PEDIATRIC OBESITY PREVENTION AND TREATMENT ... - CHAMPS Online



PEDIATRIC OBESITY PREVENTION AND TREATMENT GUIDELINE

Date: February 20, 2003

Title: Pediatric Obesity Prevention and Treatment Guideline

Rationale:

This guideline summarizes current recommendations for identification, evaluation, and treatment of the overweight and obese pediatric population in the KP Colorado region.

Background:

In 1998 the World Health Organization designated obesity as a global epidemic. In the past three decades the incidence of obesity in the United States has tripled: 22% of children have a BMI > 85th percentile and 12% have a BMI > 95th percentile. Obesity is associated with many comorbidities which have deleterious and costly health consequences. An overweight child (BMI >95th percentile) over the age of 7 has a 50% risk of becoming an obese adult; this risk increases to 80% if the child is still obese as an adolescent. Comorbidities associated with obesity include Type 2 diabetes, hypertension, dyslipidemia, nonalcoholic steatorrheic hepatitis, cholelithiasis, depression and asthma.

Factors contributing to this obesity epidemic include increased caloric intake (energy dense, high calorie, high fat food; super sized portions) and decreased energy expenditure (decreases in exercise and increases in sedentary activity, such as TV and computer time). Prevention is believed to be easier than treatment. Successful interventions described in the literature include promotion of healthy eating and methods to increase physical activity and decrease sedentary activity. Interventions focusing on family change are critical. Parents are responsible for the home environment therefore focusing any intervention on just the overweight child is detrimental. However, a family needs to be ready to change. A behavioral component, which stresses small incremental changes, which are monitored and positively reinforced, increases success rates.

This guideline provides direction for the identification of children at risk for overweight and overweight children; screening recommendations for comorbidities; treatment options and promotion of healthy lifestyles for families. The primary goal is to bring awareness of this problem to our families and foster discussions between families and their providers about this important health issue.

Recommendations for Pediatric Obesity Prevention and Intervention:

Pediatric Weight Goals:

An expert panel sponsored by the Maternal and Child Health Bureau, Health Resources and Services Administration has made the following recommendations for weight goal:

Weight maintenance in the figure below is defined as staying at the same weight or slowing weight gain while the child grows. Weight loss is recommended for children with complications from their weight or in older children that are overweight.

A. Body mass index should be determined for all children aged 3-18 years during routine well child care. Families should be informed if their child is overweight (BMI > 95th percentile) or at risk for overweight (BMI > 85th percentile but < 95th percentile). The BMI value should be entered into the medical record flowsheet by back-office staff to allow for electronic tracking.

B. Families can be given questionnaires (see attached) to assess physical activity and nutrition. The physician can review the questions with the family, using brief negotiation techniques to explore the level of interest in family behavior change. The readiness-to-change tool on the exam room physical activity poster and patient handouts can be used in these discussions (see Provider Counseling below).

C. Weight management for children is a family affair; focus should not be on the overweight child alone. Families are encouraged to exercise (e.g., walking, bicycling, and park activities) and modify their eating habits (increase fruits and vegetables, reduce portion sizes and saturated fats) together. Reducing the frequency of dining out can reduce total calories. Parents and children are encouraged to limit sedentary activity.

D. Overweight parents may benefit from enrolling in the adult Weight Management Program and, indirectly, their children may benefit as well. As a family strategy for helping children lose weight consider recommending the KP Weight Management Program (KP WMP) to overweight parents. The KP WMP is effective at helping adults maintain significant weight loss: 25% of enrollees maintain 5-10% weight loss at twelve months.

E. Screening labs:

i. A careful history and physical exam (that eliminates the need for unnecessary laboratory evaluation) can detect nearly all endogenous causes for childhood obesity.

ii. Consider ordering screening labs for overweight children. Screening labs should be discussed with the family before ordering; the yield from such tests is low and treatment for abnormal lab results will be weight loss or maintenance.

a) Fasting glucose and lipid panel may be considered for overweight children (BMI > 95th percentile), 10 years of age or older.

b) Children at risk for overweight (BMI > 85th percentile) and 10 years of age or older, may be screened if they have 2 or more risk factors for type 2 diabetes (DM2): family history of DM2; race/ethnicity at increased risk for DM2 (American Indian, African American, Asian, South Pacific Islander); signs of insulin resistance (acanthosis nigrans, ovarian hyperandrogenism).

F. For all complications associated with overweight, the primary goal is weight loss.

i. For children, who have an abnormal fasting glucose (110 – 125 mg/dl) or triglyceride > 150 mg/dl, it is recommended that a repeat fasting glucose and 2-hour glucose tolerance test are ordered. If this is diagnostic for impaired fasting glucose then consider contacting the Barbara Davis Center.

ii. Patients diagnosed with type 2 diabetes should be referred to the Barbara Davis Center.

iii. Children older than 12 years and with LDL cholesterol levels >220 mg/dl should be referred to the Skyline Endocrinology department for family counseling and discussion of medical therapy.

G. Weight loss medications have not been extensively studied in children and are not recommended as a treatment of pediatric obesity.

H. Provider Counseling:

1. ASK Measure BMI during well child visits. Ask patients with BMI> 85th percentile if they are interested in making one change in their diet and/or one change in their activity. Use the four questions below to explore current nutrition and physical activity patterns:

1. How many helpings of fruits and vegetables do you eat a day?

2. How much soda, fruit drinks and milk do you drink a day?

3. How many hours of regular exercise in a week does your child average?

4. How may hours a day does your child spend on TV, computer or video games?

2. ADVISE. Encourage families to make one change in their diet and/or one change in their activity level using brief negotiation techniques.

“I am seeing a marked increase in childhood obesity and diabetes in children. Healthy eating and physical activity can help families prevent these problems. I strongly advise you make some changes in your diet and activity.”

3. ASSESS. Explore the family’s level of interest in changing behavior using the Readiness to Change scale found on the “Get More Energy” exam room poster (see attached). Consider using the following phrases when discussing behavior change:

“You rated yourself a 4 on the 1-10 scale for readiness for change. Why didn’t you rate yourself a 2?” (Explore and praise any readiness)

“What would need to happen to move from a 4 to a 7 on the readiness scale?” (Explore and encourage a plan to help move families up on the scale)

4. ASSIST. Review the “Encouraging a Healthy Weight for Your Child” handout with your patients and families. If parents are overweight, encourage them to enroll in the KP Weight Management Program. Give overweight parents the “Body Mass Index and Your Lifestyle” handout.

Referral to RD Services.

Members may be encouraged to see an RD for more in-depth dietary counseling for weight loss. Members may call the Call Center for an RD appointment.

J. Referral to The Children’s Hospital:

The experience of Kaiser Permanente families with the Shapedown program at The Children’s Hospital (TCH) has been mixed. Of 28 patients referred the fall and spring of ‘00/’01, 8 attended only the first class, and 3 had lost weight at the 10 week visit (10%). Consider referral to TCH if 1) a family is motivated to change health behaviors and 2) the child’s BMI is >95th percentile or >85th percentile with complications.

These recommendations are consensus-based. Providers are encouraged to counsel all children and their families on physical activity and nutrition during well child visits. There is evidence that brief interventions to help change behavior can be effective for other health issues such as smoking.

Kaiser Permanente Colorado is committed to improving child obesity outcomes. To this end, the Departments of Pediatrics and Prevention will partner with researchers in the Clinical Research Unit of KP and in the community to study obesity prevention and treatment. We will encourage KP families of overweight children to participate in these studies.

Target Population: KP Colorado members age 3-18.

Responsible party: Helen Seagle, Prevention, Helen.Seagle@, 303-344-7549.

Approval: Chief, Preventive Medicine

Review Date: January 10, 2005

Settings for Application: Pediatrics and Family Practice

Methods for Measuring Compliance: We will track the proportion of well child visits in which BMI is recorded. We will also track the referral rate to TCH weight loss program and ask for data on the success of this program.

Source of evidence:

Barlow SE, Dietz WH. Obesity evaluation and treatment: expert committee recommendations. The Maternal and Child Health Bureau: HRSA. Pediatrics 1998; 102 (3): 1-11.

Epstein, LH., Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics 1998;101:554-70.

Hill JO. Trowbridge FL. Childhood obesity: future directions and research priorities. Pediatrics. 101(3 Pt 2):570-4, 1998 Mar.

Dietz WH. Overweight and precursors of type 2 diabetes mellitus in children and adolescents.[comment]. Pediatrics. 138(4):453-4, 2001 Apr.

Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics. 101(3 Pt 2):518-25, 1998 Mar.

Robinson TN. Behavioural treatment of childhood and adolescent obesity. Int J Obes Rel Metab Disorders. 23 Suppl 2:S52-7, 1999 Mar.

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These guidelines are informational only and are not intended to substitute for the reasonable exercise of independent clinical judgment of the providers using the guideline. The guidelines are to be used in conjunction with the provider's clinical judgment in developing care and treatment that is designed for the individual needs of the patient.

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