Reference values of inside leg length and inside leg length to stature ratio for Japanese children, 0-12 years of age.

BACKGROUND: Large datasets of detailed anthropometric measurements are scarce in children. The Japanese Standard Association 1978-1981 survey provides a rare opportunity to use high quality data from Japanese children. AIM: To construct inside leg length (ILL) and inside leg length to stature ratio (ILL/S) reference centile curves for Japanese children. SUBJECTS AND METHODS: The study sample consisted of 14,825 boys and 14,577 girls age 0-18 years for stature and weight measurements, and 9064 boys and 8796 girls age 0-12 years for ILL measurements, who participated in the 1978-1981 national survey on body sizes. LMS method was used to construct the reference centile curves. The reference centile curves for stature, weight, ILL, and ILL/S were compared to those of British children. RESULTS: The L, M, and S reference values for Japanese children are presented for stature, weight, ILL, and ILL/S. Compared with British children of 0-12 years of age, Japanese children of 0-12 years of age had shorter median stature, shorter median ILL, and shorter median ILL/S. CONCLUSION: We present the first reference values for ILL and ILL/S in Japanese children. Japanese children had relatively shorter legs compared to British children from infancy.

Population-based waist circumference reference values in Japanese children (0-6 years): comparisons with Dutch, Swedish and Turkish preschool children.

BACKGROUND: During 1978-1981 the Japanese Standards Association conducted a national survey to collect 64 distinct body measurements for Japanese children and adults. During 1978-1981, the prevalence of childhood obesity was relatively low yet the population was well nourished in Japanese children. The aim of this study is to construct waist circumference and waist circumference to stature ratio reference centile curves for Japanese preschool children. METHODS: We utilized 1978-1981 national survey data on body sizes. There are 4937 boys and 4758 girls age 0-6 years for waist circumference measurements. Waist circumference was measured at the level of the umbilicus. Using LMS method, centile curves were constructed for waist circumference and waist circumference to stature ratio. These reference values were compared with those of Dutch, Swedish and Turkish children. RESULTS: Centile reference curves were made for clinical and epidemiological use. Japanese children had smaller waist circumference centile values as compared to waist circumference measured at the midpoint of the lowest rib cage and the iliac crest of Dutch, Swedish and Turkish children. However, Japanese children had comparable waist circumference to stature ratio centile values to those of Dutch and Turkish children. CONCLUSIONS: This study presents the first age-, sex-, and ethnicity-specific reference values for waist circumference and waist circumference to stature ratio in Japanese preschool children.

Low plasma D-dimer predicts absence of intracranial injury and skull fracture.

BACKGROUND: Intracranial injury (ICI) is a leading cause of morbidity in children; however, the use of computed tomography (CT) to evaluate ICI has significant risks in children. A recent study suggests D-dimer is associated with ICI. We surveyed the performance of plasma D-dimer in ruling out ICI or skull fracture (SF) in children with head trauma. METHODS: In a cross-sectional study in the Emergency Department (ED) at the National Center for Child Health and Development in Tokyo, Japan we reviewed the medical records of all children age 0-16 years brought to the ED with head trauma from January 2010 to July 2013, who underwent CT based on established clinical criteria and had plasma D-dimer measured. We evaluated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of plasma D-dimer, using abnormal findings on CT (ICI, SF) as the criterion standard. We repeated analysis after stratification by age (<2 years, ≥2 years). RESULTS: Among 364 eligible children (112 children <2 year of age), abnormal findings on CT were demonstrated in 33.8% (123/364). With the cut-off set at 0.5 µg/mL, sensitivity was 100.0% (95% confidence interval [CI]: 95.6-100.0%), specificity 34.0% (95%CI: 28.1-40.4%), PPV 43.6% (95%CI: 37.7-49.6%), NPV 100.0% (95%CI: 93.5-100%). After stratification by age (<2 years and ≥2 years), sensitivity (100.0% and 100.0%) and NPV (100.0% and 100.0%) remained high in both age groups. CONCLUSIONS: Low plasma D-dimer (≤0.5 µg/mL) is useful to limit the use of CT in children by excluding traumatic ICI or SF.

National anthropometric reference values and growth curves for Japanese children: history and critical review.

Context: Child health statistics are a critical component of child health assessment. However, the importance of nationally representative data on growth is not well recognised for Japanese children. Objective: The aim of this paper is to review the national growth surveys for Japanese children and to discuss the clinical use of the national growth reference values and growth curves. Methods: There are five governmental organisations surveying health and growth in Japanese children. Based on these studies, several aspects of the current governmental policy on child growth assessment have been examined. This review focussed on national anthropometric studies reported by Japanese investigators in English for international readers to understand Japanese issues. Results: A variety of growth reference curves have been developed since the early 1980s in Japan. However, these references have several limitations: incomplete data for both infants and young adults, limited description of socio-economic factors and continued governmental use of weight-for-height rather than BMI. Conclusion: Japanese child health statistics use measures that are applicable only to Japanese children.

Caring for Children with Special Health Care Needs: Profiling Pediatricians and Their Health Care Resources.

Background and Objectives Pediatricians face numerous challenges in providing care for children with special health care needs (CSHCN). Few studies have described health care resources available to support pediatricians to care for CSHCN. This study investigated available resources to care for CSHCN and factors associated with having a greater proportion of CSHCN in practice. Methods We conducted a statewide survey of active members of the American Academy of Pediatrics in California to study pediatric subspecialty care access, community and office resources and practice barriers. We performed a logistic regression model on having an "above average proportion" of CSHCN in practice, adjusting for demographics, practice type (rural vs. suburban/urban) and medical resources, care satisfaction, and ease of subspecialty access. Results Our response rate was 50.2% (n = 1290); 75% of respondents reported providing some primary care services, with many primary care pediatricians caring for a high proportion of CSHCN. Pediatricians reported an average of 28% CSHCN in their practices. Rural pediatricians lacked subspecialty access (10-59% reporting no access to the various subspecialties). Factors relating to higher CSHCN in practice included being in academic medical centers and satisfaction in caring for CSHCN. Conclusions Pediatricians report lack of access to mental health services, care coordination and case management. Academic medical centers and higher physician satisfaction in care delivery for CSHCN are associated with more CSHCN in practice. Promoting ways to support pediatricians, such as practice collaboration with behavioral specialists, may be necessary to encourage primary care pediatricians to provide medical homes for CSHCN.

Beliefs and practices regarding solid food introduction among Latino parents in Northern California.

Latino children are more likely to be obese than non-Hispanic white children, and feeding patterns that begin in infancy may contribute to this disparity. The objective of this study was to elucidate beliefs and practices related to the introduction of solids and solid food feeding in the first year of life among low-income Latino parents residing in Northern California. We conducted 26 semi-structured interviews that explored the timing of introduction of solids, selection of foods to serve to infants, feeding strategies, sources of information on solid food feeding and concerns about infant weight. We found that most parents relied on traditional practices in selecting first foods for infants and had a strong preference for homemade food, which was often chicken soup with vegetables. Parents generally described responsive feeding practices; however a minority used pressuring practices to encourage infants to eat more. Very few parents practiced repeated gentle introduction of unfamiliar food to increase acceptance. High calorie low nutrient foods were typically introduced at around 12 months of age and parents struggled to limit such foods once children were old enough to ask for them. Parents were concerned about the possibility of infants becoming overweight and considered health care providers to be an important source of information on infant weight status. The results of this study can be used to inform the development of interventions to prevent obesity in Latino children with similar demographics to our study population.

WHO 2006 Child Growth Standards overestimate short stature and underestimate overweight in Japanese children.

BACKGROUND: It is unclear whether the World Health Organization (WHO) 2006 Child Growth Standards are applicable to East Asian populations. We investigated the applicability of the WHO standards of length/height and weight to a cohort representing middle-class children in Japan. METHODS: A cohort of children aged 0-5 years (3430 boys, 3025 girls) in the Tokyo Child Care Center Survey consecutively recruited from 2007 to 2013 were studied. Age- and sex-specific z-scores of length/height, weight and weight for length/height were calculated relative to either the WHO standards or the Japanese 2000 Growth References (nationally representative cross sectional survey data). RESULTS: Compared with the WHO standards, Japanese children at birth, 1, 3, 5 years were shorter (length/height standard deviation score [SDS] -0.26, -0.82, -0.81, -0.63 for boys, and -0.15, -0.67, -0.84, -0.62 for girls, respectively) and lighter (weight SDS -0.62, -0.36, -0.34, -0.42 for boys and -0.60, -0.17, -0.29, -0.43 for girls, respectively). Weight for length/height showed smaller differences at various length/height points (SDS -0.05 to 0.15 for boys, 0.01 to 0.29 for girls, respectively). CONCLUSIONS: Adoption of the WHO standards would substantially alter the prevalence of short stature, underweight and overweight in Japanese children 0-5 years of age. These findings advocate the use of the national references in Japan.

Obesity in elementary school children after the Great East Japan Earthquake.

BACKGROUND: Rikuzentakata was one of the cities most devastated by the Great East Japan Earthquake on 11 March 2011. Many buildings were swept away or destroyed and affected families were placed into temporary housing. The aim of this study was to determine the impact of long-term temporary housing on the body mass index (BMI) of elementary school children living in Rikuzentakata City. METHODS: A retrospective cohort study of was carried out of students attending 1st-3rd grade in 2010, and 4th-6th grade in 2013, in eight elementary schools in Rikuzentakata City. Height and weight were measured annually. We compared changes in BMI between children in temporary housing and those in permanent housing. Separately, parents of students attending one of the elementary schools were surveyed in 2013. RESULTS: Of 526 children in the present study, 32% were living in temporary housing. The prevalence of obesity climbed from 5.3% in 2010 to 7.8% in 2013 in the temporary housing group, and from 7.6% to 7.8% in the permanent housing group. BMI z-score in the temporary housing group increased by 0.102 points between 2010 and 2013 (P < 0.02). Children in temporary housing spent more time reading comic books and their walking commute time had decreased by 2 min compared with before the disaster. CONCLUSION: Obesity prevalence and BMI z-score increased in children in temporary housing compared with permanent housing. A more sedentary lifestyle may explain this trend. It is important for policy makers and health-care providers to recognize potential consequences of long-term residence in temporary housing.

Pediatricians' Comfort Level in Caring for Children With Special Health Care Needs.

BACKGROUND: Few studies have investigated pediatrician attitudes about providing primary medical care for children with special health care needs. The objective of this study was to determine pediatrician perspectives on their comfort level in providing care and on where the medical home should be for children with chronic medical and developmental conditions. METHODS: Survey of pediatricians in California in 2014. Pediatricians were randomized to receive surveys featuring either a case of a child with a chronic medical (neurofibromatosis) or a developmental condition (autism). They were then asked about their comfort level in providing primary care for the child. We developed logistic regression models to adjust for practice and provider factors, and availability of family social resources. RESULTS: The survey response rate was 50.2%. Primary care pediatricians expressed more comfort than nonprimary care pediatricians in providing a medical home for a child with chronic medical or developmental condition (range, 84%-92% comfortable vs 58%-79% comfortable), respectively. All pediatricians expressed more comfort providing care for a child with autism than neurofibromatosis. Nearly all primary care pediatricians (90%) believed that the medical home should be in pediatric primary care practice. Pediatrician comfort in becoming a medical home was higher when the family had more social resources. CONCLUSIONS: Most pediatricians endorse that the medical home for children with special health care needs be in the primary care setting. Improving access to subspecialty care and providing resources, such as case management, to address family social complexity might raise pediatrician comfort in providing primary care to children with medical and developmental conditions.

Anxiety Associated with Asthma Exacerbations and Overuse of Medication: The Role of Cultural Competency.

CASE: Toshi, a 14-year-old Japanese boy, had uncontrolled asthma after relocating from Japan with his family 1 year ago. In Japan, he was diagnosed with moderate, persistent asthma, which was controlled with salmeterol and albuterol on an as needed basis. Since moving to the United States, Toshi complained of frequent dyspnea.Initially, he was seen by a Japanese physician who prescribed 200 mg of fluticasone 3 times a day and albuterol nebulization as needed. When Toshi came to the Pediatric Primary Care Clinic, he reported using his nebulizer up to 25 times daily. A physical examination revealed a thin, anxious, jittery, hypertensive, and tachycardic adolescent with hyperreflexia and dysmetria. Toshi complained of difficulty breathing, in the absence of wheezing or respiratory distress; peak flow recordings in the office were normal. Furthermore, he had a history of "panic attacks," being a "worrier," and stopped attending school, playing sports, and socializing over the past 6 months due to his "breathing difficulties."Citalopram was prescribed for anxiety, but the family's apprehension about mental health disorders led to resistance to treatment recommendations. With motivational interviewing and negotiation, Toshi and his family agreed to a trial of citalopram. Three months later, he no longer took fluticasone or albuterol. The tachycardia, hypertension, and neurological symptoms improved. As he gained weight and improved his strength, he attended classes and participated in sports.A few months later, with improvement of his health, Toshi and his parents decided to discontinue citalopram. He then developed behaviors consistent with generalized anxiety and obsessive-compulsive disorder. Currently, his symptoms associated with anxiety have worsened, but he and his family are resistant to medication or initiating cognitive behavioral therapy due to their cultural beliefs regarding mental health disorders.

Trends in thin body stature among Japanese female adolescents, 2003-2012.

BACKGROUND: The past decades have witnessed a steady increase in thin body stature associated with unhealthy dieting among Japanese female adolescents. The most recent trends in thinness, however, have not been reported. AIM: To describe changes in the distribution of body mass index (BMI) of Japanese female adolescents, from 2003-2012. SUBJECTS AND METHODS: This study examined BMI distribution changes in 2541 relatively affluent Japanese girls, aged 12.5-17.5 years, during 2003-2012. The 2003 and 2004 data were combined and compared to the combined 2011 and 2012 data. Tukey mean-difference plots were used to study the direction and magnitude of shifts in BMI distributions. RESULTS: Prevalence of thinness (BMI <5th percentile of the 1978-1981 references) has progressively increased from 2.0-5.7% in 2003-2004 to 3.5-7.8% in 2011-2012 in Japanese girls. The downward shift in BMI was larger in 12.5-14.5 year olds than in 15.5-17.5 year olds and more prominent in the lower BMI spectrum. CONCLUSION: The trend towards thinness has continued in Japanese girls during the past decade. The distribution of BMI suggests thinner and younger sub-groups of girls are more susceptible to this trend.

Waist circumference centiles by age and sex for Japanese children based on the 1978-1981 cross-sectional national survey data.

AIM: The aim of this study was to establish reference values for waist circumference among Japanese youths using the 1978-1981 nationally representative data. SUBJECT AND METHODS: Growth charts were derived using Cole's LMS method, which adjusts the waist circumference distribution for skewness and allows waist circumference to be expressed as centile or standard deviation score. The sample population consisted of 19 233 children aged 6-18 years. Waist circumference was measured at the level of maximum waist narrowing in girls and at the level of the top of the iliac crest in boys. RESULTS: Comparison was made between the 1978-1981 and 1992-1994 waist circumference charts, showing a large increase in waist circumference over time; the mean difference was 1.1 and 0.5 SD score units in boys and girls, respectively. Defining cut-offs for central fatness as the 90th and 95th centiles of the 1978-1981 reference, the prevalences in 1992-1994 were, respectively, 42.3% and 25.2% in boys and 19.1% and 10.9% in girls. The corresponding prevalences in 1978-1981 were 10% and 5% by definition. CONCLUSION: This study showed increasing trends in waist circumference, particularly in boys during the period of the two surveys and that the 1978-1981 charts serve as better baseline references for waist circumference among Japanese youth.

Reference standard of penile size and prevalence of buried penis in Japanese newborn male infants.

The present study set forth the reference values for penile size and determined the prevalence of buried penis in Japanese full-term newborns. The stretched penile length was measured and the presence of buried penis was assessed at 1-7 days of age in 547 Japanese full-term newborn infants born between 2008 and 2012 in Tokyo. The stretched penile lengths were compared at 1-12 hours and 1-7 days of age in 63 infants and by two observers in 73 infants to estimate postnatal changes and interobserver variation, respectively. The mean stretched penile length was 3.06 cm (SD, 0.26; 95% confidence interval [CI], 3.04-3.08) and the mean ratio of penile length to body length was 6.24 × 100(-1) (SD, 0.55 × 100(-1)), both of which were significantly smaller than those in Caucasian newborn infants. Buried penis was identified in 20 of 547 infants (3.7%; 95% CI, 2.1-5.2%). The first measurements of penile length at 1-12 hours were significantly smaller than the next measurements at 1-7 days (95% CI of the difference, 0.22-0.34). The 95% CI for the limits of agreement in the penile lengths measured by the two observers was -0.58 to -0.40 for the lower limit and 0.33 to 0.51 for the upper limit. These findings indicate that the penile length should be assessed after 24 hours of age by the reference standard of the same ethnicity for identifying micropenis and that buried penis is not uncommon in Japanese full-term newborns.

Anxiety associated with asthma exacerbations and overuse of medication: the role of cultural competency.

CASE: Toshi, a 14-year-old Japanese boy, had uncontrolled asthma after relocating from Japan with his family 1 year ago. In Japan, he was diagnosed with moderate, persistent asthma, which was controlled with salmeterol and albuterol on an as needed basis. Since moving to the United States, Toshi complained of frequent dyspnea.Initially, he was seen by a Japanese physician who prescribed 200 mg of fluticasone 3 times a day and albuterol nebulization as needed. When Toshi came to the Pediatric Primary Care Clinic, he reported using his nebulizer up to 25 times daily. A physical examination revealed a thin, anxious, jittery, hypertensive, and tachycardic adolescent with hyperreflexia and dysmetria. Toshi complained of difficulty breathing, in the absence of wheezing or respiratory distress; peak flow recordings in the office were normal. Furthermore, he had a history of "panic attacks," being a "worrier," and stopped attending school, playing sports, and socializing over the past 6 months due to his "breathing difficulties."Citalopram was prescribed for anxiety, but the family's apprehension about mental health disorders led to resistance to treatment recommendations. With motivational interviewing and negotiation, Toshi and his family agreed to a trial of citalopram. Three months later, he no longer took fluticasone or albuterol. The tachycardia, hypertension, and neurological symptoms improved. As he gained weight and improved his strength, he attended classes and participated in sports.A few months later, with improvement of his health, Toshi and his parents decided to discontinue citalopram. He then developed behaviors consistent with generalized anxiety and obsessive-compulsive disorder. Currently, his symptoms associated with anxiety have worsened, but he and his family are resistant to medication or initiating cognitive behavioral therapy due to their cultural beliefs regarding mental health disorders.

Understanding how Latino parents choose beverages to serve to infants and toddlers.

To determine Latino parents' beliefs on the health effects of beverages on infants and toddlers, their sources of information on beverages and perceived barriers to following guidelines for healthy beverage consumption by children. We conducted 29 interviews with parents of Latino children ages 6-36 months. Parents were recruited in three community health centers in Northern California. The interviews were recorded, transcribed and analyzed using standard qualitative methods. The following dominant themes emerged. Parents believed that water and milk were healthy beverages for children and that sugar-sweetened beverages (SSBs) were unhealthy. Views on 100% fruit juice were mixed. Parents distinguished between homemade beverages such as "agua fresca" which they considered healthy, despite containing added sugar, and beverages from stores which were viewed as unhealthy. Participants' main source of information on beverages was the federal nutrition program for Women, Infants, and Children (WIC). Parents were confused, however, as to why WIC provides juice yet counseled parents to avoid giving their children juice. Parents preferred to receive information on beverages from experts. Differing practices among family members regarding which beverages they provide to children was the most important barrier to following beverage guidelines. Our study suggests that Latino parents are receptive to counseling on beverages from expert sources. Such counseling should address both store-bought and homemade beverages. The WIC program is a key source of information on beverages for Latino parents; thus counseling offered by WIC should be evidence-based and avoid mixed messages.

Trends in thin body stature among Japanese male adolescents, 2003-2012.

BACKGROUND: The desire for thin body stature and unhealthy eating behaviours have spread among Japanese boys. The prevalence of thinness in boys is expected to increase; however, recent trends have not been reported. AIM: To describe changes in the distribution of body mass index (BMI) of Japanese boys, from 2003 to 2012. SUBJECTS AND METHODS: BMI distribution changes were studied in 2599 relatively affluent Japanese children and adolescents, aged 12.5-17.5 years, during 2003-2012. The 2003 and 2004 data were combined and compared to the combined 2011 and 2012 data. Tukey mean-difference plots were used to study the direction and magnitude of shifts in BMI distributions. RESULTS: Prevalence of thinness has progressively increased from 2.8-4.7% in 2003-2004 to 5.1-7.6% in 2011-2012 in Japanese boys. Tukey plots showed that the increases in the prevalence of thinness are related to shifts in the entire distribution of BMI in the sample. CONCLUSION: Thin body stature was documented in increasing proportion of Japanese male adolescents. BMI z-scores decreased across the entire BMI centile spectrums, indicating that the whole school population may be at risk of thinness.

Trends and variations in infant mortality among 47 prefectures in Japan.

OBJECTIVES: To determine IMR trends and regional variations among 47 prefectures in Japan and to identify associated population-based factors. METHODS: We conducted an ecological study of infant mortality rate (IMR) by analyzing publicly available data from the Ministry of Health, Labour and Welfare of Japan. Outcome measure for trend is the IMR for each of 47 prefectures from 1999 to 2007; for variation, IMRs for 2006 and 2007 in each prefecture were averaged. We considered as covariates prefecture-level variables related to public health, socio-economic status, clinical services and health care facilities. We conducted multivariate statistical analyses to determine covariates most strongly associated with both 1999-2007 IMR trends and 2006-2007 IMR. RESULTS: The mean IMR decreased from 3.42 deaths per 1000 live births (range 2.1 to 5.1) in 1999 to 2.54 (range 1.5 to 4.4) in 2007; reductions were greater in prefectures with higher concentrations of public health nurses (PHNs) and nurses. In 2006-2007, nine prefectures had IMRs ≤ 2.25; eight had IMRs ≥ 3.0. When low-, moderate- and high-IMR prefectures were compared, per capita PHNs, maternal education, centralized water supply and household income were identified as significant covariates. CONCLUSIONS: Both national and prefecture-level IMR in Japan decreased from 1999 to 2007; however, the degree of reduction varied by prefecture. Given that more nurses and PHNs per capita were associated with greater IMR reductions from 1999 to 2007 and more PHNs with lower 2006-2007 IMRs, distribution of preventive health services may play a major role in reducing regional disparities in IMR.

BMI z-score is the optimal measure of annual adiposity change in elementary school children.

BACKGROUND: BMI or BMI% adjusted for age has been identified as the optimal measure of short-term adiposity change in kindergarten children aged 29-68 months. The optimal measure of annual adiposity change in older age children, however, has not been determined. AIM: To identify the optimal measure of annual adiposity change for Japanese children aged 6-12 years. SUBJECTS AND METHODS: A cohort of 669 Japanese children in one private school in Tokyo in whom height and weight were measured annually between 6 and 12 years. Each child's annual variability in adiposity was summarized by the standard deviation (SD) of BMI and BMI% adjusted for age, BMI z-score and BMI centile. The SDs were compared in overweight and non-overweight children and correlated with each child's baseline BMI z-score. RESULTS: The within-child BMI, BMI% and BMI centile SDs were significantly different in overweight and non-overweight children, while the BMI z-score SDs were similar in the two groups. Furthermore, the within-child BMI, BMI% and BMI centile SDs were inversely correlated with baseline BMI z-score, whereas BMI z-score SDs were not, with the exception of measurements for grade 1-2 children. CONCLUSION: The BMI z-score is the optimal measure of annual adiposity change for elementary school children.

Tracking of BMI in Japanese children from 6 to 18 years of age: Reference values for annual BMI incremental change and proposal for size of increment indicative of risk for obesity.

BACKGROUND: A large incremental increase in BMI indicates excess fat deposition in most children, but the reference values for identifying those at risk for developing obesity have not been defined. AIM: To determine the mean and SD of annual incremental change (ΔSDS) in BMI for Japanese school children. SUBJECTS AND METHODS: A cohort of 669 Japanese children in one private school in Tokyo in whom height and weight were measured annually between 6-17 years of age. Each child's BMI was converted to SDS as based on the 1978-1981 Japanese references for the 12 annual measurements to derive the correlation coefficient, r, between two successive measurements. Using the formula, SD of ΔSDS = √2(1-r), the mean and SD of ΔSDS were obtained. RESULTS: Excess BMI gain was defined in terms of ΔSDS in Japanese children. Annual incremental increase greater than 2 SD of ΔSDS, equivalent to 1-2 BMI units/year for younger children and 2-3 BMI units/year for older children, respectively, indicates rapid increase in body fat in Japanese children. CONCLUSION: Based on analysis of incremental change in BMI in this cohort, a cut-off has been identified that can be used to identify children at risk for developing obesity.