• Screening children for overweight by using body mass index (BMI) is the standard obesity measurement and should be obtained at each health care encounter for children older than 2 years of age using the National Center for Health Statistics age and gender-specific percentile curves up to 20 years of age (See appendix I of the original guideline document titled "Flow Chart - Children and Adolescents"). (Level I)
• BMI reading greater than or equal to the 95^th percentile for age and gender is overweight. A BMI between the 85^th and 95^th percentile for age and gender is considered at-risk for overweight and should be evaluated for hypertension (HTN), dyslipidemia, and diabetes. (Level I)
• A BMI greater than or equal to 95^th percentile for age and sex should be further evaluated for exogenous causes of obesity and for complications caused by overweight status. (Level I)
• Early intervention begins with children greater than or equal to two. (Level I)
• The family must be ready for change, as a lack of readiness could lead to failure. Probe for readiness to change. (Level IIa)
• Providers should educate the family on medical complications related to overweight including HTN, dyslipidemia, heart disease, and diabetes. (Level I)
• Providers should educate the family on psychosocial complications related to obesity such as depression, confidence issues, and poor self-esteem. (Level I)
• The entire family and/or all caregivers should be involved in the development and implementation of the program. (Level I)
• The family should be in agreement with the interventions. (Level I)
• Treatment programs should emphasize long-term permanent changes, not rapid weight loss or short-term diets and exercise programs. Persuade the family to seek small, gradual, but lifelong changes. (Level I)
• Support family activities that provide everyone with exercise (promote inclusiveness). (Level I)
• Low fat, low cholesterol, reduced sugar diet per age weight and nutritional requirements (www.health.gov/dietaryguidelines) (Level I)
• Encourage planned meals, especially eating breakfast. Discourage skipping meals. (Level I)
• Discourage eating while watching television. (Level I)
• Avoid the use of food as a reward or punishment. (Level I)
• Stock refrigerator with healthy food and drink choices. (Level I)
• Encourage 30 to 60 minutes of moderate physical activity most days of the week. (Level I)
• Promote a variety exercise to prevent boredom or overtraining. (Level I)
• Clinicians should maintain an open and accepting relationship to all family members involved. (Level I)
• If necessary, utilize a multi-disciplinary approach for comprehensive management. (Level I)
• Consider cultural norms and socioeconomic status. (Level I)

Medical Evaluation

Purpose

• Rule out secondary causes of childhood obesity: genetic causes include Prader-Willi, Bardet-Biedl, and Cohen diseases; endocrinologic causes are hypothyroid and Cushing syndrome.
• Assess psychological causes of obesity in patients and family members. These include low self-esteem, eating disorders, and depression.
• Assess for complications associated with obesity such as sleep apnea, metabolic syndrome, fatty liver, cholelithiasis, type II diabetes, polycystic ovary syndrome (PCOS), Blount's disease, and slipped capital femoral epiphysis (SCFE).

Management/Treatment

If a child is identified at-risk for overweight or overweight, the provider will:

• Complete the Weight Management Plan for Children and Adolescents (See Appendix 2 of the original guideline document titled "Overweight and obesity in children and adolescents: a guide for general practitioners.").
• Assess risk factors related to food and activity levels.
• Identify and rule out a mental health disorder that may be related to exacerbating child's eating habits and activity (Psychological tool – Primary Care Evaluation of Mental Disorders Questionnaire: Brief Patient Health Questionnaire). (See appendix 3 of the original guideline document).
• Introduce patient and family to Centers for Disease Control and Prevention (CDC) Body and Mind "Motion Commotion" Physical Activity Assessment Tool.
• Using the CDC Body and Mind Fit 4 Life Guideline will counsel family and patients of risks associated with overweight status.
• Counsel patient and family on dietary choices and relationship to overweight status.
• Evaluate cultural aspects of the family’s beliefs on diet, exercise, and concept of obesity.
• Counsel patient on exercise versus sedentary (computers, games, television) habits and the relationship to childhood overweight status.
• Teach patient and family how to support and maintain the challenges of initiating a diet and exercise plan.
• Encourage total family involvement in healthy living and eating.
• Establish activity calendar.
• Refer to registered dietician and physical exercise trainer (if needed).
• Refer for sleep study, cardiology, neurologist, orthopedist, geneticist, gynecologist, endocrinologist, urologist, and pulmonologist, if concomitant disease processes are present or are suspected in relationship to child’s overweight status.
• Refer to specialty weight reduction clinics including consideration of medication and/or bariatric surgery (needed in less than 1% of children and adolescents identified as obese).
• Schedule patient for regular return visits for follow-up.

Monitoring of Treatment

• CDC Fit 4 Life Program - Introduce nutritional meals and treats, review activity calendar, and discuss the importance of having a variety of activities and foods.
• Monitor improvement and/or plateau or regression as per the Weight Management Program.
• Adjust intensity of therapy and/or modality dependent on patient's enthusiasm or resistance (treatment will be individualized for each patient in order to provide the best opportunity for success).

Continuation of Follow-up Visits

• Take vital signs including blood pressure; calculate BMI and compare to prior visits.
• Evaluate patient's (family) compliance with diet.
• Evaluate patient's (family) compliance with exercise.
• Evaluate patient's (family) sedentary time activities.
• Evaluate side effects of current regimen if any; avoid consequences of intense scrutiny of one's body size – body dysmorphia, anorexia, bulimia, and/or depression.
• Support improvements other than scale weight loss:
  • Body fat per caliper measurement
  • Engagement in physical activity
  • Improved self-esteem and confidence
  • Improved family functioning
  • Engagement in self-regulating behaviors
• Identify triggers and roadblocks that might hinder short- and long-term success.
• Repeat follow-up steps above as appropriate.

Intervention

Visit 1

Subjective Assessment

• History
• Symptoms
• Past medical history
• Medication history
• Family history
• Psychosocial history
• Substance abuse history
• Dietary history
• Reproductive history (menses history for females and secondary sexual characteristics for boys and girls). Document according to Tanner Stages

Objective Assessment

• Physical exam
  • Blood pressure (mmHg)
  • Height (meters)
  • Height percentile
  • Weight
  • Weight percentile
  • BMI (weight in kg/height in meters squared)
  • BMI percentile by age and gender
  • Assess for facial dysmorphia (genetic syndrome)
  • Funduscopic exam (papilledema)
  • Tonsils (hypertrophy)
  • Thyroid (goiter)
  • Assess for acanthosis nigricans (glucose intolerance)
  • Assess for hirsutism (PCOS)
  • Assess for violaceous striae (Cushing's disease)
  • Assess for upper abdominal tenderness (gallbladder disease)
  • Assess for undescended testicle (Prader Willi Syndrome)
  • Assess for small hands and feet (Prader Willi Syndrome)
  • Assess for limited hip range of motion (SCFE)
  • Assess for lower-leg bowing (Blount’s disease)

Source: Eissa M, Gunner K. Evaluation and management of obesity in children and adolescents. Journal of Pediatric Health Care 2004 Jan; 18(1): 35-38.

Assessment/Plan

• Perform diagnostic procedures including measurements of blood pressure, hemoglobin A1C, BMI, thyroid-stimulating hormone (TSH), lipid panel, and complete metabolic panel.
• Perform additional testing as warranted (e.g. 12-lead electrocardiogram and/or echocardiogram, urinalysis, complete blood count [CBC], urine microalbumin, pulmonary function test, chest x-ray, skin fold measurements, and sleep studies).
• Categorization of weight according to BMI as optimal, at-risk for overweight, and/or overweight as defined by greater than or equal to 85^th percentile and 95^th percentile, respectively, according to growth charts for age, sex, and ethnicity.
• Provide follow-up recommendations based on screening measurement.
• Perform other tests based on positive findings in history and physical examination (e.g., PCOS, genetic screening for disease processes such as Prader-Willi Syndrome, Blount's disease, pseudotumor cerebri, gallbladder disease, metabolic syndrome, fatty liver, SCFE).

Visit II

• Provider will initiate "Weight Management Plan: A Guide for General Practitioners" http://www.obesityguidelines.gov.au/pdf/children_gp.pdf.
• Provider will introduce patient and family to CDC "Fit 4 Life" recommendations at http://www.bam.gov/fit4life/fitt.htm (for ages 9 to 13).
• Conduct assessment and determine patient and/or family readiness to engage in therapeutic lifestyle change. Primary care physician (PCP) will assess and determine motivation and stages to change (precontemplation, contemplation, preparation, action, maintenance and relapse-prevention).
• Administer Brief Quality of Life Tool to patient and parent(s) to establish baseline of self-esteem (Example: PedsQL Pediatric Quality of Life Inventory, version 4.0 for ages 8 to 12).
• Advanced practice nurse/primary care physician will monitor vital signs including blood pressure and BMI and review abnormal labs.
• If referrals were made at initial visit, determine if family complied with those initial recommendations.

Visit III

• Briefly review the Weight Management Plan, specifically psychosocial distress, labs as necessary, and risk factors.
• Monitor level of intervention based on patient and family response to weight management plan.
• Advanced practice nurse/primary care physician will monitor vital signs including blood pressure, BMI, and labs.
• Discuss compliance to diet, physical activity, and stages of change and results of self-esteem tool.
• Implement motivation tactics and strategies based on child and family’s values and reward system.
• Refer as necessary.

Visit IV

• Advanced practice nurse/primary care physician will monitor vital signs including blood pressure, BMI, and labs.
• Discuss obstacles, triggers, and roadblocks to success.
• Assess stages of change.
• Assess family's adherence to the Fit 4 Life Module, giving praise for even the smallest effort to a therapeutic lifestyle change.
• Review Weight Management Plan including level of psychosocial distress.
• Administer Patient Quality of Life Tool to patient and parent(s) to compare with baseline.

Subsequent visits

• Repeat above efforts, modify plans according to outcomes.
• Continue to monitor changes in comparison to baseline (BMI, blood pressure, quality of life, psychosocial distress, labs).

Definitions

Strength of Recommendations

Level I: Usually indicated, always acceptable, and considered useful and effective.

Level IIa: Acceptable, of uncertain efficacy, and may be controversial. Weight of evidence in favor of usefulness/efficacy.

Level IIb: Acceptable, of uncertain efficacy, and may be controversial. May be helpful, not likely to be harmful.

Levels of Evidence

Grade A: Randomized clinical trials
Grade B: Well-designed clinical trials
Grade C: Panel consensus

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