Obesity in Immigrant Children and Youth
- In general, immigration may increase risk of obesity; the longer the stay, the greater the risk, particularly among families of lower socio-economic status.
- Social, economic and cultural factors, including acculturation, particularly dietary acculturation, can influence overweight and obesity risk in young newcomers to Canada.
- Some ethnic populations are at higher risk of the medical consequences of obesity than others at the same or lower body mass index (BMI).
- The WHO age- and sex-appropriate growth charts are the best tools for identifying overweight and obesity in children, including young newcomers to Canada.
- As part of routine care, clinicians should counsel patients on how to prevent obesity by maintaining a healthy diet, regular physical activity and sleep habits.
- More research is needed to support specific recommendations for preventing, intervening and treating obesity in immigrant and refugee children.
A number of risk factors appear to predispose young newcomers to Canada to overweight and obesity. These include:
- immigration itself1
- length of residence in the host country2,3
- extent of acculturation to or adoption of Western lifestyles 4,5
- genetic predisposition6-8
- cultural norms12,13
- socioeconomic status14
- food insecurity15,16
Factors such as ethnicity and socioeconomic status also influence how overweight and obesity risks increase over time.3
Acculturation and time since immigration
Overall, first-generation immigrant children appear to have lower risk of obesity than children born in the host country.3,17 However, the risk of obesity appears to increase with acculturation4,5,18 and the length of time since immigration.2,3 An early focus on obesity prevention by health care providers can be important.3 Biculturalism (being engaged in both the heritage culture and in the new society) seems to protect against obesity, compared with complete acculturation in the new culture.19,20 More information on dietary acculturation and nutritional transitioning can be found in Selected resources.
The heritability of obesity varies considerably among individuals (variance may be as much as 60% to 80%), which in turn influences factors like adipose tissue distribution and excess weight or body fat. Most of these factors are thought to cause obesity only when environmental conditions support them.8 Epigenetics may contribute to obesity, when combined with an obesogenic environment.6-8
Certain populations, including Asian, East Indian, African-American, Native American and Mexican peoples, are at higher risk of obesity.10,11,21,22 Even at the same or lower body mass index (BMI), some people are at higher risk for medical complications when obese. For example, Southeast Asians are more prone to abdominal obesity than other ethnic groups.23
Cultural norms in a child’s country of origin can influence risk of obesity after immigration.12 For example, in sub-Saharan Africa, larger body size is considered a mark of social status, health and success; thinness is often associated with poverty and ill-health.13,24 Consuming fried food and soft drinks is sometimes considered a mark of affluence while a diet of vegetables, fruit and legumes is seen as less desirable.13 Unhealthier aspects of the Western diet are being disseminated worldwide, which explains, in part, the obesity pandemic experienced even in developing countries.25
In developed countries, overweight and obesity are clearly associated with lower socio-economic status (SES). A number of reasons have been proposed:14,16,26,27
“When you are a refugee … you eat whatever you find, so that’s what is causing bad eating … They don’t watch healthy food, they will just eat fat, the sugar. That is the problem.”16 (Quoting an African refugee)
- Irregular work schedules, lack of funds and lack of transportation may limit a child’s ability to attend extracurricular activities, a family’s ability to participate in community activities or to access and prepare nutritious food.
- Children living in low-income communities are more likely to have limited access to healthy food, safe outdoor play spaces or recreational facilities. They may spend more time indoors being sedentary, watching TV or playing video games.
- Foods that are high in calories and low in nutritional value (including fast foods) are often less expensive than healthier choices.
Immigrant families are more likely to experience poverty than native-born Canadians.29 Overweight and obesity risk over time increases for newcomer children with low SES who immigrate from low-income countries.26 This relationship appears to relate to a family’s having experienced food insecurity in the past15,16 and their degree of acculturation to new norms at a low SES level.26 Refugee children are especially vulnerable because they are more likely to be living in poverty.
The degree of deprivation experienced by parents in their country of origin,26 particularly food insecurity, is a risk factor for obesity in their children.15,16 The experience of food insecurity may contribute, along with previous cultural norms, to belief that “a fat child is a healthy child”.27 A preference for heavier children and less healthy eating practices (e.g., higher consumption of soda and candy) have been found in parents who experienced food insecurity in their country of origin, but not in families who experienced poverty without food insecurity.15
Screening and assessment of obesity
Young newcomers to Canada should be screened for overweight or obesity in the same way as Canadian-born children: By using BMI percentiles for children 2 years of age and older, and weight-for-length or percent ideal body weight in younger children.29
The WHO published standard growth indicators in 2010, with growth curves based on children from 6 countries (the U.S., Norway, Brazil, India, Ghana and Oman) to optimally reflect the world population. Asian and southwestern Pacific populations were not represented, however. Because a large percentage of immigrants to Canada come from Asia, practitioners may wish to consult alternate measures when screening newcomer children from this region (see Selected resources). Also, the weight-for-age WHO growth curve does not extend beyond 10 years of age. Therefore, practitioners may wish to consult the Canadian Pediatric Endocrine Group (CPEG) growth charts when screening children older than 10 years of age.30
BMI is easy to use but may not appropriately reflect body fat, particularly for some ethnicities. Ethnic-specific cut-off points for BMI and waist circumference are available for adults but not for children.11,31,32 When interpreting BMI, bear in mind that certain ethnic populations tend to develop medical complications at lower BMI than Caucasians.10,11,21
Waist circumference is another measurement that may help clinicians to identify obesity and quantify metabolic risk in future. However, because the cut-off values and clinical usefulness of this measure in children are not established, it cannot be recommended at the present time..
Screening for diabetes, hypertension and hypercholesterolemia
There are no evidence-based recommendations in the literature for metabolic screening for immigrant and refugee children. However, current Canadian guidelines32 and U.S. guidelines are available33 and can serve as a useful reference for screening newcomer children.
Lipids screening: An overweight or obese child should be screened at 10 years of age and older.33,34 If the child has additional risk factors, such as familial cardiovascular disease or dyslipidemia, screening should be done earlier.
Hypertension: All children should have their blood pressure measured yearly, starting at 3 years of age. Hypertension cut-offs for diagnosis are available. If this condition is confirmed, it requires appropriate investigation and management.
Type 2 diabetes: The Canadian Diabetes Association recommends screening every 2 years using a fasting plasma glucose (FPG) test for children presenting with any of the following:35
- ≥3 risk factors in nonpubertal, or ≥2 risk factors in pubertal children
- Obesity (BMI ≥95th percentile for age and gender)
- Higher risk ethnicity (e.g., Aboriginal, African, Asian, Hispanic or South Asian descent)
- Family history of type 2 diabetes and/or exposure to hyperglycemia in utero
- Signs or symptoms of insulin resistance (including acanthosis nigricans, hypertension, dyslipidemia, non-alcoholic fatty liver disease [ALT >3X upper limit of normal or fatty liver on ultrasound], polycystic ovary syndrome)
- Impaired fasting glucose or impaired glucose tolerance
- Use of atypical antipsychotic medications
Details on these tests can also be found in the Canadian guidelines on management and prevention of obesity. There are no specific screens for immigrant and refugee children.
Screening for mental health concerns
Being overweight or obese can impact a child’s or youth’s mental health and well being, and can affect family life. Low self-esteem, depression, bullying, insomnia and behaviour problems are only a few common, often recurrent examples of possible consequences of obesity. Health care providers need to be alert to such effects, ask their young patients about them, and put them in contact with supportive services as needed. More information on promoting mental health in immigrant and refugee children and youth is available in this resource.
Preventive measures for obesity in young immigrants have not been well studied. Recommendations are the same as for Canadian-born children, with a focus on improving diet and increasing physical activity and sleep. All body shapes and sizes will benefit from healthier habits. One important message to convey is that health is not the same thing as weight. Health professionals need to:
- promote healthier, more active living for all.
- make it easier for the immigrant and refugee families they see to access and follow preventive care advice. Suggestions to address such barriers, including provision of culturally appropriate advice, are offered in the sections below.
- provide a safe environment, without weight bias or discrimination.
- counsel parents on how to boost their child’s self-esteem and body image.
Efforts to improve both the quality and quantity of a newcomer family’s food intake can be based on Canada’s Food Guide, which is available in multiple languages and includes many ‘ethnic’ foods. For young newcomers, consider suggesting dietary adaptations that remain consistent with traditional eating customs (e.g., replacing white with brown rice, baking instead of frying foods, using olive oil in place of other cooking fats).12 Information on common foods and feeding practices in different countries may be helpful.
Specific recommendations include:36,37
- Exclusive breastfeeding until 6 months of age and continued breastfeeding with complementary foods for 2 years and beyond
- Introducing complementary, iron rich foods beginning at about 6 months of age
- After 6 months of age:
- Continue to breastfeed
- Limit formula or milk feedings to 450mL to 600mL (15 to 20oz) per day
- Limit juice to 120mL (4 oz) per day, and always prefer water to juice
- Limit salt and sugar in food
- Serve home-prepared foods, and limit fast-food
- Respect normal variation in appetite. Don’t insist that a child finish a snack or meal (but avoid ‘grazing’ in between meals)
- Give appropriate portion size
- Do not use food as a punishment or reward
- Eat meals together, with family and friends
- Avoid eating in front of the TV
The CPS has a position statement on developmentally appropriate strategies for encouraging physical activity and reducing sedentary time (particularly screen time) in children and youth.38 Encourage family participation in community or culturally-based activities (e.g., traditional dance) or sports that are popular internationally (e.g., soccer).12 While there are no specific recommendations for immigrant and refugee children, helpful data on physical activity levels among immigrant groups can be found on the Statistics Canada web site.
Establishing good sleep habits can help other routines, such as mealtimes, become more predictable and regular. Well rested children and teens will have more positive energy to give to physical activities. Shorter sleep durations in infancy and childhood are associated with a higher obesity risk.7,39
Immigrant and refugee families may encounter the following barriers to preventive health care:
- Socioeconomics: Recent immigrants are more likely to be among the working poor than native-born Canadians,28 at least for a few years after they arrive. This can present multiple challenges, including reduced:
- Access to safe, outdoor play or community spaces;
- Funds for transportation, impacting access to nutritious foods and recreational activities;
- Ability to schedule family mealtimes or to access social supports; and/or
- Control over food choices, especially if living with relatives.
- Language: Consider using a professional interpreter. More information on when and how to use interpreters is available in this resource.
Cultural influences and migration experience:
- Accepting nutritional advice may be a low priority for an immigrant family focused on finding housing, employment and social supports, especially if nutrition guidelines are unknown in their country of origin. Healthy, accessible, affordable foods can still be unfamiliar.13
- Low-resource countries tend to have fewer obesity-prevention programs than Canada. Do not assume that a young newcomer has been screened for or counselled about obesity in their country of origin.
- Newcomer parents are less likely to access preventive care. They may be unfamiliar with the concepts, availability and benefits of preventive care, and see a health professional only for specific medical problems. Helping families to navigate the Canadian health care system is central to culturally competent care. Encourage continuity by booking follow-up visits. More information on how to improve access to health care for newcomers is available in this resource.
- Cultural beliefs around nutrition, exercise and healthy weights may be different from those of the practitioner, which can affect perception and communication. More information on bridging the gaps to culturally competent care is available in this resource.
“Simply counselling parents and children about weight control will be almost pointless in environments that work against carrying out recommendations for healthful eating and physical activity.”27
What health professionals can do
Ask for a parent’s views on food, eating and weight, to better understand a family’s beliefs and to help negotiate a prevention or treatment plan. For example:
- Ask about the family’s background. Obesity is not considered a disease in many cultures. If deprivation was the norm in their country of origin, parents may continue practices that promote weight gain.15
- Assess the parent’s knowledge and beliefs about child health and disease by eliciting their ‘explanatory model’. This approach can provide valuable information about perceptions they may have on obesity and other health issues. Parents may not be aware of the risks of obesity or the importance of following a treatment regimen. They might rely on a child’s ‘growing out’ of overweight naturally or believe that lifestyle changes will make little difference.12
- Explore and evaluate social supports, family roles and responsibilities, and a parent’s readiness to change. Extended family members can play an important role, especially if they resist or challenge a parent’s efforts to manage diet. Consider asking: Who cares for the child when the parents are not around? Who prepares the child’s meals? Who lives with the child?12,27
- Ask about breast and bottle feeding practices, as appropriate, and about introducing first complementary foods (what and when).12
- Assess the family’s intake of carbohydrates and beverages, as well as nutritional quality, and gauge the acceptability of making substitutions.12 Helpful information on common foods and feeding practices in different countries is available from the U.N. Food and Agriculture Organization (FAO).
- Assess parental attitudes to diet, sleep, media (e.g., TV), physical activity and body size in children.12 They may value school work or family time more highly than community activities or organized sport, and may not be fully aware of the benefits of physical activity.40
The LEARN model is one framework for teaching cultural competence that is action-oriented and focuses on what health care providers can do.
- Listen with sympathy and understanding to the patient’s perception of a problem
- Explain your own perception of a problem
- Acknowledge and discuss differences and similarities
- Recommend treatment
- Negotiate agreement
Refer to the Cultural Competence section of this resource for more information on history-taking with immigrant and refugee families.
More research on the effectiveness of various nutritional therapies for obesity in children and youth is needed, especially with focus on ethnic groups and cultures.24,32 Clinicians should follow the current Canadian clinical practice guidelines.
A family-centered approach and supportive home environment are important for encouraging and reinforcing lifestyle changes.12 Practitioners may want to consider family counselling and behavioural therapy with ongoing follow-up in complex cases.38 Coordination with child care or school programs can be helpful. Addressing mental health stressors is often a key component of global treatment and patient support.
Studies suggest that the an immigrant’s risk of becoming overweight or obese increases with time lived in the new country,2,3,5 along with the long-term consequences of these conditions, such as type 2 diabetes and cardiovascular disease.16
Ali, a 10-month old baby, is seen for his first examination in Canada, accompanied by his mother. His family emigrated from Lebanon a month ago, and are now permanent residents. Ali’s father is job-hunting.
The family history reveals the presence of hyperlipidemia, without obesity, on the paternal side.
Although pregnancy with Ali and his term delivery were uneventful, Ali’s mother followed the advice of friends and stopped breastfeeding after only a week. She started formula-feeding because it was believed to be more practical and “modern”.
Ali drinks about 750 mL (25 oz)/day of whole milk and 480 mL (16 oz)/day of juice. He has started cereals and fruits but refuses vegetables and meat. When you ask, the mother mentions her fear of taking him outside in the winter cold. You observe that he is overdressed for present weather conditions. The clinical exam and the growth curves (weight, length and a weight-for-length ratio between the 3rd and 85th percentiles) are normal.
- Breast milk is the best food you can offer your baby and may help protect children from obesity. Health Canada and the Canadian Paediatric Society recommend exclusive breastfeeding to 6 months of age. Breastfeeding can be continued until 2 years old or beyond. Babies should not start eating solid foods until about 6 months. More information on promoting breastfeeding among immigrant mothers is available in this resource.
- Vitamin D and iron are essential for healthy growth and development. Parent information on Vitamin D and Iron is available from the CPS.
- Nutrition guidance consistent with traditional eating customs needs to be provided. Information for parents is available from the CPS and Health Canada.
- Reducing juice consumption is a good starting point
- Encourage family activity and outdoor play.
- Clinicians need to use WHO growth charts (0-2 years) to assess children adequately.
You next see Ali when he is sick, about to start kindergarten, at 4 ½ years of age. His mother says he is very healthy, but he is now overweight according to the WHO growth curves.
The nutritional history reveals that Ali has become a ‘picky eater’ and that his family had to really encourage him to feed between 2 and 3 years of age. At present he eats little at breakfast (a glass of juice, a slice of toast with chocolate-nut spread). He has also been a fussy eater in child care, disliking vegetables, salads and fruits and much preferring sweets at home (Lebanese pastries and ice cream). At home, Ali ‘grazes’ constantly. He prefers Western ‘fast food’ to homemade tabbouleh, mezze and shish kebab. His favorite drinks are juices and soda. Ali’s mother is disappointed by some of his choices but is happy that he is adapting so well to his new country.
In general, he prefers to stay inside playing video games.
- A complete physical exam is important, with particular attention to blood pressure and oral health.
- Start a catch-up schedule for all recommended immunizations.
- Nutrition and healthy active living guidance needs to be reinforced with special attention to the four food groups and appropriate portions, as well as limiting screen time and encouraging physical activity.
- Ensure follow-up to support the family in these changes.
The next follow-up is at 11 years of age, when Ali presents with a minor leg injury after being bullied in the schoolyard. According to the WHO curves for BMI, he is now clinically obese. His blood pressure is 135/85.
- A metabolic screening for diabetes and hypercholesterolemia is needed, as per Canadian guidelines.
- Investigate for hypertension. The U.S. National Institutes of Health has a quality resource on the diagnosis, evaluation and treatment of high blood pressure in children.
- Implement a treatment plan and consider family-centred counselling on obesity-related risk factors. Use motivational interviewing and multidisciplinary approaches to reinforce new health messages and lifestyle changes.
- Refer Ali and his parents to supportive community resources concerned with bullying, and encourage them to discuss the problem with school officials.
- Identify underlying family stressors (especially economic) and make sure to connect the family with appropriate, supportive local services. Links to local community programs for immigrant and refugee families are available in this resource.
- More information is available from the CPS about psychosocial aspects of child and adolescent obesity.
- Schedule regular follow-up visits and document progress toward reaching a healthier weight and lifestyle changes.
- L’ABCDAIRE: GUIDE DE RÉFÉRENCE DU PRATICIEN 2012, Dépistage et prise en charge de l'obésité chez l'enfant, E. Rousseau.
- Canadian Society for Exercise Physiology. Canadian physical activity guidelines and Canadian sedentary behaviour guidelines
- Caprio S, Daniels SR, Drewnowski A, et al. Influence of race, ethnicity, and culture on childhood obesity: Implications for prevention and treatment. Obesity (Silver Spring) 2008;16 (12):2566-77.
- Dixon B, Peña MM, Taveras EM. Lifecourse approach to racial/ethnic disparities in childhood obesity. Adv Nutr 2012;3(1):73-82.
- The Griegg Health Record for children and adolescents aged 6-17 years.
- NutriSTEP: Nutrition screening tool for every preschooler
- The Rourke Baby Record for infants and children to 5 years of age.
- Satia JA. Dietary acculturation and the nutrition transition: An overview. Appl Physiol Nutr Metab 2010;35(2):219-23.
- WHO. Global strategy on diet, physical activity and health.
- WHO. Obesity and overweight. Fact sheet No. 311. Geneva, Switzerland: WHO, 2012
Information for parents
- CPS, How to promote good television habits, Tips for limiting screen time at home, and Physical activity for children and youth.
- Health Canada. Canada’s Food Guide. (Available in a number of languages.)
- Public Health Agency of Canada. Health promotion: Healthy living.
- Public Health England. Migrant health guide. Lifestyle factors and health promotion
Although the WHO growth curves are the only ones officially recommended, other growth charts can be useful. More information is available at: http://adoptmed.org/topics/growth-charts.html.
- Public Health Agency of Canada, Canadian Institute for Health Information. Obesity in Canada: A joint report. Ottawa, Ont.: CIHI, 2011.
- Goel MS, McCarthy EP, Phillips RS, et al. Obesity among US immigrant subgroups by duration of residence. JAMA 2004;292(23):2860-7.
- Singh GK, Kogan MD, Yu SM. Disparities in obesity and overweight prevalence among US immigrant children and adolescents by generational status. J Community Health 2009;34(4):271-81.
- Buscemi J, Beech BM, Relyea G. Predictors of obesity in Latino children: Acculturation as a moderator of the relationship between food insecurity and body mass index percentile. J Immigr Minor Health 2011;13(1):149-54.
- Fu H, VanLandingham MJ. Disentangling the effects of migration, selection and acculturation on weight and body fat distribution: Results from a natural experiment involving Vietnamese Americans, returnees, and never-leavers. J Immigr Minor Health 2012;14(5):786-96.
- Bouchard C, Peruss, L, Rice T, et al. Genetics of human obesity. In: Bray GA, Bouchard C (eds.). Handbook of Obesity: Etiology and Pathophysiology. 2nd edn. New York, NY: Marcel Dekker, 2003.
- Han JC, Lawlor DA, Kimm SY. Childhood obesity. Lancet 2010;375(9727):1737-48.
- Crocker MK, Yanovski JA. Pediatric obesity: Etiology and treatment. Pediatr Clin N Am 2011;58(5):1217-40.
- Taveras E, Gillman MW, Kleinman K, et al. Racial/ethnic differences in early-life risk factors for childhood obesity. Pediatrics 2010;125(4):686-95.
- Chen JL, Weiss S, Heyman MB, et al. Risk factors for obesity and high blood pressure in Chinese American children: Maternal acculturation and children’s food choices. J Immigr Minor Health 2011;13(2):268-75.
- Vasudevan D, Stotts A, Anabor OL, et al. Primary care physician’s knowledge of ethnicity-specific guidelines for obesity diagnosis and readiness for obesity intervention among South Asian Indians. J Immigr Minor Health 2012;14(5):759-66.
- Peña MM, Dixon B, Taveras EM. Are you talking to ME? The importance of ethnicity and culture in childhood obesity prevention and management. Childhood Obes 2012;8(1):23-7.
- Renzaho AM. Fat, rich and beautiful: Changing socio-cultural paradigms associated with obesity risk, nutritional status and refugee children from sub-Saharan Africa. Health Place 2004;10(1):105-13.
- Pagani LS, Huot C. Why are children living in poverty getting fatter? Paediatr Child Health 2007;12(8):698-700.
- Cheah CS, Van Hook J. Chinese and Korean immigrants’ early life deprivation: An important factor for child feeding practices and children’s body weight in the United States. Soc Sci Med 2012;74(5):744-52.
- Rondinelli AJ, Morris MD, Rodwell TC, et al. Under- and over-nutrition among refugees in San Diego County, California. J Immigr Minor Health 2011;13(1):161-8.
- Harris KM, Perreira KM, Lee D. Obesity in the transition to adulthood. Arch Pediatr Adolesc Med 2009; 163(11): 1022-1028.
- Quon EC, McGrath JJ, Roy-Gagnon MH. Generation of immigration and body mass index in Canadian youth. J Ped Psychol 2012;37(8):843-53.
- Mazur RE, Marquis GS, Jensen HH. Diet and food insufficiency among Hispanic youths: Acculturation and socioeconomic factors in the third National Health and Nutrition Examination Survey. Am J Clin Nutr 2003;78(6):1120-7.
- Wang S, Quan J, Kanaya AM, et al. Asian Americans and obesity in California: A protective effect of biculturalism. J Immigr Minor Health 2011;13(2):276-83.
- Brophy S, Cooksey R, Gravenor MB, et al. Risk factors for childhood obesity at age 5: Analysis of the millennium cohort study. BMC Public Health 2009;9:467
- Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003-2006. JAMA 2008;299(20):2401-5
- Sniderman AD, Bhopal R, Prabhakaran D, et al. Why might South Asians be so susceptible to central obesity and its atherogenic consequences? The adipose tissue overflow hypothesis. Int J Epidemiol 2007;36(1):220-5.
- Renzaho AM, Gibbons C, Swinburn B, et al. Obesity and undernutrition in sub-Saharan African immigrant and refugee children in Victoria, Australia. Asia Pac J Clin Nutr 2006;15(4):482-90.
- Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev 2012;70(1):3-21.
- Van Hook J, Balistreri KS. Immigrant generation, socioeconomic status, and economic development of countries of origin: A longitudinal study of body mass index among children. Soc Sci Med 2007;65(5):976-89.
- Kumanyika S, Grier S. Targeting interventions for ethnic minority and low-income populations. Future Child 2006;16(1):187-207.
- Fleury D, Human Resources and Social Development Canada. A study of poverty and working poverty among recent immigrants to Canada: Final report, 2007.
- Dietitians of Canada, Canadian Paediatric Society, College of Family Physicians of Canada, Community Health Nurses of Canada. Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts. A collaborative statement. Abridged version. Paediatr Child Health 2010;15(2):77-9.
- Lawrence S, Cummings E, Chanoine JP, et al. Canadian Pediatric Endocrine Group extension to WHO growth charts: Why bother? Paediatr Child Health 2013;18(6): 295-7.
- World Health Organization. The Asia-Pacific perspective: Redefining obesity and its treatment. Geneva, Switzerland: WHO, 2000.
- Lau DC, Douketis JD, Morrison KM, et al.; Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ 2007;176(8):S1-13.
- Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report. Pediatrics 2011;128 Suppl 5:S213-56.
- August, GP et al. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based one expert opinion. J Clin Endocrinol Metab 2008, 93(12): 4575-99.
- Panagiotopoulos C, Riddell MC, Sellers EAC; for the Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Clinical practice guidelines: Type 2 diabetes in children and adolescents. Can J Diabetes 2013;37: S163-7.
- Leung AKC, Marchand V, Sauve R. The ‘picky eater’: The toddler or preschooler who does not eat. Paediatr Child Health 17(8):455-57.
- Canadian Paediatric Society, Feeding your baby in the first year: http://www.caringforkids.cps.ca/handouts/feeding_your_baby_in_the_first_year. [Parent Handout, 2014]
- Lipnowski S, LeBlanc CMA; CPS Healthy Active Living and Sports Medicine Committee. Healthy active living: Physical activity guidelines for children and adolescents. Paediatr Child Health 2012;17(4):209-10.
- Cummings C; CPS Community Paediatrics Committee. Melatonin for the management of sleep disorders in children and adolescents. Paediatr Child Health 2012;17(6):331-3.
- Perreira KM, Ornelas IJ. The physical and psychological well-being of immigrant children. Future Child 2011;21(1):195-218.
- Julie Bailon-Poujol, MD
- Élisabeth Rousseau Harsany, MD
- Danielle Grenier, MD
Last updated: April, 2018