Psychosocial aspects of child and adolescent obesity
Posted: Mar 1 2012
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P Nieman, CMA LeBlanc, Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee
Abridged version: Paediatr Child Health 2012;17(3):205-6
In addition to counselling families about regular physical activity and healthy nutrition, clinicians need to identify and help them to address the psychosocial factors that may be contributing to their child’s or adolescent’s obesity. Affected individuals may suffer from depression, low self-esteem, bullying, and weight bias, experiences that can make achieving desired health outcomes more difficult. Clinicians should try to identify these underlying stressors and ensure that appropriate counselling is implemented.
Key Words: Child; Mental health; Obesity; Psychosocial
Promoting healthy active living in the clinical setting has focused on helping families to effect consistent lifestyle changes, such as increasing the quality and quantity of physical activity (PA) and making better nutritional choices -. While improving nutrition and physical activity levels are critical in addressing the problem of overweight, they are only part of the solution. Clinicians must also identify and help families to address the psychosocial factors (elements in a child’s or youth’s social environment) that contribute to overweight or obesity .
Poor nutrition and inadequate PA may be direct results of psychosocial contributors to obesity . Affected children who also experience bullying, depression, low self-esteem or weight bias  will have more difficulty managing their weight. Children from economically disadvantaged homes are more likely to fall into unhealthy lifestyle patterns characterized by physical inactivity, poor nutrition and increased obesity risk . Clinicians must consider such factors when working with families, to ensure that treatment goals are realistic and appropriate .
The objectives of this statement are to explore how psychosocial factors in childhood contribute to overweight/obesity, to discuss overweight-related psychological comorbidities, and to provide clinical and public policy recommendations that address these issues. This statement was developed through conventional review of current medical literature, group consensus, and peer review by clinicians experienced in this field.
Psychosocial contributors to obesity
The patient’s perspective
Important psychosocial contributors to obesity may include stressors that trigger emotional eating : being bullied , suffering neglect and maltreatment , or a living situation where consistency, limit-setting and supervision are lacking .
Stressed children are more prone to overeating or “emotional” eating , that is, eating excessively for comfort or to make oneself unattractive. Examples of stressors that commonly lead to overeating are parental separation/divorce , bullying, physical/mental maltreatment or abuse , and living in foster care with frequent placement changes . Such challenges can predispose a child or adolescent to use food as a coping mechanism.
Chronic stress can also compound poor sleeping habits , fatigue and a reluctance to engage in regular PA at school and at home. Inadequate sleep is a known risk factor for obesity . Stress can negatively impact the immune system, increasing the risk of viral upper respiratory infections , and further impede consistent PA. Stressful living situations, including poverty, or generalized anxiety or depression can stimulate neuroendocrine responses. An activated hypothalamic-pituitary axis and sympathetic nervous system may induce intra-abdominal adiposity, insulin resistance and metabolic syndrome through excessive cortisol production .
“Weight bias”—defined as the tendency to make unfair judgments based on a person’s weight—is a significant social problem . Overweight individuals are often teased and have difficulty making friends. Overweight/obese children are more prone to being bullied, humiliated or ostracized, and they are also more likely to engage in bullying behavior . It is difficult to facilitate weight loss through lifestyle changes alone if a bullied child is not identified and supported in these other respects as well . Some bullied children are unable to follow healthy nutritional plans because of their emotional eating behaviours . A fear of bullying may lead them to exercise less and stay indoors . Discrimination against obese individuals is a harmful, pervasive and significant social problem that needs to be addressed early, concretely, and as part of a child’s or teen’s treatment regiment .
The parent’s role
Parenting plays a pivotal role in promoting healthy active living and in managing childhood/adolescent obesity . The following parental responsibilities are particularly important: good role-modelling , setting limits , purchasing healthy foods for family consumption, keeping to healthy family routines (eg, eating meals and exercising together) , effective time and money management, and ensuring that a divorce or separation remains as untraumatic as possible .
Children and youth who lack routine, consistency, limits and supervision at home are at greater risk of obesity . For reasons that are still unclear, there is also a higher incidence of obesity among children without siblings . Theoretically, the only child might eat more out of boredom or loneliness , or parents may treat their only child more like an adult, serving larger portions of food or sharing too much “screen time” instead of being physically active together. Sometimes children are pushed by parents to excel in a particular sport, which can result in an aversion for sport and exercise . They may become more sedentary because of “burn out” or disillusionment, and abandon any form of PA .
Divorce may be a sensitive topic for a parent to discuss with the clinician but it can be a significant psychosocial contributor to obesity . If divorced parents fail to communicate, or blame one another for their child’s state of health, sustained behavioural changes are difficult. Separation and divorce strain parental resources (time, money and energy), making healthy eating and regular PA more challenging. Some children counter the stresses induced by divorce by emotional eating .
The role of the community
The cost of healthy eating (ie, lots of fresh fruit and vegetables) is often higher than eating less nutritious foods . Fresh produce is also more difficult to obtain (and more expensive) in remote regions and in Northern Canada . Families with limited income, education and access to fresh produce are more likely to be overweight . Moreover, foods high in fat and sugar continue to be a major focus of television advertisements during children’s programming . Direct marketing to younger, susceptible children in an effort to develop early brand loyalty often succeeds. Poorer Canadians are more likely to purchase these foods because they are often more affordable than healthier alternatives .
First Nations, Inuit, some ethnic minorities and children living in apartments or public housing, or in neighborhoods where outdoor play is curtailed by weather or a lack of safe facilities, are also at higher risk for obesity . Limited access to recreational opportunities, parks and neighborhood playgrounds, a byproduct of urban sprawl that especially impacts low-income families, also correlate to obesity . Although many provinces/territeries have eliminated quality daily physical education (PE) classes in favour of academics, current research demonstrates that regular PE actually improves academic performance and reduces stress . The benefits of PA and participating in sports or recreation programs on the health and well-being of children and youth are all too often preempted by cost, lack of access or opportunity, and parental time constraints .
Psychosocial consequences of obesity
Overweight children and adolescents may experience deleterious psychosocial sequelae , including depression, teasing, social isolation and discrimination, diminished self-esteem, behavioural problems, dissatisfaction with body-image, and reduced quality of life .
It is not always clear whether depression is the cause or the result of obesity; both relationships may be true . Prospective studies have revealed that obese adolescents are at risk for major anxiety and depressive disorders later in life . When obesity becomes chronic, the failure to control weight gain over an extended period may predispose affected children to depression . The longer a child is overweight, the greater the risk for depression and other mental health disorders . Furthermore, depression during childhood is associated with increased body mass index (BMI) during adolescence and adulthood . Depressed individuals tend to sleep poorly and feel less energetic or motivated to engage in PA. In some patients, depression is associated with craving carbohydrates. Insulin resistance may underlie this urge as well as the associated hyperphagia and weight gain occurring in some depressive syndromes .
Dissatisfaction with body image relates to the discrepancy between an individual’s perceived self-image and the internalization of a received – and idealized – body image. This dissatisfaction can influence mood and eating practices . Obese Caucasian girls appear to have greater body image dissatisfaction and are more prone to eating disorders such as binge eating and bulimia nervosa than their male counterparts .
Children struggling to control their weight may suffer from poor self-esteem , with persistent unhealthy behaviours further lowering self-confidence, deepening frustration, and reducing motivations to change. It is important for clinicians to use positive language and motivational interviewing methods (see below)  with overweight youth, to instill hope and courage as opposed to communicating negatively either verbally or non-verbally, and further lowering a patient’s sense of self-worth .
Health-related quality of life
Although BMI is an important medical indicator of health, it does not sufficiently capture a patient’s ability to function in daily living . Quality of life, one measure of such function, is low in obese children . Youth with poor sleep habits due to obstructive sleep apnea, a frequent comorbidity of obesity, reported significantly lower quality of life scores . Obese children measure lower on self-esteem scores related to physical self-perception and physical quality of life than non-obese children . Such perceived deficits are often also associated with poor PA skills; both factors can interact as barriers to participation in games or sports . Low scores on perceived physical competence are consistently associated with reduced PA in children .
Working with patients and families in the clinical setting
Tools for clinicians
Addressing the psychosocial contributors to obesity requires clinicians to collaborate with patients and families to find practical interpersonal strategies for approaching unique situations. One useful technique is motivational interviewing (MI) , defined as a person-centered goal-oriented method of communicating that elicits and strengthens intrinsic motivation for positive change. MI is especially useful for individuals who are less confident about their ability to change existing behaviours. Combining supportive and empathetic counselling with more directive methods, clinicians can help these patients move from ambivalence to commitment to adoption of healthier active lifestyles .
One resource used to identify health-related quality of life is the “Sizing them up score”, which looks at emotional and physical functioning, teasing, marginalization, positive social attitudes, mealtime challenges and school functioning . This is a useful tool for clinicians in the office setting.
Working with parents
Clinicians need to help educate and empower parents . By using MI , they can encourage parents to be more sensitive and nonjudgmental. The focus should be on helping an entire family become healthier. Two key strategies are to determine whether changing family behaviour is a priority; and to determine how confident the parent is about achieving the necessary changes .
Clinicians need to express their own concern when a patient is overweight/obese, as well as convey their confidence that a family can achieve a healthier lifestyle. Linking the child’s weight to specific conditions in the family medical history might help to increase the motivation to change . Once a parent is engaged, they should be invited to become positive role models for the family and be encouraged to limit less appropriate food choices and sedentary activities . Parental eating choices, such as limiting high fat/sugar foods and providing healthy snacks in the home, can be hugely influential . Educating families to avoid casual snacking (a significant source of extra calories) throughout the day and evening is also important .
Counsel parents to avoid using food as a reward or bribe, or compelling a child to eat who does not wish to. Discourage “food pushing” (urging a child to eat foods especially prepared for them), while respecting the cultural impulses that may be behind this tendency , such as profound food insecurity in a family’s country of origin. While less likely to be detrimental when food choices are healthy, the combination of exposure to fast foods and food pushing may increase obesity rates. Indeed, immigrants who have lived in Canada for 10 or more years have been shown to have a higher risk of developing obesity than recently arrived immigrants .
Consistent, healthy routines for the whole family should be promoted . Children and adolescents benefit significantly by eating meals regularly with their family . A meta-analysis of longitudinal studies suggests that youth sharing three or more family meals per week reduces the odds for overweight (12%), disordered eating (35%) and increases odds (24%) for eating healthy foods . The psychosocial benefits of shared mealtimes include quality time to communicate as a family . Skipping breakfast is not uncommon in busy homes but should be avoided; the prevalence of obesity is significantly higher in children and youth who miss breakfast .
Developing effective public policy
The development of public policies that strengthen community frameworks for healthy active living is supported by the World Health Organization and other international bodies. The WHO Global Strategy on Diet, Physical Activity and Health recommends broad, comprehensive and coordinated public health efforts at national, regional and local levels , including initiatives that reduce unhealthy eating and physical inactivity, and raise awareness around the influence of diet and PA on health. These strategies must be evidence-based, multisectoral, multidisciplinary and focused on a life-course perspective. They should address issues such as culturally sensitive diets, food security, food safety and the promotion of farmers’ markets.
Young children would benefit directly from better nutritional regulation and the provision of age-appropriate PA in child care settings and schools. The WHO School Policy Framework on Healthy Eating and Physical Activity recommends that schools and communities work together on strategies that promote health information, improve health literacy, and promote healthy diet and daily physical education . Incentives to ensure safe sport and recreation for all age groups are important, and involve coordinating the efforts of decision-makers in health, education, transportation, justice, sport, finance, industry, environment and human resources. Children’s hospitals should lead by example rather than rely (as they commonly do) on fast-food vending and sedentary activities. Hospitals need to develop and implement healthier nutrition and PA guidelines for patients, their families and staff .
School-based policies that prevent bullying , and policies and legislation that explicitly support mental health (as WHO recommends for all developed countries ), would also help to resolve the psychosocial aspects of childhood and adolescent obesity.
To improve the well-being of obese children and youth, the Canadian Paediatric Society (CPS) makes the following recommendations:
Clinicians need to:
- Counsel children, youth and families in their practices to accumulate the recommended level of daily physical activity, and to restrict sedentary behaviour as outlined in national guidelines.
- Explore psychosocial issues when counselling overweight patients and their families.
- Use motivational interviewing to help families adopt and maintain lifestyle changes, including:
- Encouraging all primary caregivers to be present for counselling sessions. A written summary of goals and action items should be provided to those unable to attend, to help maintain consistency.
- Identifying sources of stress within the patient’s family and making referrals to mental health professionals as needed, before or in tandem with lifestyle counselling.
- Recognizing stress in the patient, screening for anxiety, depression, low self-esteem and reduced quality of life, and making referrals to mental health professionals as indicated.
- Identifying patients who are being bullied and recommending appropriate resources and supports.
- Advocate for national policies to achieve health equity for children and youth new to Canada, including the promotion of healthy active living.
- Advocate for national strategies that seek to eliminate health disparities for First Nations, Inuit and Métis children and youth.
- Work with other community leaders to improve nutrition and physical activity opportunities through community centres, child care facilities, schools and children’s hospitals.
Government public policy-makers need to:
- Collaborate to develop evidence-based, multisectoral, multidisciplinary healthy living strategies for each stage of life, including the prenatal period (eg, nutrition in pregnancy).
- Increase access to and monitor affordable healthy food and recreation opportunities for low-income families and families living in remote communities.
- Continue to develop and implement a national mental health strategy, with a particular focus on economically disadvantaged families.
- Develop strategies specific to First Nations, Inuit and Métis children and youth—in collaboration with Aboriginal groups—with a particular focus on psychosocial and environmental contributors to obesity, such as poverty and lack of access to affordable healthy foods, community recreation and housing.
- Legislate to prohibit advertizing that promotes unhealthy foods and physical inactivity during children’s television programming.
- Mandate school-based health literacy, healthy eating and daily physical education, as well as school programs that promote an anti-bullying environment.
This statement has been reviewed by the Adolescent Health, Community Paediatrics, and Mental Health and Developmental Disabilities Committees of the Canadian Paediatric Society, by the CPS Action Committee for Children and Teens, as well as by Dr. Gary Goldfield, Clinical Scientist, Healthy Active Living and Obesity (HALO) Research Group, Children’s Hospital of Eastern Ontario.
HEALTHY ACTIVE LIVING AND SPORTS MEDICINE COMMITTEE
Members: Tracey L Bridger MD; Kristin Houghton, MD, Claire MA LeBlanc MD (Chair); Stan Lipnowski MD (Past member); John F Philpott MD, Christina G. Templeton MD (Board Representative); Thomas J Warshawski MD
Liaison: Laura K Purcell MD, CPS Paediatric Sports and Exercise Medicine Section
Principal authors: Peter Nieman MD (Past member); Claire MA LeBlanc MD (Chair)
- Canadian Institute for Health Information. Overweight and obesity in Canada: A population health perspective, August 2004. http://secure.cihi.ca/cihiweb/products/CPHIOverweightandObesityAugust2004_e.pdf (Accessed September 1, 2011).
- Obesity Canada Clinical Practice Guidelines Expert Panel; Lau DC, Douketis JD, et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176(8):S1-13.
- Spear BA, Barlow SE, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007;120(Suppl 4):S254-88.
- Vaidya V. Psychosocial aspects of obesity. Adv Psychosom Med 2006;27:73-85.
- Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children. Psychol Bull 2007 Jul;133(4):557-80.
- Singh GK, Kogan MD, Siahpush M, van Dyck PC. Independent and joint effects of socioeconomic, behavioral, and neighborhood characteristics on physical inactivity and activity levels among US children and adolescents. J Community Health 2008;33(4):206-16.
- James WPT, Nelson M, Ralph A, Leather S. Socioeconomic determinants of health: The contribution of nutrition to inequalities in health. BMJ 1997;314(7093):1545-50.
- Whitaker RC, Phillips SM, Orzol SM, Burdette HL. The association between maltreatment and obesity among preschool children. Child Abuse Negl. 2007 ; 31(11-12): 1187-1199.Epub: doi:10.1016/j.chiabu.2007.04.008.
- Pinhas-Hamiel O, Modan-Moses D, Herman-Raz M, Reichman B. Obesity in girls and penetrative sexual abuse in childhood. Acta Paediatr. 2009 ;98(1):144-7. Epub: doi:10.1111/j.1651-2227.2008.01044.x.
- American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Helping children and families deal with divorce and separation. Pediatrics2002;110(5):1019-23.
- Steele JS, Buchi KF. Medical and mental health of children entering the Utah foster care system. Pediatrics 2008;122(3):e703-9. Epub:doi:10.1542/peds.2008-0360.
- Ievers-Landis CE, Storfer-Isser A, Rosen C, Johnson NL, Redline S. Relationship of sleep parameters, child psychological functioning, and parenting stress to obesity status among preadolescent children. J Dev Behav Pediatr 2008;29(4):243-252.
- Walsh NP, Gleeson M, Pyne DB, et al. Position statement. Part Two: Maintaining immune health. Exerc Immunol Rev 2011;17:64-103.
- Anagnostis P, Athyros VG, Tziomalos K, Karagiannis A, Mikhailidis DP. Clinical review: The pathogenetic role of cortisol in the metabolic syndrome: A hypothesis. J Clin Endocrinol Metab 2009;94(8):2692-701.
- Washington RL. Childhood obesity: Issues of weight bias. Prev Chronic Dis 2011;8(5):A94.
- American Academy of Pediatrics, Council on Sports Medicine and Fitness, Council on School Health. Active healthy living: Prevention of childhood obesity through increased physical activity. Pediatrics 2006;117(5):1834-42.
- Chen AY, Escarce JJ. Family structure and childhood obesity, early childhood longitudinal study – kindergarten cohort. Prev Chronic Dis 2010;7(3):A50.
- Brenner JS, AAP Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics 2007;119(6):1242-5.
- Yannakoulia M, Papanikolaou K, Hatzopoulou I, Efstathiou E, Papoutsakis C, Dedoussis GV. Association between family divorce and children’s BMI and meal patterns: The GENDAI Study. Obesity 2008;16(6):1382-7.
- Rydén PJ, Hagfors L. Diet cost, diet quality and socio-economic position: How are they related and what contributes to differences in diet costs? Public Health Nutr 2010;14(9):1680-92.
- Shields M. Measured obesity: Overweight Canadian children and adolescents. Ottawa, Ont.: Statistics Canada, Cat. no. 82-620-MWE2005001.
- Powell LM, Schermbeck RM, Szcypka G, Chaloupka FJ, Braunschweig CL. Trends in the nutritional content of television food advertisements seen by children in the United States. Arch Pediatr Adolesc Med 2011;165(12):1078-86.
- Caprio S, Daniels SR, Drewnowski A, et al. Influence of race, ethnicity, and culture on childhood obesity: Implications for prevention and treatment. Obesity 2008;16(2):2566-77.
- Young TK, Katzmarzyk PT. Physical activity of Aboriginal people in Canada. Can J Public Health 2007;98 Suppl 2:S148-60.
- Razani N, Tester J. Childhood obesity and the built environment. Pediatr Ann 2010;39(3):133-9.
- Rasberry CN, Lee SM, Robin L, et al. The association between school-based physical activity, including physical education, and academic performance: A systematic review of the literature. Prev Med 2011;52 S1:S10-20.
- Canadian Fitness and Lifestyle Research Institute. Bulletin 03: Barriers to physical activity among children. Accessed September 1, 2011.
- Mustillo S, Worthman C, Erkanli A, Keeler G, Angold A, Costello EJ. Obesity and psychiatric disorder: Developmental trajectories. Pediatrics 2003;111(4 Pt 1):851-9.
- Erermis S, Cetin N, Tamar M, Bukusoglu N, Akdeniz F, Goksen D. Is obesity a risk factor for psychopathology among adolescents. Pediatr Int 2004;46(3):296-301.
- Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. [Comment]. JAMA 2003;289(14):1813-9.
- Pine DS, Goldstein RB, Wolk S, Weisman MM. The association between childhood depression and adulthood body mass index. Pediatrics 2001;107(5):1049-56.
- Anderson SE, Cohen P, Naumova EN, Jacques PF, Must A. Adolescent obesity and risk for subsequent major depressive disorder and anxiety disorder: Prospective evidence. Psychosom Med 2007;69(8):740-7.
- Goodman E, Whitaker RC. A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics 2002;110(3):497-504.
- Docherty JP, Sack DA, Roffman M, Finch M, Komorowski JR. A double-blind, placebo-controlled, exploratory trial of chromium picolinate in atypical depression: Effect on carbohydrate craving. J Psychiatr Pract 2005;11(5): 302-14.
- Franklin J, Denyer G, Steinbeck KS, Caterson ID, Hill AJ. Obesity and risk of low self-esteem: A statewide survey of Australian children. Pediatrics 2006;118(6):2481-7.
- Miller WR, Rose GS. Toward a theory of motivational interviewing. Am Psychol. 2009; 64(6):527-37.
- Manus HE, Killeen MR. Maintenance of self-esteem by obese children. J Child Adolesc Psychiatr Nurs 1995;8(1):17-27.
- Pinhas-Hamiel O, Singer S, Pilpel N, Fradkin A, Modan D, Reichman B. Health-related quality of life among children and adolescents: Associations with obesity. Int J Obes 2006;30(2):267-72.
- Morgan PJ, Okely AD, Cliff DP, Jones RA, Baur LA. Correlates of objectively measured physical activity in obese children. Obesity 2008;16(12):2634-41.
- Crocker PR, Eklund RC, Kowalski KC. Children's physical activity and physical self-perceptions. J Sports Sci 2000;18(6):383-94.
- Haga M. Physical fitness in children with high motor competence is different from that in children with low motor competence. Phys Ther 2009;89(10):1089-97.
- Resnicow KJ, Davis R, Rollnick S. Motivational interviewing for pediatric obesity: Conceptual issues and evidence review. J Am Diet Assoc 2006;106(12):2024-33.
- Schwartz RP. Motivational interviewing (patient-centered counseling) to address childhood obesity. Pediatr Ann 2010;39(3):154-8.
- Modi AC, Zeller MH. Validation of a parent-proxy, obesity-specific quality-of-life measure: Sizing them up. Obesity 2008;16(12):2624-33.
- Bolling C, Crosby L, Boles R, Stark L. How pediatricians can improve diet and activity for overweight preschoolers: A qualitative study of parental attitudes. Acad Pediatr 2009;9(3):172-8.
- Ogden J, Reynolds R, Smith A. Expanding the concept of parental control: A role for overt and covert in children’s snacking behaviour. Appetite 2006;47(1):100-6
- Kral TV, Rauh EM. Eating behaviors of children in the context of their family environment. Psychol Behav 2010;100(5):567-73.
- Piernas C, Popkin BM. Trends in snacking among U.S. children. Health Aff (Millwood) 2010;29(3):398-404.
- Freedman MR, Alvarez KP. Early childhood feeding: Assessing knowledge, attitude, and practices of multi-ethnic child-care providers. J Am Dietetic Assoc 2010;110(3):447-451.
- Hammons AJ, Fiese BH. Is frequency of shared family meals related to the nutritional health of children and adolescents? Pediatrics 2011;127(6):e1565-74.
- Deshmukh-Taskar PR, Nicklas TA, O'Neil CE, Keast DR, Radcliffe JD, Cho S. The relationship of breakfast skipping and type of breakfast consumption with nutrient intake and weight status in children and adolescents: The National Health and Nutrition Examination Survey 1999-2006. J Am Diet Assoc 2010;110(6):869-78.
- World Health Organization (WHO). Global strategy on diet, physical activity and health. Geneva, Switzerland: WHO Document Production Services, 2004.
- World Health Organization (WHO). School policy framework: Implementation of the WHO global strategy on diet, physical activity and health. Geneva, Switzerland: WHO Document Production Services, 2008.
- Solh, Z, Adamo, K, Platt JL, et al. Practicing what we preach: A look at healthy active living policy and practice in Canadian paediatric hospitals. Paediatr Child Health 2010; 15(10):e42-8.
- Srabstein JC, Berkman BE, Pyntikova E. Antibullying legislation: A public health perspective. J Adoles Health 2008;42(1):11-20.
- Koehlmoos TP, Anway S, Cravioto A. Global health: Chronic diseases and other emergent issues in global health. Infect Dis Clin N Am 2011;25(3):623-38.
Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.