For Healthcare Professional use

OVERWEIGHT AND OBESITY

Learning points 1

The prevalence of obesity in toddlers is increasing.

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The toddler years are an ideal time for families to make lifestyle choices to prevent obesity in childhood.

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Medical causes of obesity are rare but toddlers in whom excess energy intake has been ruled out should be referred to a paediatrician. Any toddler with a BMI over the 99.6th centile should also be referred.

Body Mass Index (BMI) is a calculated relationship between height and weight and plotting BMI on a centile chart is used to assess overweight and obesity. A BMI over the 91st centile indicates overweight, and above the 98th centile is defined as obesity.

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Parental obesity is a very strong predictor of childhood obesity.

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Often parents do not realise their toddlers or children are overweight.

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Normally the BMI of toddlers decreases from around their first birthday onwards as they become slimmer until about 5-6 years when it begins to increase.

10 Healthy family lifestyles are the key to preventing childhood obesity and treating obesity in toddlers.

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An early adiposity rebound, the point at which a toddler's BMI starts to increase again, is associated with a greater risk of obesity in childhood.

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The vast majority of obesity is caused by an imbalance between energy intake from food and energy expenditure through activity levels, growth and development.

11 Healthcare professionals need an empathetic and nonjudgemental approach to empowering families to make lifestyle changes.

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OVERWEIGHT AND OBESITY IN TODDLERS Obesity was once unusual in toddlers but, as in other age groups, it is now becoming increasingly prevalent. Healthcare professionals can help families with toddlers to adopt a healthy lifestyle to prevent obesity at this early age and later in childhood. Healthcare professionals also need the skills to help families of toddlers who are already obese to make lifestyle changes. In most cases the cause of the obesity will be multifactorial and a single solution will not suit every family.

PREVALENCE IN THE UK Recent national statistics show that around 12 per cent of English toddlers aged 2-3 years are obese and a further 15 per cent are overweight1. In Scotland almost 11 per cent of 2-6 year olds were found to be obese with a further 15 per cent overweight2 (National statistics define overweight as between the 85th and 95th BMI centiles and obesity as at or above the 95th BMI centile).

CAUSES OF OVERWEIGHT AND OBESITY The vast majority of overweight and obesity is caused by an imbalance between energy intake (amount of calories consumed in food and drinks) and energy expenditure (amount of energy used in activity). In toddlers, as in older children, the excessive weight gain is a result of eating food energy in excess of the energy requirements for their activity level and their growth and development. The excess weight gain accumulates as extra adipose tissue (fat) which contributes to the physical and metabolic changes seen in obesity. Eating patterns, activity levels, ethnicity, genetics and environment all play a part in the development of obesity. Evidence is emerging that genetic differences may make some toddlers more susceptible to obesity in an obesogenic environment3,4. Epidemiological research has shown strong associations between overweight toddlers and parental obesity. Having one obese parent increases the risk, and if that parent is the mother the risk is higher. The highest risk is in toddlers with two obese parents1,5,6,7,. This could be due to a combination of genetic, social or environmental factors. Medical causes of overweight and obesity are rare but when environmental factors have been excluded, obese toddlers should be referred to a paediatric endocrinologist. Medical causes include: • endocrine disorders often signalled by short stature such as hypothyroidism, Cushing's syndrome, growth hormone deficiency and leptin deficiency • chromosomal disorders such as Prader-Willi syndrome

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USING BODY MASS INDEX (BMI) TO DETECT OBESITY Studies have shown that using clinical judgement to determine whether a young child is overweight or obese is unreliable. Overweight and obesity must be assessed more objectively, using the BMI. BMI is defined as weight in kilograms divided by the square of height in metres (BMI=Wt/(Ht)2). Thus a toddler who weighs 13.2 kg and is 91cm tall has a BMI of 13.2/0.91x0.91 = 15.9 (a healthy BMI range for adults of 18.5 - 25 is not applicable to children).

To assess if a toddler is overweight or obese, he or she should be weighed and measured accurately using calibrated equipment. See Factsheet 3.1 Calculate the BMI to one decimal place and plot it on a BMI centile chart for children. There is one for boys and one for girls (see figures 1 and 2). These charts can be ordered from www.healthforallchildren.co.uk and all healthcare professionals should have access to them. Fig. 1 BMI centile chart with 3 plots of two-and-a-half year old boys showing: (a) - overweight, (b) - obese, (c) - over the 99.6th centile, requiring referral

Calculating BMI Weight in kilograms BMI = (Height in metres)2

For a toddler with a weight of 13.2kg and a height of 91cm (0.91m) BMI =

13.2

= 15.9

0.91 x 0.91

It is normal for BMI to vary with increasing age and this variation is different between boys and girls. BMI should decrease during the toddler years as the body fat accumulated towards the end of infancy diminishes when the young toddler begins walking. With increased mobility the toddler's energy expenditure rises and body fat is replaced with more muscle tissue. The average BMI at one year is 17.5, falling to about 15.5 at five to six years of age. The BMI of obese toddlers may not decrease or may decrease less than expected.

• A child with a BMI between the 91st & 98th centiles is considered overweight (plot (a) in Fig. 1) • A child with a BMI above the 98th centile is considered obese (plot (b) in Fig. 1) NHS Trusts and hospitals should have a locally agreed protocol for treating childhood obesity. Scottish guidance recommends that toddlers with a BMI over the 99.6th centile (plot (c) in Fig. 1) should be referred to a paediatrician for investigation8.

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TODDLERS WHO RISK DEVELOPING OBESITY IN CHILDHOOD Adiposity rebound is the term given to the time when BMI begins to increase after falling to a low point at around four to five years. The Avon Longitudinal Study of Parents and Children (ALSPAC), also known as Children of the 90s, showed that toddlers who have an early adiposity rebound at three to four years of age are at risk of becoming obese in childhood7. Fig. 2 Girls BMI chart showing early adiposity rebound7.

Breastfeeding Whether breastfeeding in early infancy plays a role in preventing obesity in childhood, remains controversial. Formula-fed infants lose less weight in the first few days after birth and their growth rate and pattern is different to that of exclusively breastfed babies. This is one reason why the World Health Organisation has created growth charts based on the measurement of healthy breast-fed babies9. However there are many confounding lifestyle factors throughout the toddler years and early childhood, in addition to the mode of milk feeding during infancy, that may contribute to the development of obesity6,10. Exclusive breastfeeding remains the ideal way of feeding an infant until weaning for many other health reasons.

CONSEQUENCES OF OVERWEIGHT AND OBESITY Obese toddlers who remain obese into childhood will be at risk of: • lower levels of fitness • increased severity of asthma and other respiratory disease • social discrimination that can lead to: • low self-esteem • lower quality of life • lower academic achievement • increased risk of insulin resistance and type II diabetes • higher incidence of atherosclerosis • increased risk of cardiovascular disease An overweight child has a 40-70 per cent chance of becoming an obese adult11.

ALSPAC also identified the following risk factors for childhood obesity at seven years irrespective of whether the child was overweight as a toddler7: • parental obesity of one or both parents • high birth weight • rapid weight gain in the first year • catch-up growth between birth and two years • sedentary behaviour: more than eight hours watching TV per week at three years • less than ten hours sleep per day at three years

Picture reproduced with the permission of MEND

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LIFESTYLE IDEALS TO PREVENT OBESITY Because preschool children are dependent on parents and carers for their food and opportunities for physical activity, it is parents and carers who must take responsibility for a healthy family lifestyle. However providing food is an emotional issue for parents and many are more concerned about their toddlers being underweight than overweight12. Initiatives to improve lifestyles in families at risk of obesity need to be undertaken sensitively and should involve support for parents to improve their parenting skills. Home visits by healthcare professionals during pregnancy and infancy may be a time when parents are receptive to advice on healthy eating for young children13.

Limiting sedentary behaviour Many toddlers spend a lot of time being babysat by a TV/DVD/video. There are no evidence based guidelines for this in the UK, but in the USA and elsewhere watching television is not recommended for the under-two's. For those three and over the American Academy of Pediatrics recommends no more than two hours per day of sedentary behaviours such as TV viewing15. The ALSPAC study showed that three year olds who watched TV for more than eight hours a week (which is over one hour per day) were at a higher risk of becoming obese at seven years old than those who watched less7. Parents may need help exploring physical activities that can be substituted for sedentary behaviour watching TV or DVDs.

Encouraging physical activity Toddlers should have plenty of opportunities and be encouraged to take part in active play every day, to promote development of co-ordination and skills that will allow them to enjoy sport as they get older. Most toddlers do not need encouragement to play and will enjoy active play particularly with their parents. Parents can encourage active play by praising their toddlers when they are active. There is little evidence-based guidance regarding the optimum daily amount of exercise but the Department of Health now recommend that under fives are physically active for at least three hours each day14. This can be made up of short episodes spread over the whole day. Any active play inside or outside as well as walking up stairs, bouncing on a trampoline, dancing, running, walking to nursery, and other similar activities all count. Getting enough sleep Toddlers normally sleep about 12 hours in each 24 and this is important for growth. The ALSPAC study also found that three year olds who were sleeping for less than 10 hours per day were found to be at greater risk of being obese at seven years7. Encouraging healthy eating Toddlers learn by copying so parents need to adopt healthy eating patterns themselves. Changing eating habits is usually difficult, but particularly so for parents and families who: • do not understand the principles of healthy eating • do not have the cooking skills necessary to prepare simple home-cooked food and instead rely on convenience foods, which are usually higher in energy, fat, sugar and salt • do not have set mealtimes, either as a family or for their toddlers, and consequently frequent snacking forms part of their eating pattern Picture reproduced with the permission of MEND

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Healthcare professionals report that running cookand-eat sessions for parents improves their cooking skills and their knowledge of healthy eating, and empowers parents to provide healthier family meals. A balanced diet based on a combination of foods from five groups is outlined in detail in Factsheet 1.2 By eating the number of servings recommended in Table 1 toddlers will be assured of getting all the nutrients they need to grow and develop. Foods in the fifth food group are high in fat and sugar. Small amounts of these foods are acceptable in a toddler diet but many toddlers eat these foods to excess16 - particularly sweetened drinks and high-fat snack foods such as crisps. Restricting these foods in today's environment requires discipline, as preschool children naturally prefer energy dense foods17. Healthcare professionals could help parents to plan more nutritious meals and snacks that they can then substitute for the high-fat and high-sugar foods that they may normally offer. Family meals Toddlers need encouragement to learn to eat a variety of foods and they learn by copying others See Factsheets 1.1 and 2.2 This is best achieved during meals where the family all eat nutritious food together in a calm, relaxed atmosphere with the TV switched off and no other distractions. Toddlers should be allowed to stop eating when they signal they have had enough - they should not be pressured to finish all the food on their plate. Toddlers will also benefit from a routine of meals and planned nutritious snacks that fit around their sleeping pattern so that the nutritious meals and snacks are given when they will accept them willingly. Toddlers who are over-tired or over-hungry at a meal time may refuse to eat.

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NICE guidance published in 2006 recommends that18: All nurseries and childcare facilities should: • minimise sedentary activities during play time, and provide regular opportunities for enjoyable active play and structured physical activity sessions • implement Department for Education and Skills, Food Standards Agency and Caroline Walker Trust19 guidance on food procurement and healthy catering • ensure that children eat regular, healthy meals in a pleasant, sociable environment free from other distractions (such as television). Children should be supervised at mealtimes and, if possible, staff should eat with children Any programme to prevent obesity in preschool or childcare settings should incorporate a range of components (rather than focusing on parental education alone). diet: interactive cookery demonstrations, videos and group discussions on practical issues such as meal planning and shopping for food and drink physical activity: interactive demonstrations, videos and group discussions on practical issues including: - ideas for activities - encouraging more walking instead of always using the car or pushing toddlers around in a pushchair - opportunities for active play - concern for safety - availability of local facilities To comply with this guidance it is good practice for healthcare professionals to have local knowledge of facilities where toddlers can enjoy opportunities for physical activity. Where facilities and opportunities are poor practitioners could lobby their local authority to provide affordable activities for families of young children through Children's Centres. For example, this may include a regular weekly subsidised parent/toddler swim or an organised parent/toddler health walk or active play group.

Table 1 Healthy eating recommendations for toddlers Food Group

Foods included

Main nutrients supplied

Recommendations for toddlers

1. Bread, cereals and potatoes

Bread, chapatti, breakfast cereals, rice, couscous, pasta, millet, potatoes, yam, and foods made with flour such as pizza bases, buns, pancakes

Carbohydrate B vitamins Fibre Some iron, zinc and calcium

Serve at each meal and some snacks

2. Fruit and vegetables

Fresh, frozen, tinned and dried fruits and vegetables Also pure fruit juices

Vitamin C Phytochemicals Fibre Carotenes

Serve at each meal and some snacks. The more variety the better, although this may be difficult to achieve with fussy eaters

3. Milk, cheese and yogurt

Breast milk, infant formula milks, follow-on and growing up milks, cows' milk, yogurts, cheese, calcium enriched soya milks, tofu

Calcium Protein Iodine Riboflavin

Three servings a day One serving is • about 100-120ml/3-4oz milk in a • beaker or cup • one pot yogurt or fromage frais • a serving of cheese in a sandwich or on a pizza • a milk based pudding • a serving of tofu

4. Meat, fish and vegetarian alternatives

Meat, fish eggs, pulses, dahl, nuts

Iron Protein Zinc Magnesium B vitamins Vitamin A Omega 3 long chain fatty acids: EPA and DHA from oily fish

Two servings a day Three for vegetarians

Oils such as olive, soya, walnut and rapeseed give a good balance of omega 3 & 6 fatty acids

Small amounts in addition to but not instead of the other food groups. Too much of them increases the risk of obesity

5. Foods high in fat and / or sugar

Cream, butter, margarines, cooking and salad oils, mayonnaise, chocolate, confectionery, sweetened drinks, jam, syrup, crisps and other high fat savoury snacks

Fish should be offered twice per week and oily fish at least once per week but no more than four servings per week for boys and two servings per week for girls

See Factsheets 1.1 and 1.2 for further information about healthy eating.

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Treating OVERWEIGHT AND obesity NICE guidelines recommend that18: • a supportive environment should be created that helps overweight or obese children and their families to make lifestyle changes • decisions on the approach to management of a child's overweight or obesity should be made in partnership with the child and family and be tailored to the needs and preferences of both • weight management interventions should include behaviour change strategies to increase physical activity levels or decrease inactivity, improve eating behaviour and the quality of the diet and reduce energy intake • dietary changes should be individualised, tailored to food preference and allow for flexible approaches to reducing calorie intake

Most parents do not recognise that their toddlers are overweight or obese, so healthcare professionals need to be sensitive when discussing the issue. Parents could be asked how they feel about their child's weight as a way of beginning a discussion. Measurement of the toddler's weight and height/length could then be offered. Showing parents how the BMI of their overweight/obese toddler relates to the normal range, by using the BMI centile chart, is a good way to continue the discussion. Unless parents acknowledge that there is a problem and are ready to change their lifestyle there is little that can be achieved for an overweight or obese toddler. There is usually no need for overweight toddlers and young children to actively lose weight, but weight gain should be slowed or stopped temporarily through healthy eating and physical activity so that BMI declines as the child grows taller.

Picture reproduced with the permission of MEND

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The aim of treatment is to improve the energy imbalance and this will be achieved by a combination of any of the following: • decreasing the energy content of food and drinks eaten by limiting high calorie foods and drinks • increasing physical activity • decreasing sedentary behaviour • ensuring adequate sleep for growth The barriers to making these changes may be considerable for some families because of: • • • • •

the family lifestyle lack of knowledge of what a healthy balanced diet is lack of cooking skills to prepare lower energy foods housing and immediate local environment limited finances

SUPPORTING PARENTS TO MAKE LIFESTYLE CHANGES The whole family will need to make lifestyle changes that become a normal part of their family life so that they are maintained long-term. At the outset healthcare professionals should initiate a sensitive discussion with parents to determine which factors in their lifestyle are contributing to obesity. These may be complex, and will need a structured assessment of need. Parents are likely to be aware of factors but they may involve emotional issues making change seem more difficult12. Once contributing factors have been identified, healthcare professionals should help parents explore which of these factors they feel they may be able to change. There will be pros and cons and solutions may not always be clear cut. For instance, excess sedentary behaviour and lack of physical activity could be a major factor for a family living in a cramped flat in a high-rise building with no access to a playground or garden. Taking a toddler to play outside would impact on the time a busy mother might have to prepare ideal foods. A carefully structured assessment of need will enable healthcare professionals to support parents in balancing needs and priorities. It is important to encourage families to set small achievable goals. Up to three could be tackled at one time. If there are financial concerns or if both parents need to work and have limited free time, parents may be encouraged to share a care plan with staff in the child's day care setting. With time, when these changes have been made and sustained, the family can be encouraged to consider another set of lifestyle changes.

Support for parents who are not ready to make lifestyle changes Parents need help to understand that obesity is a clinical condition with health implications rather than just a question of how someone looks18. Discuss the benefits of making changes to physical activity and eating patterns and give them details of someone they can contact when they are ready to consider making changes.

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Lifestyle changes may benefit from: • Goal setting. Begin by agreeing simple goals for behaviour change and what benefits they will achieve. Make sure the goals will not lead to conflict between family members and limit the number of goals to three or less. Make the goals SMART (Table 2). Keep records of the goals and the achievements so that they can be reviewed when necessary. When goals are not achieved, make it an opportunity to re-evaluate motivation and the complexity or effort required to achieve that goal.

• Removing inconsistencies in the family environment. Parents should limit the availability of foods and triggers that lead to overeating. Ideally they should, for example:

• Reward systems. Toddlers are more willing to repeat behaviours which are rewarded with parental attention and praise. Parents should be encouraged to praise their toddlers for good behaviour and never to use food or drinks as rewards. More suitable rewards are, for example, playing indoor games with them, reading books to them, taking them on a swimming trip or playing with them in the park.

• not bring high calorie, low nutrient foods into the house at all • buy an individual packet rather than multi packs of snack foods or biscuits that must be stored somewhere in the house • not go to 'all you can eat for £x' style restaurants • have set mealtimes, preferably with all the family eating together • have readily available healthy snacks to use in between meals • resist spontaneous snack rewards or incentives in and outside the home

Table 2: Examples of good and poor SMART Goals

Aspect of goal

Good examples

Poor examples

Specific

Have water or diluted fruit juice in place of sweetened squashes and fizzy drinks. Dilute fruit juice using one part juice to 6-10 parts water

Choose healthy drinks

Measurable

Limit crisps for everyone to 4-6 crisps at one meal each week

Eat fewer crisps

Achievable

1. Toddlers can walk the last 200 metres to nursery rather than being pushed in the buggy or driven in the car

1. Walk all the way to nursery (which might be over a mile and too far for a toddler to walk)

2. Use the stairs rather than escalators or lifts in the shopping centre particularly when not encumbered with heavy shopping or pushchairs

2. Only use stairs, never escalators (the family may live at the top of a tall tower block)

Relevant

Include fruit with each meal

Eat more pomegranates

Time limited

Go swimming on Saturday afternoons this month

Go swimming more often this year

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Page suitable for photocopying for healthcare professionals to give to parents

OVERWEIGHT AND OBESITY GUIDANCE & TIPS FOR PARENTS • Obesity in children is becoming more common and obese children tend to remain obese as they grow up and become adults. • Obese children have a weight that is too great for their height. The excess weight is stored as fat which affects their health. • Medical causes of obesity are very rare and most children become obese because of their lifestyle. • Children who are obese are more likely to get health problems such as asthma, high blood pressure, heart disease and diabetes. They are also more likely to be bullied. • There are no medicines to treat young children who are obese. The only way to help toddlers and children overcome obesity is to increase activity and change the type of foods that the whole family eats. • Toddlers learn by copying you and others around them. The whole family making changes towards a healthy family lifestyle while your child is a toddler will help to prevent them becoming overweight or obese as they get older. In this way toddlers learn and develop healthy habits. • You may need to make lifestyle changes such as: • increasing the time when you are all physically active - walking, playing together e.g. ball games, dancing, swimming • decreasing the time you spend in sedentary pursuits - such as sitting watching TV or playing computer games

•

•

• •

•

•

•

• eating a healthy diet and limiting foods high in fat or sugar such as crisps, sweets, and fizzy drinks to once a week or less It is best to make small gradual changes to family behaviour. Make a list of changes you think will be possible for your family to make. Choose up to three of them. Discuss them in your family and decide when you will start each change. Talk to your extended family, such as grandparents, aunts and uncles, about the changes you are making so that they will not undermine them when they see your toddler. Also tell any other people who come to your home, such as baby sitters and friends. When the changes are successful choose up to three more to change. Praise your children when they make these changes. They are more likely to follow them again as they like praise from parents. Praise your children when they are active. For example: 'You are good at running and you run so fast now.' When choosing rewards for your children, choose things other than food. Do not give sweets or high-fat foods such as crisps as rewards. If toddlers are overweight or obese they do not have to lose weight. By staying the same weight they will get slimmer as they grow taller.

Practical help and information on nutrition and development Supported by an educational grant from Danone UK

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References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

17. 18. 19.

Health Survey for England 2010. Chapter 11 Children's BMI overweight and obesity. The Scottish Health Survey. Vol 1: Main Report. Table 7.4 Proportion of children with BMI outwith the healthy range, and prevalence of overweight and obesity in children, 1998, 2003, 2008, 2009, 2010, by age and sex. Lagou V, Manios Y, Moran CN, Bailey ME, Grammatikaki E, Oikonomou E et al. Developmental changes in adiposity in toddlers and preschoolers in the GENESIS study and associations with the ACE I/D polymorphism, 2007. Oswal A, Yeo GS. The leptin melanocortin pathway and the control of body weight: lessons from human and murine genetics. Obes Rev 2007 Jul; 8(4): 293-306. Dorosty AR, Emmett PM, Cowin IS, Reilly JJ. ALSPAC Study Team. Factors associated with early adiposity rebound. Pediatrics 2000;105:1115-1118. Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant breastfeeding and overweight in young children. JAMA 2001;285:2453-2460. Reilly JJ, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I et al. Early life risk factors for obesity in childhood: cohort study. BMJ 2005;330:1357-1359. Scottish Intercollegiate Guidelines Network (SIGN). Obesity in children and young people: a national clinical guideline SIGN 69 (www.sign.ac.uk). www.who.int/childgrowth/standards Clifford TJ. Breastfeeding and Obesity. BMJ 2003;327:879-880. National Audit Office (NAO). Tackling Child Obesity - First Steps. London: The Stationery Office, 2006. Pagnini DL, Wilkenfeld RL, King LA, Booth ML, Booth SL. Mothers of pre-school children talk about overweight and obesity: The Weight of Opinion study,Journal of Paediatrics and Child Health 2007 (in press). Bull J, McCormick G, Swann C, Mulvihill C. Ante-and post-natal home-visitng programmes: a review of reviews: Evidence Briefing Health Development Agency 2004. Department of Health 2011 Start active, stay active: a report on physical activity from the four home countries’ Chief Medical Officers. DH, London. Gidding SS, Dennison BA, Birch LL, Daniels SR, Gillman MW, Lichtenstein AH et al. American Heart Association Dietary recommendations for children and adolescents: a guide for practitioners. Pediatrics 2006 117(2):544-59. Gregory JR, Collins DL, Davies PSW, Hughes JM, Clarke PC. National Diet and Nutrition Survey: children aged 11/2 to 41/2 years. Volume 1: Report of the diet and nutrition survey. Ministry of Agriculture, Fisheries and Food and Department of Health. 1995. London: HMSO. Cooke L. The development and modification of children's eating habits. Nutrition Bulletin 2004;29:31-35. NICE. Clincial Guideline 43. Obesity. 2006. The Caroline Walker Trust (2005) http://www.cwt.org.uk

Further Reading 1. Matyka K. Managing obesity in children. Obesity In Practice 2002: 4 (2) 2-8. 2. Taheri S. The link between short sleep duration and obesity: we should recommend more sleep to prevent obesity. Arch Dis Child 2006: 91: 881-884. 3. Zaninotto P, Wardle H, Stamatakis E, Mindell J and Head J. Forecasting Obesity to 2010. Prepared by the Joint Health Surveys Unit for the Department of Health. 2006. 4. The Information Centre. Statistics on Obesity, Physical Activity and Diet: England, January 2008. Government Statistical Centre. 2008. www.ic.nhs.uk/pubs/opadjan08

Glossary Cushing's syndrome: caused by excessive levels of the hormone cortisol which causes rapid weight gain, particularly of the trunk and face endocrine disorders: abnormalities of hormone secretion or action growth hormone: a hormone secreted by the pituitary gland which stimulates growth and cell reproduction. It controls the growth in toddlers and young children hypothyroidism: insufficient production of thyroid hormone by the thyroid gland leptin: a hormone secreted by adipose tissue, that plays a key role in regulating energy intake and energy expenditure, including the regulation of appetite and metabolism Prader-Willi syndrome: a condition due to a chromosomal abnormality. Babies are floppy at birth and go on to develop obesity due to an excessive appetite and overeating. Other characteristics are small hands and feet, mental retardation, poor emotional and social development and immature development of sexual organs and other sexual characteristics

Additional copies of this Factsheet can be downloaded from www.infantandtoddlerforum.org The information contained within this Factsheet represents the independent views of the members of the Forum and copyright rests with the Forum members. BMI charts reproduced with the permission of the Child Growth Foundation. Supplies and further information from www.healthforallchildren.co.uk

ITF129 - March 2008 Revised - April 2012