body fatness shows that the majority of children with BMI-for-age at or above the 95th percentile have high adiposity and less than one-half of the children in the 85th to <95th percentiles have high adiposity (4). Although an imperfect tool, elevated BMI among children most often indicates increased risk for future adverse health outcomes and/or development of diseases (5). BMI should serve as the initial screen and as the starting point for classification of health risks (3).

Use of the 95th percentile to define obesity identifies those children with a greater likelihood of being obese as adolescents and adults, with increased risk of obesity-related disease and mortality. It is recommended that an obese child (>= 95th percentile) undergo a medical assessment and careful evaluation to identify any underlying health risks or secondary complications (3). Obesity can result from excessive energy intake, decreased energy expenditure, or a medical condition that impairs the regulation of energy metabolism. In addition, obesity in early childhood may signify problematic feeding practices or evolving family behaviors that, if continued, may contribute to health risks in adulthood related to diet and inactivity.

The Information System automatically assigns risk code 113 based on a child’s calculated BMI-for-age; however, the CPA must manually assess if the condition is high risk. The child’s growth should meet at least one of the following criteria to be considered high risk for this condition:

• BMI of ≥ 95% for age with a high rate of weight gain that does not follow a growth curve parallel to the recommended curve; or
• BMI of ≥ 95% for age with a weight gain of ≥ 5 pounds in the past 6 months; or
• BMI-for-age plots more than 2 squares above the 95% BMI-for-age channel line

The CPA may resolve the high risk status if the child does not meet at least one of the criteria listed above and the participant does not have any other high risk conditions. The reason for resolving high risk status must be documented.

The objectives related to risk code 113 are to:

• Promote healthy growth.
• Develop healthy feeding patterns.
• Promote opportunities for regular active play and limited screen time.
• Identify when additional intervention may be warranted and make appropriate referrals as necessary (e.g., medical referral).

Assessment and Counseling for Risk Code 113

Complete a thorough assessment of all topics in the chart below before beginning counseling. Individualize and prioritize counseling based on risk and the parent/guardian’s interest and readiness for change, utilizing a weight inclusive approach. Refer to the chart below for Risk Code 113 assessment and counseling tips:

Follow-up Guidance for Risk Code 113

• Consider the most beneficial course of action for follow-up. Consider the participant’s current medical care, ability to attend WIC appointments, and actual benefit of increased weight monitoring, prior to increasing frequency of WIC follow-up and/or monitoring weight changes.
  • For example, for a child assigned this risk factor based on a single height and weight measurement, it may be fitting to plan a verbal follow-up in three months with a re-assessment of measurements at the next mid-certification/re-certification.
• The high risk designation may be resolved by the CPA if the participant is showing steady growth and has no other related risk factors. Document the reasons for resolving the high risk status.

References

Satter, E. (2005). Your child's weight: Helping without harming. New York: Kelcy Press.

Ellen Satter's Division of Responsibility (https://www.ellynsatterinstitute.org/how-to-feed/the-division-of-responsibility-in-feeding/)

https://www.ellynsatterinstitute.org/how-to-feed/child-weight-issues/

Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics 2023 Feb 1;151(2):e2022060640.

https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and

The WIC Program plays an important role in public health efforts to reduce the prevalence of obesity by actively identifying and enrolling young children who may be obese or at risk of overweight/obesity in later childhood or adolescence. When identifying this risk, it is important to communicate with parents/caregivers in a way that is supportive and nonjudgmental, and with a careful choice of words that convey an empathetic attitude and minimize embarrassment or harm to a child’s self-esteem (4). In recognition of the importance of language, the 2007 American Medical Association Expert Committee Report recommends the use of the terms overweight and obese for documentation and risk assessment only and the use of more neutral terms (e.g., weight disproportional to height, excess weight, BMI) when discussing a child’s weight with a parent/caregiver (3) .

BMI is calculated and plotted on growth charts at each WIC certification. However, growth charts are meant to be used as a screening tool and comprise only one aspect of the overall growth assessment. A clinical assessment to determine if a child is at a healthy weight is more complex. Weight classification (derived from the growth chart) should be integrated with the growth pattern, familial obesity, medical risks, and dietary and physical activity habits to determine the child’s obesity risk (1, 5).

The goal in WIC nutrition counseling is to help the child achieve recommended rates of growth and development. WIC staff can frame the discussion to make achieving normal growth a shared goal of the WIC Program and the parent/caregiver and make clear that obesity is a medical condition that can be addressed (4). Parents/caregivers of children may need education on recognition of satiety cues and other physiological needs that lead to crying, and ways to comfort a child (holding, reading, rocking) other than by feeding. The foods provided by the WIC Program are scientifically-based and intended to address the supplemental nutritional needs of the Program’s target population and can be tailored to meet the needs of individual participants. Emphasis can be placed on promoting food choices of high nutritional quality while avoiding unnecessary or excessive amounts of calorie rich foods and beverages, and reducing inactivity (like decreasing sedentary TV viewing).

Beliefs about what is an attractive or healthy weight, the importance of physical activity, what foods are desirable or appropriate for parents to provide to children, family mealtime routines, and many other lifestyle habits are influenced by different cultures, and should be considered during the nutrition assessment and counseling (6). The following resources for obesity prevention can be found at:

• Fit WIC Materials
• MyPyramid for Preschoolers

In addition, WIC staff can greatly assist families by providing referrals to medical providers and other services, if available, in their community. Such resources may provide the recommended medical assessments, in order to rule out or confirm medical conditions, and offer treatment when necessary and/or in cases where growth improvement is slow to respond to dietary interventions.

The 2000 CDC Birth to 36 months growth charts cannot be used as a screening tool for the purpose of assigning this risk because these charts are based on recumbent length rather than standing height data. However, these charts may be used as an assessment tool for evaluating growth in children aged 24-36 months who are not able to be measured for the standing height required for the 2000 CDC 2-20 years growth charts.

1. uczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Advance data from vital and health statistics; no. 314. Hyattsville (MD): National Center for Health Statistics. 2000.

2. Grummer-Strawn LM, Reinold C, Krebs NF. Use of World Health Organization and CDC growth charts for children aged 0-59 Months in the United States. CDC Morbidity and Mortality Weekly Report (September 2010); no 59(rr09); 1-15. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_w. Accessed September 2010.

3. 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; S164-S192.

4. Ogden CL, Flegal KM. Changes in Terminology for childhood overweight and obesity. National health statistics reports; no. 25. Hyattsville (MD): National Center for Health Statistics. 2010.

5. U.S. Department of Health and Human Services. The Surgeon General’s vision for a healthy and fit nation. Rockville (MD): U.S. Department of Health and Human Services, Office of the Surgeon General. 2010.

6. Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007; 120 Suppl 4:S103-S228.