If genetic and medical conditions are not the cause of a child's obesity, then family and environmental factors must play an important role. Parents are role models and make decisions that directly impact the types and amount of food eaten by pre-adolescent children [16,17]. Obesigenic family clusters are a risk for young girls to have a higher BMI; parents in such family clusters have a greater intake of dietary fat and are less physically active than parents in non-obesigenic family clusters . Added to the factors just mentioned is the reality that many parents do not recognize that their obese child has a medical condition that needs professional attention  and that in some populations there is now a trend for children to become obese prior to beginning elementary school . A disease condition that begins very early in life, is fueled by the family's lifestyle, and is not recognized by the parents to be serious are difficult barriers for the primary care physician to overcome in order to help identify and treat an overweight or obese child.
The pediatric BMI is the most powerful tool available to help the physician lessen these barriers and to express concern specifically about a child's weight. The physician can use the BMI chart as a visual tool to help the parents understand how their child's weight compares to normal weight children. In this way the physician is trying to nudge the parent from a pre-contemplation stage of change with regard to the child's weight to a contemplation stage of change. Specific examples as to how to use the BMI in this way are provided in the case presentations.
Parents will ask why their child is overweight or obese. If the cause is not the result of a genetic syndrome or hormonal condition then it is related to modifiable behaviors both within the family and the individual. Specific behaviors associated with childhood obesity include a higher dietary fat intake compared to non-obese children , watching >4 hours of TV per day , eating while watching TV , use of electronic games , and lower levels of physical activity . During the weight management program, the physician will help the parents identify the variables that contribute to their child's obesity.
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