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Pediatric primary care providers' adherence to recommendations for the assessment and management of childhood overweight is low. There are scarce data addressing how to improve provider practices. This study evaluated the effect of provider training and office-based tool dissemination on pediatric providers' assessment and management of childhood overweight. Provider practices before and after training and office-based tool dissemination were compared. Participants were resident and faculty providers at 6 urban, community-based primary care clinics affiliated with an academic medical center. Three months after completion of two 1-hour training sessions, clinic sites were provided with tools in bulk, and office staff were coached to distribute the tools during patient encounters. Provider practices were ascertained by medical record abstraction at baseline and at 3 and 6 months. The proportion of medical records with documentation of recommended practices, including recording of body mass index percentile (BMI%), obtaining a nutrition-activity history, and providing nutrition-activity counseling, was compared with χ 2 tests and logistic regression. During the initial 3 months after training, provider documentation of recommended practices did not significantly improve compared with baseline. During the subsequent 3 months, after office-based distribution of tools, provider documentation of recommended practices improved significantly compared with baseline (28.8% vs 11.6% for BMI% [ P < .001], 80.2% vs 49.8% for nutrition-activity history [ P < .001], and 47.7% vs 33.3% for nutrition-activity counseling [ P < .001]). Pediatric providers' adherence to recommendations for the assessment and management of childhood overweight may improve with provider training linked to the office-based distribution of tools to promote performance of recommendations.

Public health nutrition programs are intended to serve low-income families who are at greater nutritional risk than the general population. Not all persons who are program-eligible are at equal risk, however. It would be desirable to evaluate a program's ability to enroll persons from higher risk backgrounds in the population (coverage) and, conversely, the extent to which those enrolled in this program are at higher risk (targeting). A method for the evaluation of coverage and targeting was developed using data from the Tennessee Women, Infants, and Children Special Supplemental Food Program (WIC) linked with birth certificates. The linked computer file was created by matching the name and date of birth in both record files. The birth records were the common source of information used to characterize the risk background for both the WIC and non-WIC participants. Maternal sociodemographic information on the birth records was used to define the health risk background of each child. The coverage and targeting of \"at-risk\" children were computed and compared for 50 counties or county-aggregates in Tennessee. Considerable variation in the coverage and targeting rates of at-risk children was observed among Tennessee counties, although the counties within each WIC administrative region tended to have similar coverage and targeting patterns. Using the existing data in linked program and vital records provides a direct evaluation of a program. Coverage and targeting evaluation can be used to detect underserved populations within small geographic areas.

Pediatric surveillance data for 1982 are examined in terms of the prevalence of growth stunting and obesity. Results indicate that growth stunting is observed in approximately 6%-16% of children in the age group from birth through 4 years. Overall, the prevalence of stunting trends to increase with age. Native American and Hispanic children show the highest prevalence of stunting. Obesity is observed to vary from 5%-13% in different age and ethnic subgroups. Obesity increases in prevalence among 1-year-olds relative to infants less than 1 year of age, but from 2-4 years of age there are no consistent trends in the prevalence of obesity with increasing age. Native American children, followed by Hispanic children, have the highest prevalence of obesity as reflected in high weight-for-height. The prevalence of growth stunting and obesity in the populations under surveillance is greater the 5% level \"expected\" when compared with the reference population, suggesting that the children attending publicly supported health programs are at increased nutritional risk. At the same time, the prevalence of low weight-for-height is generally less than the 5% level, suggesting that thinness is not a significant public health program in the populations under surveillance. The observation of increased stunting as well as high weight-for-height among Hispanic and Native American children raises a number of issues in interpretation and suggests that the diet of these children may be relatively adequate in quantity but inadequate in quality of nutrient intake.

An examination of length, weight, and birth weight data routinely collected from the clinics supported by the Navajo Nation Special Supplemental Program for Women, Infants, and Children (WIC) showed an association between birth weight and subsequent growth status. Navajo children less than 2 years of age entering the WIC Program were divided into low, normal, and high birth weight groups, and their growth patterns were plotted when they returned periodically for reassessment. Overall, the children tended to have low length-for-age and high weight-for-length measures, relative to the reference population, that suggest suboptimal nutritional status. Children with birth weights less than 2,500 grams (g) were consistently shorter, lighter, and thinner than children with birth weights greater than 2,500 g. Although the overall growth status of the children improved between 1975 and 1980, the growth among the children with low birth weights never fully caught up with that of the other Navajo children. Moreover, during that period, the normal birth weight group had a modest improvement in length-for-age relative to the reference population, but the low birth weight group did not. These findings suggest that prenatal interventions to improve the birth weight status of Navajo infants may result in improving the growth status of Navajo children.

Iron deficiency is the most common known form of nutritional deficiency. Its prevalence is highest among young children and women of childbearing age (particularly pregnant women). In children, iron deficiency causes developmental delays and behavioral disturbances, and in pregnant women, it increases the risk for a preterm delivery and delivering a low-birthweight baby. In the past three decades, increased iron intake among infants has resulted in a decline in childhood iron-deficiency anemia in the United States. As a consequence, the use of screening tests for anemia has become a less efficient means of detecting iron deficiency in some populations. For women of childbearing age, iron deficiency has remained prevalent. To address the changing epidemiology of iron deficiency in the United States, CDC staff in consultation with experts developed new recommendations for use by primary health-care providers to prevent, detect, and treat iron deficiency. These recommendations update the 1989 \"CDC Criteria for Anemia in Children and Childbearing-Aged Women\" (MMWR 1989;38(22):400-4) and are the first comprehensive CDC recommendations to prevent and control iron deficiency. CDC emphasizes sound iron nutrition for infants and young children, screening for anemia among women of childbearing age, and the importance of low-dose iron supplementation for pregnant women.

The CDC Pediatric Nutrition Surveillance System (PedNSS) monitors the general health and nutritional characteristics of low-income U.S. children who participate in multiple public health programs. This system is intended to characterize trends and patterns in key indicators of nutritional status so that the information can be used for program planning and targeting. The indicators monitored by PedNSS are birth weight, childhood growth status, anemia, and breast-feeding patterns. From 1980 through 1991, the trends for low birth weight, low height-for-age (shortness), low weight-for-height (thinness), and high weight-for-height (overweight) were stable for all children monitored by the PedNSS, with the exception of Asian children, who were predominantly of Southeast Asian refugee background. In the early 1980s, the prevalence of low birth weight and shortness was higher among Asian children than among children of other racial or ethnic groups who were monitored by the PedNSS. However, these prevalences declined steadily from 1980 through 1991. By 1991, the prevalences of low birth weight and shortness for Asian children were similar to those observed for children of other races/ethnic groups. Overall, low-income U.S. children had a slightly lower height-for-age than expected, indicating that some of these children were at a health and nutritional disadvantage. The prevalence of overweight varied among different racial/ethnic groups; Hispanic and Native American children had the highest prevalences of overweight. The 20%–30% prevalence of anemia among low-income children monitored by the PedNSS was higher than among the general population, reflecting in part the preferential enrollment and retention of anemic children by public health nutrition programs and also indicating that many children had inadequate iron nutrition. From 1980 through 1991, the prevalence of anemia declined >5% for most of the age- and race/ethnicity-specific groups monitored by PedNSS. That decline represents an improvement in iron nutritional status. PedNSS is a useful system for the monitoring and characterization of the nutrition status of low-income children at both state and national levels.

Since 1979, the CDC Pregnancy Nutrition Surveillance System (PNSS) has monitored behavior and nutritional risk factors among low-income pregnant women participating in public health programs. Although the states contributing to the the have varied over the period, the PNSS is able to characterize the behavior and health outcomes of pregnant women from diverse low-income populations. In 1990, 66.2% of the women in the system initiated prenatal care during the first trimester of pregnancy; 26.4% smoked during pregnancy. Since 1979, the prevalence of smoking remained relatively stable for white women, but declined for blacks and Hispanics. Prepregnancy body mass index (BMI, defined as kg/m²) showed marked changes from 1979 through 1990; the prevalence of underweight (BMI <19.8) declined steadily and the prevalence of overweight (BMI >26) increased steadily. In 1990, 39.3% of the women had gestational weight gains below levels recommended by the National Academy of Sciences. Both prepregnancy underweight and inadequate gestational weight gain were associated with greater risk for low birth weight in the PNSS. The prevalence of anemia at each trimester has remained stable since 1979. In 1990, 9.8%, 13.8%, and 33% of the women reported by the PNSS were anemic in the first, second, and third trimesters, respectively. Anemia in the first trimester appeared to be strongly associated with a high risk of low birth weight; this association was attenuated in later trimesters. These findings indicate the need to improve iron nutrition among low-income women.

Because of the adverse effects of low birth weight (LBW) on infant morbidity and mortality, one of the 1990 health objectives for the nation has been to reduce the incidence of LBW to 5% among all live births in the United States. Public health surveillance of cigarette smoking during pregnancy has demonstrated an association between smoking and an increased risk of LBW, defined as birth weight of <2,500 g. For the period 1978-1988, information on nearly 248,000 women from CDC's Pregnancy Nutrition Surveillance System showed an LBW rate of 6.9%, a high prevalence of smoking during pregnancy (29.7%); and a strong association between smoking during pregnancy and the likelihood of delivering an LBW infant in all age, racial/ethnic, and prepregnancy weight groups. The risk of LBW was greater for smokers than for nonsmokers (9.9% versus 5.7%), creating an excess LBW risk of 4.2% associated with smoking. Overall, the average birth-weight deficit related to smoking was 178 g. Among both smokers and nonsmokers, black women had a higher percentage of LBW infants than did white women, and the risk of LBW related to smoking was greater among black women. That risk tended to increase with age, especially among women with low pregravid weight. Major reductions in LBW might be achieved if smoking were eliminated among pregnant women.