Overweight and Obesity Among Hispanic Children Entering Foster Care

Abstract

This retrospective medical chart review examined the prevalence of overweight/obesity (≥85th percentile) and obesity (≥95th percentile) in Hispanic foster children aged 2–18 years in Los Angeles, California. Logistic regression was used for boys and girls separately to analyze polyvictimization (i.e., one vs. two or more types of maltreatment), type of maltreatment (abuse vs. neglect), and age-group as risk factors for overweight and obesity. Almost 40% of participants were overweight/obese, with the highest prevalence (47.7%) observed among children aged 12–18. Children aged 6–18 were at an increased risk of overweight/obesity and obesity compared with children aged 2–5. Although polyvictimization has been shown to have adverse health effects, in this study, it was related to slightly lower odds of obesity for boys but was unrelated to high weight for girls. Addressing the obesity epidemic among Hispanic foster children is vital to preventing continued obesity and the development of obesity-related health problems, especially by focusing on important community and family influences.

Keywords

maltreatment obesity overweight foster children polyvictimization

During the 1990s, one of the primary medical problems identified among children in foster care was underweight (Halfon, Mendonca, & Berkowitz, 1995; Silver et al., 1999). Several recent studies, however, have found that children in foster care are more likely to be overweight and obese than the general population (Helton & Diaz, 2012; Kim, Ham, Lee, & Lee, 2009; Schneiderman, Leslie, Arnold-Clark, McDaniel, & Xie, 2011). Studying weight problems among Hispanic children in foster care is particularly critical, because rates of both obesity and placement in foster care have been increasing for this population. The proportion of Hispanic children in foster care has more than doubled from 1982 to 2006, from 6.7% to 19% of the U.S. foster care population (Casey Family Programs, 2009). In 2010, Hispanic children comprised 44% of the total foster care population in California (National Kids Count Program, 2010). In a national sample, 39% of the Hispanic children and adolescents between 2 and 19 years old were overweight, and approximately 21% were obese compared to rates of 32% and 17%, respectively, across all racial and ethnic groups (Ogden, Carroll, Kit, & Flegal, 2012). High-weight problems can put all children at risk of health consequences (Koplan, Liverman, & Kraak, 2005; McCarthy et al., 2008), but some cardiovascular health problems and type 2 diabetes seem to affect obese ethnic minority children more often than obese White children (Flores et al., 2002; Kumanyika & Grier, 2006; Narayan, Boyle, Thompson, Sorensen, & Williamson, 2003).

The toxic stress framework suggests that great, frequent, or prolonged adversity, such as child maltreatment, may activate children’s stress response systems and have detrimental consequences on health and development (Shonkoff, 2010). One potential pathway from toxic stress to negative health outcomes may be problems regulating cortisol (McEwen & Seeman, 1999; Shonkoff, Richter, van der Gaag, & Bhutta, 2012), which may increase the risk of overweight or obesity (Dockray, Susman, & Dorn, 2009; Peeke & Chrousos, 1995). According to the toxic stress framework, children experiencing more prolonged or severe maltreatment would exhibit poorer health and developmental outcomes, including more weight problems. Research on adverse childhood experiences (ACEs) has supported this hypothesis. Adults with ACEs were at increased risk of substance use, risky sexual activity, smoking, and serious health consequences, such as cardiovascular disease and obesity (Felitti et al., 1998). The ACE study also found that these stressors were interrelated and that having one increased the likelihood of having multiple ACEs (Dong et al., 2004). Child maltreatment researchers have found that examining exposure to multiple types of abuse or neglect, or polyvictimization, may help explain adverse consequences more clearly than comparing types of abuse and neglect with one another (Finkelhor, Ormrod, & Turner, 2007a). Studies have found that polyvictimization experienced by children was associated with trauma symptoms, psychological distress, and lower grades in school (Finkelhor, Ormrod, & Turner, 2007b; Holt, Finkelhor, & Kantor, 2007). Children with four or more ACEs had twice the odds of being overweight or obese than children with no ACEs (Burke, Hellman, Scott, Weems, & Carrion, 2011). Thus, polyvictimization may better predict overweight and obesity in children entering foster care than individual types of maltreatment.

Researchers have explored the relationship between childhood maltreatment and overweight and obesity, and numerous retrospective studies have found links between adult obesity and self-reported childhood maltreatment (Aaron & Hughes, 2007; Chartier, Walker, & Naimark, 2009; Dube, Cook, & Edwards, 2010; Felitti et al., 1998; Midei, Matthews, & Bromberger, 2010; Noll, Zeller, Trickett, & Putnam, 2007; Williamson, Thompson, Anda, Dietz, & Felitti, 2002). In contrast to what is known about the relationship between childhood maltreatment and later weight problems during adulthood, little is known about the relationship between maltreatment and weight problems during childhood. Furthermore, research investigating whether weight problems are associated with all forms of child maltreatment or only certain forms has been inconsistent.

Studies examining the link between neglect and high-weight problems suggest a complex picture. In one study of 3- to 9-year-old children, which used caregiver ratings and observations in the home, care neglect was related to higher weight categories for younger but not older children, and supervisory neglect was related to higher weight categories for older but not younger children (Knutson, Taber, Murray, Valles, & Koeppl, 2010). In a sample of preschool children from 20 metropolitan U.S. cities, maternal self-report of neglectful behavior was associated with an increased risk of childhood obesity (Whitaker, Phillips, Orzol, & Burdette, 2007), whereas another study using child welfare records suggested that chronic neglect was related to lower weight percentiles for children between 8 and 9 years old (Bennett, Sullivan, Thompson, & Lewis, 2010). Child welfare records of maltreatment among young adolescents also indicated that neglect reduces the odds of obesity for girls but not for boys (Schneiderman, Mennen, Negriff, & Trickett, 2012).

It may be that other types of maltreatment provoke a greater stress reaction than neglect—particularly sexual abuse and physical abuse (Margolin & Gordis, 2000; Trickett, Negriff, Ji, & Peckins, 2011). Physical and sexual abuses have been linked to cortisol attenuation in adults (Harkness, Stewart, & Wynne-Edwards, 2011). In one study, emotional abuse also predicted cortisol attenuation (Carpenter et al., 2009), although another study found that emotional abuse was less related to cortisol regulation than physical and sexual abuse (Cicchetti, Rogosch, Gunnar, & Toth, 2010). The relationship between abuse, including physical, emotional, and sexual abuse, and high-weight problems is also unclear. In a study using self-reported history of maltreatment, adolescents who were victims of physical abuse had a greater tendency to be overweight in late adolescence or young adulthood than adolescents who had been sexually abused, neglected, or both (Clark, Thatcher, & Martin, 2010). Other studies, which also used self-reported history of maltreatment, found no association between a childhood history of sexual abuse and weight problems in adolescence or early adulthood (Holmberg & Hellberg, 2010; Hussey, Chang, & Kotch, 2006). Counter to these findings, boy and girls with child welfare-documented sexual and physical abuse had slightly reduced odds of obesity (Schneiderman et al., 2012). Emotional abuse has not been examined as often as physical and sexual abuse in the childhood overweight and obesity literature. Thus, there is some indication that specific types of abuse may be associated with both increased and decreased rates of obesity, but there is more evidence that childhood abuse is related to a stress response, although more research is needed to determine how abuse is related to weight problems.

Inconsistent findings regarding maltreatment and childhood obesity and overweight may stem from the poor quality of some previous studies. Specifically, some studies have used self- or caregiver-reported height and weight (e.g. Holmberg & Hellberg, 2010) which have been found to be inaccurate (Dubois & Girad, 2007; Sherry, Jefferds, & Grummer-Strawn, 2007). Measuring heights and weights to identify weight problems is more valid and reliable (Akerman, Williams, & Meunier, 2007; Merrill & Richardson, 2009) than self- or caregiver-reported heights and weights. Also, some studies have used self- or caregiver-reported maltreatment (e.g., Knutson et al., 2010; Whitaker et al., 2007) which may not include all types of maltreatment. Using the toxic stress framework, we sought to clarify current understanding of how types of maltreatment and polyvictimization, in particular, might put Hispanic children at risk of overweight or obesity. A recent meta-analysis found that childhood maltreatment was related to obesity throughout the life course, but the relationship was not significant in studies of children and adolescents, although only 9 of the 41 research papers included children as participants, and polyvictimization was not studied (Danese & Tan, 2013).

To address these gaps in the extant research, we undertook a retrospective medical chart review, using height and weight measurements and child welfare-documented maltreatment from medical records of a sample of Hispanic children entering foster care in Los Angeles, CA, to examine (a) the prevalence of weight categories upon entrance to foster care and (b) the relationships between high-weight categories, including overweight/obesity and obesity, and number and type of maltreatment, gender, and age. We predicted that children who had been polyvictimized would be at greater risk of high-weight problems. We also examined the relationships among physical abuse, sexual abuse, emotional abuse, or a combination of two or more, compared with only neglect, and high-weight categories. We predicted that children who had been abused would more likely be overweight or obese than children who had been neglected only. Underweight participants (n = 42; 2.02%) were excluded when examining the relationships among number of maltreatment types, age, and gender with overweight or obesity because the subsample was too small for regression analysis.

Method

Setting and Sample

The setting for data collection was the Community-Based Assessment and Treatment Center (CATC), a pediatric clinic linked to the Los Angeles County Department of Children and Family Services (DCFS) that only serves children receiving child welfare services. Los Angeles County requires that all children entering foster care receive a comprehensive medical evaluation at a specialized foster care clinic. CATC is one of the specialized clinics and receives direct referrals from DCFS. We collected data on all children between 2 and 18 years old who (a) attended an initial medical appointment when they entered foster care at CATC and (b) were not pregnant (N = 2,927). We limited our participants to those children who had maltreatment type listed in their medical records or forensic exam records (N = 2,577) and excluded 350 participants who did not have maltreatment data. CATC is located in East Los Angeles, a predominately Hispanic area of Los Angeles. Our sample included a greater percentage of Hispanics (80.6%) than the total population served by DCFS (58.5%; County of Los Angeles DCFS, 2012). We used a within-group design and restricted our study to Hispanic participants who met all inclusion criteria (N = 2,078), excluding 499 participants who were not Hispanic. There were no differences in the proportions of obesity, overweight, and underweight between study participants and excluded participants. The University of Southern California Institutional Review Board, DCFS, and the Juvenile Division of the Los Angeles Superior Court granted approval (with individual consent exemption) for this retrospective study.

The medical records were dated from April 2006 to February 2011. From the medical records, we collected child characteristics including birth date, gender, ethnicity, examination date, weight in kilograms, and height in centimeters. Heights and weights were measured by a trained nursing assistant at the beginning of the pediatric medical exam using a Scale-Tronix scale and Seca height instrument. We also collected information on child maltreatment type (neglect, physical abuse, emotional abuse, and sexual abuse) from the medical records (Barnett, Manly, & Cicchetti, 1993). Maltreatment type was listed in a section on each medical record featuring DCFS referral information. We were unable to obtain original DCFS records. The reliability of the DCFS-identified maltreatment type was high (100% agreement), because the description entered was simple and brief (e.g., “general neglect” or “child and sibling physically abused”). For a small amount of participants (8%), DCFS-identified maltreatment type was missing; therefore, we read the full-length forensic examination documentation that included maltreatment history. For those children, we collaboratively identified the type of maltreatment in conjunction with expert consultation from a board-certified Child Abuse Pediatrician.

Data Analysis

Frequencies of age, gender, type of maltreatment, and number of maltreatment types were calculated. We divided participants into the three age categories used in the National Health and Nutrition Examination Survey (NHANES): 2–5, 6–11, and 12–19 years. Age- and gender-adjusted weight percentile rankings were calculated for all participants based on the Centers for Disease Control and Prevention (CDC) 2000 growth chart (Centers for Disease Control and Prevention, 2011). The weight categories for the participants were identified using body mass index (BMI) percentiles: normal weight (≥5th percentile and <85th percentile), obese (≥95th percentile), overweight (≥85th percentile and <95th percentile), and underweight (<5th percentile). To identify high-weight problems in the population, we also examined the prevalence of overweight and obesity combined (≥85th percentile). BMI percentile is a measure of relative weight rather than adiposity and is the preferred measure of overweight and obesity (Whitlock, Williams, Gold, Smith, & Shipman, 2005). Children in high-weight categories have been found to more likely have adverse health risks and become obese adults than children with normal weights (Freedman & Sherry, 2009).

Logistic regression was used to analyze the relationships between overweight and obesity and polyvictimization (i.e., one type of maltreatment vs. two or more types of maltreatment), abuse (physical, sexual, emotional, or a combination without neglect vs. neglect without abuse), and age compared with normal weight. All analyses were conducted separately for boys and girls, because the development of weight problems can differ between genders (Pigeot et al., 2009; Prentice-Dunn & Prentice-Dunn, 2012; Wisniewski & Chernausek, 2009) as can relationships between certain types of maltreatment and weight problems (e.g., Schneiderman et al., 2012). For all analyses, the significance level was p < .05.

Results

The sample was distributed relatively evenly across age and gender, although boys were younger than girls (p < .001; see Table 1 for details on the types of maltreatment experienced by children of different ages and genders). Most children were in foster care because of neglect, followed by physical abuse, sexual abuse, and emotional abuse. The specific combinations of maltreatment are presented in Table 2. Table 2 also identifies the categorization of abuse without neglect, which was used in the regression model. Most participants had only one type of reported maltreatment, with 30.8% of children experiencing at least two types and 8.2% experiencing at least three types. The distribution of weight categories of participants is presented in Table 3. Approximately 40% of the participants in this study were overweight/obese.

Table 1.

Description of Hispanic Sample.

		Maltreatment, n (%)
Variable	Overall	1 Type	2+ Types	Any PA	Any EA	Any SA	Any Neglect	Only Neglect	Only Abuse
n	2,078	1,437 (69.2)	641 (30.8)	561 (27.0)	264 (12.7)	351 (16.9)	1,726 (83.1)	1,155 (55.6)	352 (16.9)
Age
2–5	769	533 (69.3)	236 (30.7)	199 (25.9)	94 (12.2)	101 (13.1)	674 (87.7)	458 (59.6)	95 (12.4)
6–11	770	544 (70.7)	226 (29.4)	201 (26.1)	98 (12.7)	116 (15.1)	650 (84.4)	442 (57.4)	120 (15.6)
12–18	539	360 (66.8)	179 (33.2)	161 (29.9)	72 (13.4)	134 (24.9)	402 (74.6)	255 (47.3)	137 (25.4)
Gender
Male	1,018	718 (70.5)	300 (29.5)	272 (26.7)	129 (12.7)	125 (12.3)	872 (85.7)	600 (58.9)	146 (14.3)
Female	1,060	719 (67.8)	341 (32.2)	289 (27.3)	135 (12.7)	226 (21.3)	854 (80.6)	555 (52.4)	206 (19.4)

Note. PA = physical abuse; EA = emotional abuse; SA = sexual abuse; Any = children who experienced this type of maltreatment in any combination with other types of maltreatment; Only Neglect = children who were neglected but did not experience any other type of maltreatment; Only Abuse = children who experienced either emotional, physical, or sexual abuse (in any combination) but not neglect; SD = standard deviation. Males were younger than females in this sample (M = 0.70 years apart, SD = 4.5 years; p < .001). Combined values of specific maltreatment types may exceed 100%, because 804 (31.2%) participants reported more than one type of maltreatment.

Table 2.

Combinations of Maltreatment Types in Descending Order.

Maltreatment Combinations	n	%
Neglect only	1,155	55.58
Neglect + physical abuse	182	8.76
Physical abuse only^a	162	7.8
Neglect + sexual abuse	121	5.82
Sexual abuse only^a	115	5.53
Neglect + emotional abuse	106	5.1
Neglect + physical abuse + emotional abuse	82	3.95
Neglect + physical abuse + sexual abuse	55	2.65
Physical abuse + emotional abuse^a	35	1.68
Physical abuse + sexual abuse^a	24	1.15
Neglect + emotional abuse + sexual abuse	13	0.63
Neglect + physical abuse + emotional abuse + sexual abuse	12	0.58
Physical abuse + emotional abuse + sexual abuse^a	9	0.43
Emotional abuse only^a	5	0.24
Emotional abuse + sexual abuse^a	2	0.1

^aCombinations of abuse included in the abuse-only category.

Table 3.

Prevalence of Weight Categories.

Variable	Underweight	Normal	Overweight n (%)	Obese	Overweight/Obese
n	42 (2.0)	1,215 (58.5)	381 (18.3)	440 (21.2)	821 (39.5)
Age
2–5	19 (2.5)	505 (65.7)	117 (15.2)	128 (16.6)	245 (31.8)
6–11	11 (1.4)	440 (57.1)	141 (18.3)	178 (23.1)	319 (41.4)
12–18	12 (2.2)	270 (50.1)	123 (22.8)	134 (24.9)	257 (47.7)
Gender
Male	24 (2.4)	588 (57.8)	173 (17.0)	233 (22.9)	406 (39.9)
Female	18 (1.7)	627 (59.2)	208 (19.6)	207 (19.5)	415 (39.2)

Note. CDC = Centers for Disease Control and Prevention; Underweight = <5th percentile; normal = ≥5th and <85th percentiles; overweight = ≥85th and <95th percentiles; obese = ≥95th percentile; overweight/obese = ≥85th percentile on CDC 2000 growth charts (CDC, 2011).

Relationships Among Overweight and Obesity, Age, and Maltreatment

In Table 4, the odds ratios (OR) and confidence intervals (CIs) estimating the relationships between age, polyvictimization, and abuse versus neglect, and high-weight categories are presented. For both girls and boys, children between 6- and 18 years old were significantly more likely than 2- to 5-year-old children to be obese or overweight/obese than normal weight (p < .05). Furthermore, children between 12 and 18 years old were more likely to be obese or overweight/obese than 6- to 11-year-old children (p < .05). Specifically, children in the 6–11 years age-group were approximately 1.5 times more likely to be overweight/obese or obese than normal weight. Children in the 12–18 years age-group were approximately 2 times more likely to be overweight/obese or obese than normal weight. Polyvictimization, compared with having only one maltreatment type, did not significantly increase or decrease the likelihood of being in the high-weight categories for girls in this Hispanic sample. However, boys who experienced polyvictimization were less likely to be obese (OR = 0.56, 95% CI [0.35, 0.90]) or overweight/obese (OR = 0.67, 95% CI [0.46, 0.97]). Abuse did not put girls or boys at increased risk of obesity or overweight/obesity compared with neglect.

Table 4.

The Relationships Between Age and Maltreatment With Overweight and Obesity by Gender.

Variable	Obese vs. Normal OR [95% CI]	Overweight/Obese vs. Normal OR [95% CI]
Girls
Age
2–5	Ref	Ref
6–11	1.52 [1.04, 2.23]	1.58 [1.17, 2.15]
12–18	1.67 [1.11, 2.50]	2.14 [1.55, 2.94]
p value for age contrast (12–18 vs. 6–11)	<.05	<.001
Maltreatment experiences
1 Maltreatment type	Ref	Ref
2+ Maltreatment types	1.02 [0.68, 1.53]	1.01 [0.73, 1.39]
Only neglect (ref) vs. only abuse	1.02 [0.72, 1.43]	0.82 [0.62, 1.08]
Boys
Age
2–5	Ref	Ref
6–11	1.71 [1.19, .46]	1.43 [1.07, 1.91]
12–18	2.60 [1.72, 3.94]	1.95 [1.39, 2.75]
p value for age contrast (12–18 vs. 6–11)	<.001	<.001
Maltreatment experiences
1 Maltreatment type	Ref	Ref
2+ Maltreatment types	0.56 [0.35, 0.90]	0.67 [0.46, 0.97]
Only neglect (ref) vs. only abuse	0.71 [0.50, 1.01]	0.77 [0.58, 1.02]

Note. CDC = Centers for Disease Control and Prevention; CI = confidence interval; Only neglect = neglect without any other types of maltreatment; only abuse = physical abuse, emotional abuse, sexual abuse, or a combination without neglect; Ref = reference category; OR = odds ratio; Normal = ≥5th and <85th percentiles; obese = ≥95th percentile; and overweight/obese = ≥85th percentile on CDC 2000 growth charts (CDC, 2011). ORs in bold are significant at p < .05. Forty-two participants were underweight and were not included in the analysis.

Discussion

Using validated records of height, weight, and maltreatment history, we found that the prevalence of overweight/obesity among Hispanic foster children in this study was similar to Hispanic children in the 2007–2008 NHANES (39.5% vs. 38.2%, respectively; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). However, the prevalence of overweight/obesity among 12- to 18-year-old children was 6% higher than a similar Hispanic age-group in the NHANES, and the prevalence of obesity was 4% higher for 12- to 18-year-old children in our sample compared with the NHANES (the NHANES sample included children from 2 to 19 years old). In 2007–2008, the prevalence of obesity in fifth-, seventh-, and ninth-grade public school children in Los Angeles county was 23% (County of Los Angeles Department of Public Health, 2011), which is similar to the 6- to 11-year-old children (23.1%) and 12- to 18-year-old children (24.9%) in our study. The obesity levels in our sample reflect the childhood obesity epidemic present in Los Angeles county. Underweight was not a significant problem for children in this sample; the prevalence of underweight among our population was smaller than that recorded in the NHANES estimates for 2007–2008 for all ethnicities (2.0% vs. 3.7%, respectively; Fryar & Ogden, 2010).

The only significant relationship between maltreatment and the high-weight categories contradicted our study hypotheses. According to the toxic stress framework, negative experiences such as polyvictimization and child abuse may interfere with healthy development and lead to weight problems for children in the child welfare system. However, polyvictimization was associated with a reduced probability of high-weight problems for boys. These results should be interpreted cautiously because they do not replicate previous research. Nonetheless, it is possible to understand reduced high-weight problems among polyvictimized boys in terms of gender differences concerning emotional and binge eating. Boys are no more likely to overeat under conditions of worry, tension, and anxiety than when these distressing triggers are not present (Nguyen-Rodriguez, Unger, & Spruijt-Metz, 2009). Binge eating is also more common in adolescent females than males (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011), and this may also play a role in the gender differences we found; however, binge eating prevalence was found to be more similar between genders in young children in other research (Tanofsky-Kraff et al., 2012). Future research on high-weight problems among foster children should measure emotional distress and related binge eating at different stages of development and across genders. For example, young girls and boys with adverse circumstances, such as childhood maltreatment, may engage in emotional or binge eating at similar rates, but older boys may be less likely to overeat when experiencing emotional distress and rather exhibit externalizing symptoms (Bongers, Koot, van der Ende, & Verhulst, 2004; Gavazzi, Lim, Yarcheck, Bostic, & Scheer, 2008; Sanchez, Lambert, & Cooley-Strickland, 2013) that would less likely result in obesity or overweight.

Based, in part, on data from the ACE study, the CDC has proposed that maltreatment leads to childhood toxic stress that affects childhood health (Middlebrooks & Audage, 2008). Although we expected abuse to be a more stressful experience than neglect and be associated with increased risk of weight problems, in this study, we did not find any significant differences between abuse and neglect relating to high-weight categories. ACEs include not only childhood maltreatment but also family experiences, such as having an alcohol abuser, drug abuser, or both in the home; an incarcerated household member; a mother who has been treated violently; or the presence of only one parent or no parents (Burke et al., 2011). Unfortunately, in this retrospective study, we were only able to collect data on maltreatment. It may be that maltreatment does not represent the complete picture of possible childhood life stresses that lead to obesity. In a study of obesity among young adolescents, participants with maltreatment had a similar prevalence of obesity as a comparison sample from the same community (Schneiderman et al., 2012). Community and family influences could be more influential in the development of obesity in children than maltreatment. It is also possible that negative outcomes of maltreatment may be cumulative and occur over a longer time frame. For example, in a prospective longitudinal study by Noll, Zeller, Trickett, and Putnam (2007), there were no significant differences in weight between sexually abused girls and a comparison group during adolescence, although the sexually abused group had higher BMI levels than the comparison group in early adulthood.

Although our hypotheses were not confirmed, the Hispanic study population had a high prevalence of overweight and obesity. The American Medical Association recently identified that obesity is a disease that requires active treatment by the medical and social welfare communities (American Medical Association, 2012). Many obesity prevention or intervention programs for Hispanic children have been designed to address several factors that contribute to overweight or obesity (i.e., diet, exercise, and thoughts about weight; Olvera et al., 2010; Stevens, 2012) and to promote change at several environmental levels (i.e., the individual child, the family, the school, and the community; Crespo et al., 2012). For younger Hispanic children, parent-focused interventions may be the most effective, especially in terms of promoting nutritious eating and physical activity (Crespo et al., 2012); however, these interventions have not been tested with foster care families. In this study, adolescents had the highest rates of overweight and obesity. Preliminary research has suggested that both classroom- and home-based nutrition interventions may be promising approaches to reducing obesity in Hispanic adolescents (Davis et al., 2007). In addition, including physical activities (e.g., dance classes or cardiovascular exercises) in obesity interventions for Hispanic teens may be important (e.g., Shaibi et al., 2012).

Limitations

The primary limitation of this study was the use of existing medical records, which limited the type of data collected. For example, the maltreatment data used in this study were taken from the children’s medical records. DCFS shared the maltreatment information upon referral to CATC, and the data analyzed in this study may not include other types of maltreatment identified by DCFS after the medical referral was made. However, using medical records rather than self- or caregiver-reported weight and height also represents a strength of this study, because it likely improved the BMI percentile accuracy. We were unable to control for gestational age or birth weight of young children; this information is usually not known by foster caregivers or medical providers (Taveras et al., 2009). Also, we were unable to control parental weight status, which is a predictor of child and adolescent obesity (Davison, Francis, & Birch, 2005). Additionally, we were unable to control for pubertal status among older children. Some researchers have questioned the validity of BMI percentile weight categories for measuring the percentage of body fat and risk of negative health consequences (Bray, DeLany, Volaufova, Harsha, & Champagne, 2002; Zimmermann, Gubeli, Puntener, & Molinari, 2004). BMI weight categories are thought to be valid indicators of body fatness at the higher end of the BMI scale, but the value of this measure may be limited for underweight children (Freedman & Sherry, 2009). This fact suggests that the results from this study pertaining to children in the overweight or obesity categories are more valid than the results for children in the normal or underweight category. Future research could benefit from using other measures of body fatness (e.g., skinfold measures or waist circumference). However, these measures were not included in the medical records used in this study.

Unfortunately, because this study was a retrospective medical record review, we were not able to access potentially relevant additional variables, such as those that might reflect the likely heterogeneity within our Hispanic sample (e.g., language and birth place of parents or children). The use of official child welfare reports of maltreatment captured only what professionals noted in their investigations and official reports and, thus, may not have captured the totality of participant experiences (Shaffer, Huston, & Egeland, 2008). The experiences of children with self- or caregiver-reported maltreatment may differ from the experiences of children with child welfare-documented maltreatment (Gilbert et al., 2009). To more fully test the toxic stress framework’s predictions regarding the relationship between childhood maltreatment and high-weight problems, it would have been helpful to have more information about the maltreatment experienced in this sample (e.g., severity and chronicity). However, we did have the ability to examine how multiple maltreatment experiences might have induced greater stress responses and subsequent increased weight gain. Generalizability was limited due to the urban and Hispanic characteristics of the sample population; thus, the results cannot be extended to nonurban or non-Hispanic populations. No comparable local sample of children not involved in the child welfare system was available.

Conclusion

Child welfare officials need to work with the pediatric health community to address obesity among Hispanic foster children. Although Hispanic adolescents in this study were more likely to be overweight or obese than younger children, as well as other Hispanic adolescents in the total U.S. population, addressing obesity in early childhood might be important, because obesity may be self-perpetuating and more difficult to treat during adolescence (Skinner, Steiner, & Perrin, 2012). Afterschool physical activity programs have proven useful in reducing weight among overweight or obese children (Mahoney, Lord, & Carryl, 2005), and child welfare workers can refer foster caregivers of overweight or obese children to local afterschool programs. Further research is required to determine the relationships among all ACEs with weight problems among children entering foster care and the relationship between obesity and co-occurring health problems in the population of children in foster care. Hispanic children in this study who were maltreated and entered foster care had a high prevalence of overweight and obesity, and the coordinated efforts of child welfare and the pediatric health care community are needed to address this pervasive public health threat.

Footnotes

Acknowledgments

The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institutes of Health or the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The authors acknowledge the University of Southern California, School of Social Work, Hamovitch Center for Science in the Human Services for a grant from the Larson Endowment for Innovative Research and Teaching. The authors thank Eric Lindberg for editorial assistance.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors want to acknowledge the National Institutes of Health for the grant that supported this research: the Eunice Kennedy Shriver National Institute of Child Health & Human Development K01-HD05798 (PI: Schneiderman) and University of Southern California, School of Social Work, Hamovitch Center for Science in the Human Services for a grant from the Larson Endowment for Innovative Research and Teaching.

References

Aaron

D. J.

Hughes

T. L.

(2007). Association of childhood sexual abuse with obesity in community sample of lesbians. Obesity, 15, 1023–1028. doi:10.1038/oby.2007.634

Akerman

Williams

M. E.

Meunier

(2007). Perception versus reality: An exploration of children’s measured body mass in relation to caregivers’ estimates. Journal of Health Psychology, 12, 871–882. doi:10.1177/1359105307082449

American Medical Association House of Delegates. (2012). Obesity should be considered a chronic medical disease state. Retrieved from http://www.ama-assn.org/assets/meeting/2013a/a13-addendum-refcomm-d.pdf

Barnett

Manly

J. T.

Cicchetti

(1993). Defining child maltreatment: The interface between policy and research. In Cicchetti

Toth

S. L.

(Eds.), Child abuse, child development, and social policy (pp. 7–73). Norwood, NJ: Ablex.

Bennett

D. S.

Sullivan

M. W.

Thompson

S. M.

Lewis

(2010). Early child neglect: Does it predict obesity or underweight in later childhood? Child Maltreatment, 15, 250–254. doi:10.1177/1077559510363730

Bongers

I. L.

Koot

H. M.

Van Der Ende

Verhulst

F. C.

(2004). Developmental trajectories of externalizing behaviors in childhood and adolescence. Child Development, 75, 1523–1537. doi:10.1111/j.1467-8624.2004.00755.x

Bray

G. A.

DeLany

J. P.

Volaufova

Harsha

D. W.

Champagne

(2002). Prediction of body fat in 12-y-old African American and white children: Evaluation of methods. American Journal of Clinical Nutrition, 76, 980–990.

Burke

N. J.

Hellman

J. L.

Scott

B. G.

Weems

C. F.

Carrion

V. G.

(2011). The impact of adverse childhood experiences on an urban pediatric population. Child Abuse & Neglect, 35, 408–413. doi:10.1016/j.chiabu.2011.02.006

Carpenter

L. L.

Tyrka

A. R.

Ross

N. S.

Khoury

Anderson

G. M.

Price

L. H.

(2009). Effect of childhood emotional abuse and age on cortisol responsivity in adulthood. Biological Psychiatry, 66, 69–75. doi:10.1016/j.biopsych.2009.02.030

10.

Casey Family Programs. (2009). Fact sheet: Latino children in child welfare. Retrieved from http://www.casey.org/Resources/Publications/LatinoChildren.htm

11.

Centers for Disease Control and Prevention. (2011). About BMI for children and teens. Retrieved from http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html

12.

Chartier

M. J.

Walker

J. R.

Naimark

(2009). Health risk behaviors and mental health problems as mediators of the relationship between childhood abuse and adult health. American Journal of Public Health, 99, 847–854. doi:10.2105/AJPH.2007.122408

13.

Cicchetti

Rogosch

F. A.

Gunnar

M. R.

Toth

S. L.

(2010). The differential impacts of early physical and sexual abuse and internalizing problems on daytime cortisol rhythm in school-aged children. Child Development, 81, 252–269. doi:10.1111/j.1467-8624.2009.01393.x

14.

Clark

D. B.

Thatcher

D. L.

Martin

C. S.

(2010). Child abuse and other traumatic experiences, alcohol use disorders, and health problems in adolescence and young adulthood. Journal of Pediatric Psychology, 35, 499–510. doi:10.1093/jpepsy/jsp117

15.

County of Los Angeles Department of Children and Family Services. (2012). Fact sheet: Child welfare services, July 2012. Retrieved from http://www.lacdcfs.org/aboutus/fact_sheet/DRS/July2012/Fact_Sheet.htm

16.

County of Los Angeles Department of Public Health. (2011). Obesity and related mortality in Los Angeles County: A cities and communities health report. Retrieved from http://publichealth.lacounty.gov/ha/reports/habriefs/2007/Obese_Cities/Obesity_2011Fs.pdf

17.

Crespo

N. C.

Elder

J. P.

Ayala

G. X.

Slymen

D. J.

Campbell

N. R.

Sallis

J. F.

Arredondo

E. M

. (2012). Results of a multi-level intervention to prevent and control childhood obesity among Latino children: The Aventuras Para Niños Study. Annals of Behavioral Medicine, 43, 84–100. doi:10.1007/s12160-011-9332-7

18.

Danese

Tan

. (2013). Childhood maltreatment and obesity: Systematic review and meta-analysis. Molecular Psychiatry. Advance online publication. doi:10.1038/mp.2013.54

19.

Davis

J. N.

Ventura

E. E.

Alexander

K. E.

Salguero

L. E.

Weigensberg

M. J.

Crespo

N. C.

Goran

M. I

. (2007). Feasibility of a home-based versus classroom-based nutrition intervention to reduce obesity and type 2 diabetes in Latino youth. International Journal of Pediatric Obesity, 2, 22–30. doi:10.1080/17477160601133077

20.

Davison

K. K.

Francis

L. A.

Birch

L. L.

(2005). Reexamining obesigenic families: Parents’ obesity-related behaviors predict girls’ change in BMI. Obesity Research, 13, 1980–1990. doi:10.1038/oby.2005.243

21.

Dockray

Susman

E. J.

Dorn

L. D.

(2009). Depression, cortisol reactivity, and obesity in childhood and adolescence. Journal of Adolescent Health, 45, 344–350. doi:10.1016/j.jadohealth.2009.06.014

22.

Dong

Anda

R. F.

Felitti

V. J.

Dube

S. R.

Williamson

D. F.

Thompson

T. J.

Giles

W. H

. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse and Neglect, 28, 771–784. doi:10.1016/j.chiabu.2004.01.008

23.

Dube

S. R.

Cook

M. L.

Edwards

V. J

. (2010). Health-related outcomes of adverse childhood experiences in Texas, 2002. Preventing Chronic Disease, 7, A52. Retrieved from http://www.cdc.gov/pcd/issues/2010/may/09_0158.htm

24.

Dubois

Girad

(2007). Accuracy of maternal reports of pre-schoolers’ weights and heights as estimates of BMI values. International Journal of Epidemiology, 36, 132–138. doi:10.1093/ije/dyl281

25.

Felitti

V. J.

Anda

R. F.

Nordenberg

Williamson

D. F.

Spitz

A. M.

Edwards

Marks

J. S

. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. doi:10.1016/S0749-3797(98)00017-8

26.

Finkelhor

Ormrod

R. K.

Turner

H. A.

(2007a). Poly-victimization: A neglected component in child victimization. Child Abuse & Neglect, 31, 7–26. doi:10.1016/j.chiabu.2006.06.008

27.

Finkelhor

Ormrod

R. K.

Turner

H. A.

(2007b). Polyvictimization and trauma in a national longitudinal cohort. Development and Psychopathology, 19, 149–166. doi:10.1017/S0954579407070083

28.

Flores

Fuentes-Afflick

Barbot

Carter-Pokras

Claudio

Lara

Weitzman

. (2002). The health of Latino children: Urgent priorities, unanswered questions, and a research agenda. Journal of the American Medical Association, 288, 82–90. doi:10.1001/jama.288.1.82

29.

Freedman

D. S.

Sherry

(2009). The validity of BMI as an indicator of body fatness and risk among children. Pediatrics, 124, S23–S34. doi:10.1542/peds.2008-3586E

30.

Fryar

C. D.

Ogden

C. L

. (2010). Prevalence of underweight among children and adolescents: United States, 2007-2008. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/nchs/data/hestat/underweight_child_07_08/underweight_child_07_08.htm

31.

Gavazzi

S. M.

Lim

Yarcheck

C. M.

Bostic

J. M.

Scheer

S. D.

(2008). The impact of gender and family processes on mental health and substance use issues in a sample of court-involved female and male adolescents. Journal of Youth and Adolescence, 37, 1071–1084. doi:10.1007/s10964-008-9306-7

32.

Gilbert

Widom

C. S.

Browne

Fergusson

Webb

Janson

(2009). Burden and consequences of child maltreatment in high-income countries. Lancet, 373, 68–81. doi:10.1016/S0140-6736(08)61706-7

33.

Halfon

Mendonca

Berkowitz

(1995). Health status of children in foster care: The experience of the Center for the Vulnerable Child. Archives of Pediatrics & Adolescent Medicine, 149, 386–392. doi:10.1001/archpedi.1995.02170160040006

34.

Harkness

K. L.

Stewart

J. G.

Wynne-Edwards

(2011). Cortisol reactivity to social stress in adolescents: Role of depression severity and child maltreatment. Psychoneuroendocrinology, 36, 173–181. doi:10.1016/j.psyneuen.2010.07.006

35.

Helton

J. J.

Diaz

. (2012). Foster youth and obesity: Who is at risk? Retrieved from

University of Illinois at Urbana-Champaign, Children and Family Research Center

website: http://cfrc.illinois.edu/pubs/po_20120601_FosterYouthAndObesityWhoIsAtRisk.pdf

36.

Holmberg

L. I.

Hellberg

(2010). Sexually abused children: Characterization of these girls when adolescents. International Journal of Adolescent Medicine and Health, 22, 291–300. doi:10.1515/IJAMH.2010.22.2.291

37.

Holt

M. K.

Finkelhor

Kantor

G. K.

(2007). Multiple victimization experiences of urban elementary school students: Associations with psychosocial functioning and academic performance. Child Abuse & Neglect, 31, 503–515. doi:10.1016/j.chiabu.2006.12.006

38.

Hussey

J. M.

Chang

J. J.

Kotch

J. B.

(2006). Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences. Pediatrics, 118, 933–942. doi:10.1542/peds.2005-2452

39.

Kim

H.-S.

Ham

O.-K.

Lee

C.-Y.

Lee

T.-W.

(2009). Health problems and health behaviors of Korean preschoolers living with parents and under guardianship. Public Health Nursing, 26, 207–217. doi:10.1111/j.1525-1446.2009.00773.x

40.

Knutson

J. F.

Taber

S. M.

Murray

A. J.

Valles

N.-L.

Koeppl

(2010). The role of care neglect and supervisory neglect in childhood obesity in a disadvantaged sample. Journal of Pediatric Psychology, 35, 523–532. doi:10.1093/jpepsy/jsp115

41.

Koplan

J. P.

Liverman

C. T.

Kraak

V. I

. (2005). Preventing childhood obesity: Health in the balance: Executive summary. Journal of the American Dietetic Association, 105, 131–138. doi:10.1016/j.jada.2004.11.023

42.

Kumanyika

Grier

(2006). Targeting interventions for ethnic minority and low-income populations. Future of Children, 16, 187–207. doi:10.1353/foc.2006.0005

43.

Mahoney

J. L.

Lord

Carryl

. (2005). Afterschool program participation and the development of child obesity and peer acceptance. Applied Developmental Science, 9, 202–215. doi:10.1207/s1532480xads0904_3

44.

Margolin

Gordis

E. B.

(2000). The effects of family and community violence on children. Annual Review of Psychology, 51, 445–479.

45.

McCarthy

W. J.

Yancey

A. K.

Siegel

J. M.

Wong

W. K.

Ward

Leslie

Gonzales

. (2008). Correlation of obesity with elevated blood pressure among racial/ethnic minority children in two Los Angeles middle schools. Preventing Chronic Disease, 5, A46. Retrieved from http://www.cdc.gov/pcd/issues/2008/apr/06_0121.htm

46.

McEwen

B. S.

Seeman

(1999). Protective and damaging effects of mediators of stress: Elaborating and testing the concepts of allostasis and allostatic load. Annals of the New York Academy of Sciences, 896, 30–47. doi:10.1111/j.1749-6632.1999.tb08103.x

47.

Merrill

R. M.

Richardson

J. S

. (2009). Validity of self-reported height, weight, and body mass index: Findings from the National Health and Nutrition Examination Survey, 2001-2006. Preventing Chronic Disease, 6, A121. Retrieved from http://www.cdc.gov/pcd/issues/2009/oct/08_0229.htm

48.

Middlebrooks

J. S.

Audage

N. C

. (2008). The effects of childhood stress on health across the lifespan. Retrieved from

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control

website: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf

49.

Midei

A. J.

Matthews

K. A.

Bromberger

J. T.

(2010). Childhood abuse is associated with adiposity in midlife women: Possible pathways through trait anger and reproductive hormones. Psychosomatic Medicine, 72, 215–223. doi:10.1097/PSY.0b013e3181cb5c24

50.

Narayan

K. M. V.

Boyle

J. P.

Thompson

T. J.

Sorensen

S. W.

Williamson

D. F.

(2003). Lifetime risk for diabetes mellitus in the United States. Journal of the American Medical Association, 290, 1884–1890. doi:10.1001/jama.290.14.1884

51.

National Kids Count Program. (2010). Children in foster care by race or Hispanic origin (percent)–2010. Retrieved from http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=6246

52.

Nguyen-Rodriguez

Unger

J. B.

Spruijt-Metz

(2009). Psychological determinants of emotional eating in adolescence. Eating Disorders: The Journal of Treatment & Prevention, 17, 211–224. doi:10.1080/10640260902848543

53.

Noll

J. G.

Zeller

M. H.

Trickett

P. K.

Putnam

F. W.

(2007). Obesity risk for female victims of childhood sexual abuse: A prospective study. Pediatrics, 120, e61–e67. doi:10.1542/peds.2006-3058

54.

Ogden

C. L.

Carroll

M. D.

Curtin

L. R.

Lamb

M. M.

Flegal

K. M.

(2010). Prevalence of high body mass index in US children and adolescents, 2007-2008. Journal of American Medical Association, 303, 242–249. doi:10.1001/jama.2009.2012

55.

Ogden

C. L.

Carroll

M. D.

Kit

B. K.

Flegal

K. M.

(2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. Journal of the American Medical Association, 307, 483–490. doi:10.1001/jama.2012.40

56.

Olvera

Bush

J. A.

Sharma

S. V.

Knox

B. B.

Scherer

R. L.

Butte

N. F.

(2010). BOUNCE: A community-based mother–daughter healthy lifestyle intervention for low-income Latino families. Obesity, 18, S102–S104. doi:10.1038/oby.2009.439

57.

Peeke

P. M.

Chrousos

G. P.

(1995). Hypercortisolism and obesity. Annals of the New York Academy of Sciences, 771, 665–676. doi:10.1111/j.1749-6632.1995.tb44719.x

58.

Pigeot

Barba

Chadjigeorgiou

de Henauw

Kourides

Lissner

Siani

. (2009). Prevalence and determinants of childhood overweight and obesity in European countries: Pooled analysis of the existing surveys within the IDEFICS Consortium. International Journal of Obesity, 33, 1103–1110. doi:10.1038/ijo.2009.142

59.

Prentice-Dunn

(2012). Physical activity, sedentary behavior, and childhood obesity: A review of cross-sectional studies. Psychology, Health & Medicine, 17, 255–273. doi:10.1080/13548506.2011.608806

60.

Sanchez

Y. M.

Lambert

S. F.

Cooley-Strickland

(2013). Adverse life events, coping and internalizing and externalizing behaviors in urban african american youth. Journal of Child and Family Studies, 22, 38–47. doi:10.1007/s10826-012-9590-4

61.

Schneiderman

J. U.

Leslie

L. K.

Arnold-Clark

J. S.

McDaniel

Xie

(2011). Pediatric health assessments of young children in child welfare by placement type. Child Abuse & Neglect, 35, 29–39. doi:10.1016/j.chiabu.2010.06.007

62.

Schneiderman

J. U.

Mennen

F. E.

Negriff

Trickett

P. K.

(2012). Overweight and obesity among maltreated young adolescents. Child Abuse & Neglect, 36, 370–378. doi:10.1016/j.chiabu.2012.03.001

63.

Shaffer

Huston

Egeland

(2008). Identification of child maltreatment using prospective and self-report methodologies: A comparison of maltreatment incidence and relation to later psychopathology. Child Abuse & Neglect, 32, 682–692. doi:10.1016/j.chiabu.2007.09.010

64.

Shaibi

G. Q.

Konopken

Hoppin

Keller

C. S.

Ortega

Castro

F. G.

(2012). Effects of a culturally grounded community-based diabetes prevention program for obese Latino adolescents. Diabetes Educator, 38, 504–512. doi:10.1177/0145721712446635

65.

Sherry

Jefferds

M. E.

Grummer-Strawn

L. M.

(2007). Accuracy of adolescent self-report of height and weight in assessing overweight status: A literature review. Archives of Pediatrics & Adolescent Medicine, 161, 1154–1161. doi:10.1001/archpedi.161.12.1154

66.

Shonkoff

J. P.

(2010). Building a new biodevelopmental framework to guide the future of early childhood policy. Child Development, 81, 357–367. doi:10.1111/j.1467-8624.2009.01399.x

67.

Shonkoff

J. P.

Richter

van der Gaag

Bhutta

Z. A.

(2012). An integrated scientific framework for child survival and early childhood development. Pediatrics, 129, e460–e472. doi:10.1542/peds.2011-0366

68.

Silver

DiLorenzo

Zukoski

Ross

P. E.

Amster

B. J.

Schlegel

(1999). Starting young: Improving the health and developmental outcomes of infants and toddlers in the child welfare system. Child Welfare, 78, 148–165.

69.

Skinner

A. C.

Steiner

M. J.

Perrin

E. M.

(2012). Self-reported energy intake by age in overweight and healthy-weight children in NHANES, 2001–2008. Pediatrics, 130, e936–e942. doi:10.1542/peds.2012-0605

70.

Stevens

. (2012). Salud con sabor Latino para los ninos: A feasibility study. Available from Proquest Dissertations and Theses database. (Proquest No. 1021143769).

71.

Swanson

S. A.

Crow

S. J.

Le Grange

Swendsen

Merikangas

K. R.

(2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68, 714–723. doi:10.1001/archgenpsychiatry.2011.22

72.

Tanofsky-Kraff

Shomaker

L. B.

Stern

E. A.

Miller

Sebring

DellaValle

Yanovski

J. A

. (2012). Children’s binge eating and development of metabolic syndrome. International Journal of Obesity, 36, 956–962. doi:https://dx-doi-org.web.bisu.edu.cn/10.1038/ijo.2011.259

73.

Taveras

E. M.

Rifas-Shiman

S. L.

Belfort

M. B.

Kleinman

K. P.

Oken

Gillman

M. W.

(2009). Weight status in the first 6 months of life and obesity at 3 years of age. Pediatrics, 123, 1177–1183. doi:10.1542/peds.2008-1149

74.

Trickett

P. K.

Negriff

Peckins

(2011). Child maltreatment and adolescent development. Journal of Research on Adolescence, 21, 3–20. doi:10.1111/j.1532-7795.2010.00711.x

75.

Whitaker

R. C.

Phillips

S. M.

Orzol

S. M.

Burdette

H. L.

(2007). The association between maltreatment and obesity among preschool children. Child Abuse & Neglect, 31, 1187–1199. doi:10.1016/j.chiabu.2007.04.008

76.

Whitlock

E. P.

Williams

S. B.

Gold

Smith

P. R.

Shipman

S. A.

(2005). Screening and interventions for childhood overweight: A summary of evidence for the US Preventive Services Task Force. Pediatrics, 116, e125–e144. doi:10.1542/peds.2005-0242

77.

Williamson

D. F.

Thompson

T. J.

Anda

R. F.

Dietz

W. H.

Felitti

(2002). Body weight and obesity in adults and self-reported abuse in childhood. International Journal of Obesity, 26, 1075–1082. doi:10.1038/sj.ijo.0802038

78.

Wisniewski

A. B.

Chernausek

S. D.

(2009). Gender in childhood obesity: Family environment, hormones, and genes. Gender Medicine, 6, 76–85. doi:10.1016/j.genm.2008.12.001

79.

Zimmermann

M. B.

Gubeli

Puntener

Molinari

(2004). Detection of overweight and obesity in a national sample of 6–12 year-old Swiss children: Accuracy and validity of reference values for body mass index from the US centers for disease control and prevention and the international obesity task force. American Journal of Clinical Nutrition, 79, 838–843.