Childhood Obesity

Description

“The complexity of obesity prevention lies in influencing families to change behaviors when habits, culture, and environment promote less physical activity and more energy intake. Handing families a list of recommended eating and activity habits, as if it were an antibiotic prescription, fits into traditional medical training but such an approach is rarely effective.” [Barlow: 2007]

Other Names

Childhood obesity
Adolescent obesity
Overweight

Diagnosis Coding

ICD-10

E66.xx, overweight and obesity

E66.0x, obesity due to excess calories

E66.3, overweight

The “x” indicates need for one or two additional digits to indicate root cause and severity. See ICD-10 Overweight and Obesity Coding Reference for details.

Note: The Affordable Care Act stipulates that obesity screening and counseling are covered benefits under insurance plans that are not exempt.

Description

Childhood obesity is defined as children who have a body mass index (BMI), as determined by plotting on BMI growth curves, at or above the 95th percentile. Overweight is defined as children who have a BMI between the 85th and 95th percentiles. Every effort should be made during childhood and adolescence to help patients avoid becoming at risk for overweight or obesity. If overweight or obese, clinicians should not wait to address the issue until adulthood, when lifestyles and habits are more difficult to change and the pathophysiologic changes associated with overweight and obesity are established. Clinical approaches involve communication, education, motivation, and life-style interventions that focus on the entire family.

Prevalence

Since 1980, prevalence of childhood obesity has increased three-fold. [Hughes: 2008] Nearly one out of three children is overweight or obese, and the proportion approaches 40% in ethnic populations. [Hassink: 2010] The results of the National Health and Nutrition Examination Survey, conducted in 2009-2010, are shown in the figure below:
Prevalence of Obesity among Children and Adolescents in the U.S, 2009-2010
Prevalence of Obesity Among Children and Adolescents: United States, 2009-2010
Image: Centers for Disease Control and Prevention [Ogden: 2012]

Past studies have been criticized because they involved primarily middle class white children, ages 8 -12 who are seen in obesity clinics. [Gilles: 2008] [Jelalian: 2007] [Hughes: 2008] There are few studies on specific minority populations that may be at a higher risk for obesity due to ethnic and cultural influences, although it has been suggested that African American children have greater lean mass than their Caucasian peers. [Freedman: 2009]

Genetics

Variations of the FTO gene can influence eating and satiety in obese children. [Epstein: 2010] Melanocortin 4 receptor (MC4R) mutations, found in 4-6% of morbid obesity cases, are the most common genetic cause of obesity. These patients present with early onset morbid obesity, increased fat mass, hyperphagia, hyperinsulinemia, and mild hypothalamic hypothyroidism. Children with proopiomelanocortin (POMC) defects, which result in disruption of the melanocortin signaling and cause dysfunction of the hypothalamic-pituitary-adrenal axis, can present with abnormal thyroid levels. [Sothern: 2006] The inheritance patterns for these genes and their impact on children at the population level have yet to be detailed. [Goran: 2005] Parents and children share both genetics and their environment, complicating study of their relative contributions. Fat cells produce leptin, which influences the hypothalamus to suppress appetite, decrease insulin, and increase the expenditure of energy. Fat cells of very obese humans contain increased amounts of mRNA for leptin, implying a defect or resistance to leptin.

Genetic syndromes associated with childhood obesity include Prader-Willi syndrome, Turner syndrome, and Laurence-Moon-Bardet-Biedl syndrome. Findings such as developmental delay, short stature/delayed growth, dysmorphic features, abnormal or absent genitalia, and digital anomalies should raise suspicion of an underlying genetic disorder. [Lönnqvist: 1995] [Sothern: 2006]

Prognosis

Childhood obesity is associated with a spectrum of complications that may affect short- and long-term physical and mental health. Common co-morbid conditions include hypertension, diabetes, sleep apnea, chronic inflammation, polycystic ovary syndrome (PCOS), asthma, liver and gall bladder disease, and orthopedic problems. [Daniels: 2006] [Hughes: 2008] Research suggests that obese children have weaker immune systems and are at increased risk of chronic illnesses. [Herrera: 2004] Obese children are at greater risk than their non-obese peers of becoming obese adults. [Jelalian: 2007] Prognosis often depends on the effectiveness of treatment, when treatment begins, and support of the family.

Roles Of The Medical Home

Effective identification and treatment of childhood obesity requires that primary care clinicians routinely screen children for obesity risk using BMI measurements and percentiles. [Barlow: 2007] Non-judgmental conversations about weight should occur early, since lifestyles that contribute to obesity begin as young as age four. [Ruxton: 2004] Motivational interviewing (MI) can be used to determine the family's readiness for change and to support families with the cognitive steps needed to accept treatment. More detail about the use of MI can be found later in this module: Childhood Obesity, Treatment & Management.

Clinicians assist with setting realistic, achievable goals and monitoring behaviors targeting change. Clinicians should expect imperfect adherence and communicate positive messages focused on long-term progress. The Medical Home may suggest involvement of a dietician or a weight specialist, behavior specialist, exercise specialist, or bariatric medicine specialist and coordinate the care provided.

Practice Guidelines

Barlow SE.
Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120 Suppl 4:S164-92. PubMed abstract / Full Text

National Heart, Lung, and Blood Institute Expert Panel.
Integrated guidelines for cardiovascular health and risk reduction in children and adolescents.
National Institutes of Health. NIH Publication No. 12-7486; October 2012. / http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf
Addresses the major population-based risk factors for cardiovascular disease in a single evidence-based set of guidelines.

Helpful Articles

Baker JL, Farpour-Lambert NJ, Nowicka P, Pietrobelli A, Weiss R.
Evaluation of the overweight/obese child - practical tips for the primary health care provider: recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obesity.
Obes Facts. 2010;3(2):131-7. PubMed abstract / Full Text
Simple and practical tools for the identification and management of children with, or at risk of, overweight and obesity in the primary care setting.

Rao G.
Childhood obesity: highlights of AMA Expert Committee recommendations.
Am Fam Physician. 2008;78(1):56-63. PubMed abstract / Full Text
An American Medical Association expert panel reviewed evidence about how best to manage and prevent obesity. The Committee recommends a four-stage approach to treatment of childhood obesity. Many of these recommendations can be carried out by family physicians.

Goran MI, Sothern MS.
Handbook of Pediatric Obesity: Etiology, Pathophysiology, and Prevention.
Boca Raton: CRC Press / Taylor & Francis Group; 2005. 1574449125
Features contributions from leading experts on childhood obesity at the social, behavioral, environmental, metabolic, and genetic levels.

Sothern MS, Gordon ST, von Almen TK.
Handbook of Pediatric Obesity: Clinical Management.
Boca Raton, FL: CRC Press/Taylor & Francis; 2006. 1574449133
Compilation of management, medical, nutrition, psychological, and physical activity facts, models, theories, interventions, and evaluation techniques regarding management of pediatric obesity.

Clinical Assessment

Overview

The history and physical of the obese child, as well as of family members, can help the clinician assess contributing factors and formulate a plan for achieving healthier weight.

Screening

BMI screening is the most useful tool in identifying obesity. While BMI does not measure fat mass, it correlates well and is a good indicator of health risk. [Hughes: 2008] Weight and BMI should be addressed with every child, every year. [Barlow: 2007] The Portal's Childhood Obesity Screening & Prevention provides further details for screening, screening for risk factors, and screening tools.

Of Family Members

While screening of family members is not important for the diagnosis of childhood obesity, it can provide clues for how to help patients and family members change their lifestyle, which is the key to successful treatment.

For Complications

The National Heart, Lung, and Blood Institute recommends for children with BMI ≥95th percentile: annual fasting lipid profile beginning at 2 years of age; annual fasting glucose beginning at 10 years of age. All children, regardless of weight status, should have annual blood pressure measurement beginning at 3 years of age. [National: 2012]

Diagnostic Criteria

The definitions of overweight and obesity are based on BMI, derived from the child’s height and weight: BMI = (Weight [lb] / Height [inches] x Height [inches]) x 703. In children older than two, clinicians should use BMI percentiles specific to the age and sex of the child. [Hassink: 2010] BMI percentiles are derived from NHANES data collected prior to 1980, when the prevalence of obesity was 5%. See Clinical Growth Charts (CDC & WHO).

Clinical Classification

Overweight is defined as children who have a BMI between the 85th and 95th percentiles. Children with BMI at, or above, the 95th percentile are considered obese. Additional classifications for children who are above the 97th percentile may be useful for those in need of more aggressive treatment. [Hughes: 2008]

Medical Conditions Causing Childhood Obesity

Excess caloric intake and sedentary behaviors are the most common causes of childhood obesity. Rare causes of childhood obesity include:
  • Cushing syndrome (obesity resolves with treatment)
  • hypothyroidism
  • polycystic ovary syndrome (PCOS)
  • insulinoma
  • growth hormone deficiency
  • hypothalamic disorders
  • congenital leptin deficiency
  • medications (insulin, thiazolidinedione, antipsychotics, antidepressants)
  • genetic causes:
    • Down syndrome - while obesity is not a defining factor of Down syndrome, obesity can occur later in adolescence as a result of inactivity. The Medical Home Portal's Down Syndrome module provides further diagnosis and management information.
    • Fragile X syndrome - The Medical Home Portal's Fragile X Syndrome module provides further diagnosis and management information.
    • Prader-Willi syndrome (hypotonia, hypogonadism, hyperphagia, cognitive impairment, morbid obesity). The Medical Home Portal's Prader-Willi Syndrome module provides further diagnosis and management information.
    • Laurence-Moon Bardet-Biedl syndrome (polydactyly, renal anomalies, retinitis pigmentosia, cognitive impairment, truncal obesity).
    • Cohen syndrome (microcephaly, hypotonia, short stature, truncal obesity, ocular anomalies, neutropenia).
    • Biemond syndrome (diabetes mellitus, polydactyly, coloboma, facial abnormalities, hypogonadism).

Comorbid Conditions

Obese youth are more likely than healthy-weight children to have risk factors for cardiovascular disease. In a population-based sample of 5- to 10-year-old children with obesity, 58% have one cardiovascular risk factor and 25% have two. [Hughes: 2008] Cardiovascular risks include increased left ventricular mass and decreased cardiac function with abnormal endothelial function; elevated blood pressure (4.5 times more likely); and abnormal lipid levels (2.4 - 7.1 times more likely). [Hughes: 2008]

In addition, obese children are more likely than non-obese children to develop:
  • type 2 diabetes mellitus
  • hyperinsulinemia and increased insulin resistance (12.6 times more likely)
  • metabolic syndrome (18-50% compared to <1% in children of healthy weight)
  • bone and joint problems
  • sleep apnea
  • social and psychological problems such as stigmatization and poor self-esteem
[Hughes: 2008] [Daniels: 2005] [Dietz: 2005]

Obese adolescents are more likely to develop heart disease and diabetes as adults. [Hughes: 2008]

Pearls & Alerts

TSH is a low-yield test.

Hypothyroidism is a rare cause of obesity.

History & Examination

Family History

Family conditions that may confer increased risk for the child or may affect family functioning include: [Barlow: 2007]
  • obesity
  • cardiac events
  • diabetes (type 2)
  • high blood pressure
  • hypercholesterolemia

Pregnancy Or Perinatal History

Maternal or gestational diabetes or other complications of pregnancy (hypertension, impaired intrauterine growth, small or large for gestational age) may be factors that contribute to obesity. [Barlow: 2007]

Current & Past Medical History

Key items to assess include: [Barlow: 2007]
  • sleep patterns (duration, snoring, nocturnal binge eating, nocturia)
  • physical limitations due to orthopedic problems
  • mood
  • eating patterns (focus on history of dieting and binge-eating)
  • in female adolescents, the regularity of periods and the presence of hyperandrogenism

Developmental & Educational Progress

Psychological conditions may include: [Herrera: 2004]
  • social stigma
  • low self-esteem
  • poor parent child interaction
  • behavior problems
  • binge eating
  • depression

A high BMI in children ages 5 -10 predicts a lower self-esteem score four years later. [Hughes: 2008] Obese children and adolescents also endure social stigma. Improved self-esteem and body image, reduction in behavior problems, and an increased quality of life are seen after success in weight management programs. [Nemet: 2005]

Maturational Progress

Short stature or abnormal growth patterns should trigger consideration of further investigation for endocrine or genetic causes of obesity.

Social & Family Functioning

Detailed assessment of dietary and activity patterns may provide important insights. [Barlow: 2007] Specifics may include:
  • assessment of eating behaviors and physical activity patterns
    • self-efficacy and readiness to change
    • identification of the following specific dietary practices, which may be targets for change
      • frequency of eating outside the home at restaurants or fast food establishments
      • excessive consumption of sweetened beverages
      • consumption of excessive portion sizes for age
    • additional practices to be considered in the qualitative dietary assessment include:
      • excessive consumption of 100% fruit juice (more than 6 oz. of fruit juice per day), regular soda, punch, and other sugar-sweetened drinks
      • breakfast consumption (frequency and quality)
      • excessive consumption of foods that are high in energy density
      • low consumption of fruits and vegetables
      • meal frequency and snacking patterns (including quality)
    • assessment of physical activity patterns
    • self-efficacy and readiness to change
    • environment and social support and barriers to physical activity
    • meeting recommendations of 60 minutes of moderate to vigorous physical activity per day
    • amount of sedentary behavior, including hours of screen time such as viewing television, watching DVDs, playing video games, and using a smartphone

Physical Exam

The American Academy of Pediatrics' Physical Examination Findings in Obesity Assessment and Possible Causes (AAP) details the physical exam by systems and offers explanations for specific findings. [Barlow: 2007]

General

Assess for dysmorphic features associated with syndromes that include obesity.

Vital Signs

Check blood pressure and heart rate.

Growth Parameters

Record height and weight, BMI and BMI percentile for age and gender.

Skin

Examine skin for signs of acanthosis nigricans, striae, or manifestations of hyperandrogenism (hirsutism, moderate acne) in females.

HEENT

Assess for ocular abnormalities such as retinitis pigmentosa, coloboma microcephaly, and facial abnormalities.

Mouth/Teeth

Assess for large tonsils that may cause obstruction, enamel erosion that may be evidence of purging.

Chest

Breast exam for pubertal staging in girls, evidence of pseudogynecomastia in boys.

Heart

Assess for point of maximal impulse (PMI), rate, rhythm, and the presence of murmurs.

Abdomen

Evaluate for enlarged liver.

Genitalia

Assess pubertal staging and hypogonadism in males.

Extremities/Musculoskeletal

Examine the musculoskeletal system focusing on skeletal deformities and limitation of motion and polydactyly.

Testing

The American Academy of Pediatrics' Medical Screening According to BMI Category (AAP) details laboratory testing recommendations specific to BMI and history. [Barlow: 2007]

Laboratory Testing

Lab tests to consider in the evaluation of the obese child include CBC, CMP, TSH, free T4, fasting lipid panel, insulin, glucose, and Hb A1c. [Baker: 2010]

Other Testing

Developmental evaluation is appropriate if there is suspicion of delay.

Subspecialist Collaborations & Other Resources

Nutrition/Dietary (see Services below for relevant providers)

Provides counseling regarding diet and may be able to assist with diagnosing eating disorders.

Developmental Evaluation (see Services below for relevant providers)

Performs testing when underlying condition is suspected.

Pediatric Genetics (see Services below for relevant providers)

Offers diagnosis, management, and genetic counseling services for genetic disorders, birth defects, and developmental disabilities.

Pediatric Metabolic Genetics (see Services below for relevant providers)

Offers genetic counseling and consultation for individuals of all ages with a wide range of genetic conditions including chromosomal disorders, single gene disorders, and recognizable syndromes.

Treatment & Management

Overview

An Expert Committee, convened by the American Medical Association (AMA), the Health Resources and Services Administration (HRSA), and the Centers for Disease Control and Prevention (CDC), established stages for management of pediatric obesity. [Barlow: 2007]
  1. The first stage includes setting goals of eating five fruits and vegetables a day, eating breakfast, eating meals as a family, and not drinking sweetened beverages; avoid providing strict dietary guidelines at this time.
  2. The second stage is led by both a primary care clinician and a dietitian, reinforcing behaviors from stage one, providing information regarding structured meals and snacks, and setting behavioral targets.
  3. The third stage incorporates a multi-disciplinary approach with the help of a dietitian, clinician, behavior specialist, exercise specialist, and a pediatric weight specialist who have expertise in childhood obesity. Structured diet and physical activity recommendations are discussed. Behavior modification, modification of home environment, and goal setting are important components.
  4. The fourth stage is facilitated by professionals and specialists in bariatric medicine. This includes structured programs in which restrictive diets are used in addition to medication and/or bariatric surgery. [Ross: 2010]
Simple recommendations that could be provided during primary care visits include:
  • No or very few sugar-sweetened beverages.
  • Aim for five fruits and vegetables a day.
  • Limit screen time to two hours per day.
  • Eat breakfast every day.
  • Limit eating out and fast food.
  • Encourage family meals.
  • Limit portion size.
  • Eat a balanced diet rich in nutrients, calcium, and fiber.
  • Encourage exclusive breastfeeding for six months, then breastfeeding with solid food intake from 6-12 months.
  • Aim for 60 minutes of physical activity a day.
  • Limit consumption of high calorie foods
Specific counseling by the primary care clinician varies by the child’s age and BMI, as well as parents’ weight status and involvement. Weight Goals and Intervention Stages (AAP) provides recommendations for goals and interventions according to age and BMI categories.

Pearls & Alerts

Contraception may be less effective and exacerbate obesity

Transdermal combined hormonal contraception is less effective in girls with obesity and intramuscular depo medroxy progesterone acetate (Depo-Provera) may exacerbate obesity. Better options include combined oral contraceptives, intra-vaginal ring (NuvaRing), subcutaneous progestin-containing implantable rod (Implanon), or the levonorgesterel intrauterine device (Mirena).

Replace simple carbohydrates with complex carbohydrates

For example: brown rice instead of white rice, corn chips instead of potato chips, whole-grain bread instead of white bread, fruit instead of cookies, water instead of soda.

Systems

Mental Health/Behavior

Behavioral Therapy
Behavioral therapy is the most commonly used psychosocial modality for initiating change in obese children and it has proven successful as a method for change in adults. [Gilles: 2008] Behavior modification techniques typically address targets such as diet, increased physical activity, and decreased sedentary behavior. [Gilles: 2008] Specific techniques include self-monitoring, praise and modeling, reinforcement, and contracting. [Saelens: 2007] Success has also been found with techniques such as contingency management and environmental control. [Saelens: 2007] Behavioral therapists theorize that obesity results from the lack of ability to control food intake. This innate ability is lost at about age 10 or 11, and the use of food as reward or punishment may contribute. Behavioral therapy may be more effective than cognitive therapy in very obese children (BMI>97th percentile). [Ruxton: 2004] [Herrera: 2004] Approaches targeting specific cognition, such as problem solving, have been used to enhance self-control and adherence to diet and exercise programs. [Gilles: 2008] A meta-analysis found cognitive-based therapies were not beneficial for weight loss programs and may detract from behavioral components. [Gilles: 2008] For some children, referral to an experienced behavioral health specialist may be beneficial.

Behavioral modification that takes place in an inpatient or residential setting, such as an intensive weight loss camp, can have dramatic results. In one study, weight loss after one year of behavioral modification in an inpatient setting resulted in a decrease of 50% of excess body weight. One-third of those patients demonstrated continued weight loss and weight maintenance up to a year after treatment was completed. [Latzer: 2009] One obstacle to these intense programs is that they are generally expensive and require patients to be removed from their natural environment. The choice of control groups in these studies has been poor for comparison of outcomes, which threatens external validity. [Latzer: 2009]

Psychiatric Disorders
Binge eating is seen in obese children but is hard to quantify due to poor measurement tools. A compilation of multiple studies estimates that between 5-30% of overweight and obese children have a binge eating disorder. [Jelalian: 2007] Obese children are also at a higher risk for depression. [Jelalian: 2007] Unfortunately, depressive symptoms increase perceived barriers to weight loss and lifestyle changes, creating a vicious cycle. [Janicke: 2007]

In a study of body shape and health status, school age children were asked to describe children whose pictures reflected four body shapes. They described the obese child as unpopular, unhealthy, and lacking academic success. [Nemet: 2005] In another study, children ages 10-11 were asked to rank pictures of obese, disabled, and non-disabled children according to which they liked most to least. Irrespective of race, socioeconomic status, disability, or sex, pictures of obese children were consistently ranked last. [Hughes: 2008]

Motivational Interviewing
(MI)
Motivational interviewing is a communication model that strengthens motivation by resolving ambivalence in a way that requires the patient to do the psychological work of change. Key elements are reflective listening, shared decision-making, and agenda setting. The tone is listening and reflective, using a nonjudgmental demeanor and supportive climate where patients and their parents feel comfortable expressing their beliefs regarding current behaviors. There is no confrontation of irrational thoughts or denial. Instead, the interviewer helps the patient and their family to express the reasons they are for and against change. The interviewer may discuss how their current health status and behavior choices contribute to the patient’s and family’s long-term goals. The interviewer/clinician gives the patient/parents health information that facilitates the patient/parent’s motivation to change. [Resnicow: 2006]

A pilot study reported up to a 2.6% decrease in BMI among participants reporting that the intervention helped them think more about changing their family’s eating habits. [Schwartz: 2007] The model appears to be most effective in the early stages of change. The non-profit website Motivational Interviewing provides further information, resources, and training.

Subspecialist Collaborations & Other Resources

Behavioral Programs (see Services below for relevant providers)

Offers child and family counseling focusing on learning new skills, problem solving, and managing feelings.

Nutrition/Growth/Bone

While controversy exists regarding the ideal diet for children, most researchers agree that providing nutritional education instead of a prescribed diet leads to more informed patients and families and better compliance. However, structured diet regimens can produce short-term weight reductions of 10-20%. [Latzer: 2009] Many studies use a modified version of the Traffic Light Diet, developed by Leonard Epstein and associates from their work with family-based pediatric obesity interventions. [Epstein: 1988] Children are encouraged to consume a planned diet consisting of three meals a day, with 1-2 snacks that contain balanced macronutrients, in portions appropriate for dietary/caloric intake recommendations. The plan suggests low-energy-dense foods with a high water and fiber content, such as fruits and vegetables, and avoiding calorie-containing beverages. [Barlow: 2007]

The Traffic Light Diet assigns all foods a color: red, yellow, or green. Red light foods should not be eaten or should be eaten rarely by a child undergoing diet modification; yellow foods should be consumed in moderation, such as 2-3 times per week; and green light foods, such as fruits and vegetables, may be consumed in unlimited quantities. [Epstein: 2008] The Traffic Light Diet Common Food List (PDF Document 140 KB) has classifications of many available foods.

Subspecialist Collaborations & Other Resources

Nutrition/Dietary (see Services below for relevant providers)

Offers services that assist in treating eating disorders and teaching healthy living habits.

Recreation & Leisure

A non-randomized controlled trial that looked at changes in weight status and cardiovascular risk factors found positive effects from exercise, such as reduction in adiposity, increased fitness, and activity levels, as well as improved cardiac risk factors and decreased insulin resistance. These changes were sustained 12 months after the intervention ended. [Hughes: 2008] Even modest exercise (e.g., walking) can improve health outcomes, although encouraging children to reduce the amount of time they participate in sedentary activities is often more effective than encouraging physical activity. [Nowicka: 2007] Overweight children are more likely to engage in physical activity if it is non-competitive, they are able to go at their own pace, and they perceive it as fun. [Latzer: 2009]

Current recommendations for pediatric patients include reduction of screen time (less than 2 hours per day) and encouraging spontaneous play (at least 1 hour per day). Children and parents should be educated about practical ways to meet physical activity goals, such as breaking up an hour of activity into smaller increments. Clinicians should encourage participation in individual and/or team sports and physical education classes at school. There is also benefit in educating children and families about engaging in daily physical activities that encourage playing, being physically active, and taking up hobbies. Clinicians should also talk with families about increasing the variety of activities, being flexible and patient in the development of skills, and the significance of the involvement of family and friends. [Nowicka: 2007]

Conditions associated with childhood obesity that can affect exercise goals include:
Condition Treatment Goal
Sleep problems (≥50% among
adolescents with severe obesity) [Kalra: 2005]
Removal of tonsils and adenoids if obstructive sleep apnea; evaluation for continuous positive airway pressure therapy during sleep. [Barlow: 2007]
Asthma (can be confused
with poor physical conditioning [Ford: 2005]
Treatment is no different from that for healthy-weight children. [Ford: 2005]
Musculoskeletal discomfort
and increased risk for fractures [Taylor: 2006]
Early intervention (including physical therapy, when indicated). [Taylor: 2006]
Depression [Ford: 2005] Referral to specialist as needed. [Ford: 2005]

Subspecialist Collaborations & Other Resources

Recreation Programs/Activities (see Services below for relevant providers)

Offers physical and educational opportunities for children, teens, and the family.

Family

Studies consistently show that parent-only or parent-plus-child interventions for weight management are typically superior to that of child-only interventions for children 13 and under. For adolescents, who tend to be more independent, clinicians should discuss health behaviors directly with them and encourage parents to make the home environment as healthy as possible. [Sothern: 2006]

While some controversy exists on how best to incorporate family and peers in pediatric obesity treatment, parental modeling is a powerful predictor of a child’s weight change. [Epstein: 2010] [Wilfley: 2007] A recent meta-analysis suggests that success is more likely when parental involvement is combined with behavioral modification. Education needs to target both children and parents with reinforcement, as this leads to better short- and long-term outcomes, especially if the parent is overweight or obese. [Sothern: 2006] [Jelalian: 2007] Involvement of peers, especially in adolescent years, produces increased self-esteem and promotion of teamwork. [Jelalian: 2007] Clinicians can discuss or provide information about age-specific parenting actions. Recommendations need to take into account cultural values and beliefs.

Subspecialist Collaborations & Other Resources

Behavioral Programs (see Services below for relevant providers)

Offers various child and family counseling focusing on learning new skills, problem solving, and managing feelings.

Pharmacy & Medications

Weight loss medications are generally not used in children and adolescents, though may be considered for adolescents only. Currently, only two medications are FDA-approved for weight loss in adolescents: Orlistat (Alli, available over the counter, or Xenical, available by prescription) and phentermine. Medications that are not approved for weight loss but are approved for other indications and may result in weight loss include: bupropion, metformin, topiramate, thyroid hormone, and stimulant medications used for ADHD.

Orlistat inhibits pancreatic lipase, which results in the loss of triglycerides in the feces. It is FDA-approved for children 12 years and older. To date, five randomized controlled trials have been conducted, with mixed results. Most had favorable results; however, one reported no change between the treatment and control group. The risks and side effects of treatment are generally diarrhea and flatulence in those who consume higher quantities of fat. The studies found that the low-fat diet required to avoid side effects of the medication is difficult to maintain long-term. [Latzer: 2009]

Phentermine is only approved for use in individuals 17 years and older, and only for a 12-week period. Adverse effects include tachycardia and elevated blood pressure. There is limited data on its efficacy in adolescents.

In an adolescent with co-existing depression, bupropion may be an excellent option for treating the depression. It has the added potential to decrease impulsive eating and diminish appetite.

Some clinicians use metformin to aid weight management, however this medication is considered “weight neutral” and is probably most effective as an adjunct to increased physical activity in those with severe insulin resistance.

Topiramate is undergoing clinical trials as an appetite suppressant, but it has several side effects (mental slowing, fatigue, constipation) that may be poorly tolerated by adolescents. It has not been studied in a pediatric population for this indication, thus its efficacy is unknown. Qsymia (a combination of phentermine and topiramate) and Belviq (lorcaserin) are new weight loss therapies that can be used in patients 18 years and older. Qsymia requires risk strategy mitigation and monitoring of contraception in females of reproductive age.

Thyroid hormone should only be used in those patients with laboratory findings consistent with hypothyroidism and never used to treat obesity. Likewise, stimulant medications used to treat ADD/ADHD have not been demonstrated to be effective weight loss medications and have the potential to cause tachycardia and hypertension.

Surgery

Bariatric surgery is an extreme intervention that may prevent the continuation of co-morbid conditions into adulthood. Screening criteria are strict: patients must meet National Institutes of Health BMI criteria (>40), have two or more co-morbid conditions, have failed other treatment options, and reached 95% of their adult height. Behavior modification, nutrition, and physical activity must be addressed with the adolescent patient, and there is often hesitancy to recommend the surgery because of the drastic lifestyle changes that are required. In addition, complications, such as reoperation and possible poor long-term results, have been reported. [Jen: 2010]

From the NIDDK Bariatric Surgery for Youth - Weight-control Information Network (WIN) website:

"Experts in childhood obesity and bariatric surgery suggest that families consider surgery only after youth have tried for at least 6 months to lose weight and have not had success. Candidates should meet the following criteria:
  • have extreme obesity (BMI > 40)
  • be at their adult height (usually at age 13 or older for girls and 15 or older for boys)
  • have serious health problems linked to weight, such as type 2 diabetes or sleep apnea, that may improve with bariatric surgery
In addition, health care providers should assess potential patients and their parents to see how emotionally prepared they are for the surgery and the lifestyle changes they will need to make."
Young patients should be referred to special bariatric surgery centers that focus on meeting the unique needs of youth. [Inge: 2004]

Frequently Asked Questions

How do I address these concerns without offending parents?

A good dialogue opener regarding obese children could be phrased, “Your child’s BMI is at the ____th percentile. Do you have any concerns about that?”

My patients don’t seem motivated, what do I do?

The Expert Committee recommends treating only motivated patients. Clinicians must do their best to assess each patient's and family’s stage in the change process and then aid them in moving through the stages of change. For patients and families in the pre-contemplative stage of change, the goal of the clinician should be to create doubt with regard to the family’s position on current health behaviors. For example: “I am worried about the health of your child. Children who are overweight have a higher risk for developing diabetes. When you and your child are ready, I’m here to help you.” See Motivational Interviewing.

Do insurances pay for obesity services?

As of February 2014, the Affordable Care Act stipulates that obesity screening and counseling are covered benefits under insurance plans that are not exempt. Depending on the insurance plan, children may be able to get these services at no cost to families. Source: Help Your Child Stay at a Healthy Weight - Healthfinder.gov

Issues Related to Childhood Obesity

Gastro-Intestinal & Bowel Function

Obesity and Complications in Prader-Willi Syndrome

Resources

Information for Clinicians

The Portal's Childhood Obesity Screening & Prevention discusses screening for risk factors, screening for the conditon, and role of the medical home in preventing obesity.

Pediatric Obesity Intervention for Providers
Blog with resources and guidance for providers in the prevention and treatment of obesity.

Guidelines for Physical Fitness (CDC)
Physical activity guidelines for adults and children; Centers for Disease Control and Prevention.

Obesity Statistics (CDC)
Statistics regarding childhood obesity and educational resources for patients; Centers for Disease Control and Prevention.

Obesity and Medical Home (AAP)
Provider resources and tools for the treatment of obesity; American Academy of Pediatrics National Center for Medical Home Implementation.

Childhood Obesity Projects (NICH)
Lists approximately a dozen childhood obesity projects taking place around the United States; National Initiative for Children’s Healthcare Quality.

Robert Wood Johnson Foundation for Childhood Obesity
Improving the nation’s nutrition through access to healthy food and health policy.

Yale Rudd Center for Food Policy and Obesity
Nonprofit research center dedicated to combating obesity and improving nutrition.

Adolescent Obesity Time Tool (ACPM)
This tool is designed to assist the provider in managing adolescent obesity issues and offers CME; American College of Preventive Medicine.

Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/ Fake Food World
A book, containing a nine-week program offering the tools -- including tasty recipes, motivational tips, and activities -- that can help families prevent the kitchen table from becoming a battleground.

Helpful Articles

Baker JL, Farpour-Lambert NJ, Nowicka P, Pietrobelli A, Weiss R.
Evaluation of the overweight/obese child - practical tips for the primary health care provider: recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obesity.
Obes Facts. 2010;3(2):131-7. PubMed abstract / Full Text
Simple and practical tools for the identification and management of children with, or at risk of, overweight and obesity in the primary care setting.

Goran MI, Sothern MS.
Handbook of Pediatric Obesity: Etiology, Pathophysiology, and Prevention.
Boca Raton: CRC Press / Taylor & Francis Group; 2005. 1574449125
Features contributions from leading experts on childhood obesity at the social, behavioral, environmental, metabolic, and genetic levels.

Rao G.
Childhood obesity: highlights of AMA Expert Committee recommendations.
Am Fam Physician. 2008;78(1):56-63. PubMed abstract / Full Text
An American Medical Association expert panel reviewed evidence about how best to manage and prevent obesity. The Committee recommends a four-stage approach to treatment of childhood obesity. Many of these recommendations can be carried out by family physicians.

Sothern MS, Gordon ST, von Almen TK.
Handbook of Pediatric Obesity: Clinical Management.
Boca Raton, FL: CRC Press/Taylor & Francis; 2006. 1574449133
Compilation of management, medical, nutrition, psychological, and physical activity facts, models, theories, interventions, and evaluation techniques regarding management of pediatric obesity.

Clinical Tools

Algorithms/Care Processes

Prevention of Pediatric Overweight and Obesity (AAP)
Policy and summary regarding health supervision recommendations; American Academy of Pediatrics.

Care/Action Plans

Prevention of Pediatric Overweight and Obesity (AAP)
Dietary recommendations; American Academy of Pediatrics, 1995.

Growth/BMI Charts

Growth Charts (CDC)
Growth Charts 2000; Center for Disease Control.

Children’s BMI Risk Category Dependent on Age (CDC)
Child and Teen Body Mass Index (BMI) calculator; Centers for Disease Control and Prevention.

Calculating Child's BMI (Baylor College of Medicine)
BMI calculator for children; includes a chart parents can use to track child’s BMI-for-age.

Mobile Apps for BMI
Mobile phone applications for BMI measurement, clinical apps for iPhone, iPod Touch, and iPad.

Patient Education & Instructions

10 Tips Series on Healthy Eating (USDA)
Patient education handouts that provide easy to use tips on food groups, eating more fruits and vegetables, and healthy habits; U.S. Department of Agriculture.

BAM! Body and Mind (CDC)
Educates children and parents through games and activities regarding nutrition and physical activity; Centers for Disease Control and Prevention.

Live Well (IHC)
Education for families about healthy lifestyles; Intermountain Healthcare.

About BMI for Children and Teens (CDC)
Answers to frequently asked questions about BMI such as how it is calculated, what percentiles mean, and how children BMIs differ from adult BMI calculators; Centers for Disease Control and Prevention.

Toolkits

Obesity Tool Kits for Practitioners and Families (NICHQ)
For prevention and treatment of obesity, a variety of tool kits for assessment, management, care coordinators and parents, as well as community resources; National Initiative for Children’s Healthcare Quality.

Other

Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (NHLBI)
Integrated guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute.

Diagnosaurus (McGraw-Hill)
Free app that provides differential diagnoses; searchable by symptom, disease, and organ system.

Information & Support for Families

Family Diagnosis Page

Information on the Web

Let's Move! (whitehouse.gov)
Resources for families, parents, children, communities, and health care providers for providing healthy food in schools, improving access to healthy, affordable foods, and increasing physical activity; First Lady Michelle Obama’s initiative for healthy families.

Nutrition & Fitness (KidsHealth)
Nutrition, fitness, and overall health information for parents, kids, teens, and educators. Include recipes, safety tips, and discussion of feelings; sponsored by the Nemours Foundation.

Shapedown Program
Fee-based, family-centered weight management program for children and adolescents.

Bright Bodies Program
Weight management program for children ages 7-16. Includes recommendations for education. exercise, and lifestyle modification; Yale Center for Clinical Investigation and Pediatric Endocrinology, Yale School of Medicine.

Aim for a Healthy Weight (NHLBI)
Research, training, and education programs to enhance health, and prevent and treat obesity; National Heart, Lung and Blood Institute.

Weight-Control Information Network (WIN)
Up-to-date, science-based information on weight control, obesity, physical activity, and related nutritional issues; National Institute of Diabetes and Digestive and Kidney Disease (NIDDK).

Healthy Living through Environment, Policy, and Improved Clinical Care Program (UDOH)
Information and resources, for kids and adults, to reduce the incidence of diabetes, heart disease, and stroke by targeting risk factors including reducing obesity, increasing physical activity and nutritious food consumption, and improving diabetes and hypertension control; Utah Department of Health.

National Initiative for Children’s Healthcare Quality (NICHQ)
Includes tips for making exercise fun, education about portion sizes and the amount of sugar in drinks, toolkits and guidelines for prevention and treatment of obesity; National Initiative for Children’s Healthcare Quality.

Body Works Program (National Office on Women’s Health)
Program focusing specifically on families and adolescents. Training is available to become a Body Works instructor.

Camp Shane - Weight Loss Camps
Pediatric weight-loss camp located in California, Arizona, New York, and Georgia.

Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/ Fake Food World
A book, containing a nine-week program offering the tools -- including tasty recipes, motivational tips, and activities -- that can help families prevent the kitchen table from becoming a battleground.

Support National & Local

Child Obesity Support
Support for families and caregivers of obese children; includes newsletter, story sharing, and resources.

Studies/Registries

Adolescent Weight Control Registry (WCDRC)
Registry for adolescents, site includes, inspiring weight loss stories and interesting facts about people in the registry; Weight Control and Diabetes Research Center.

Services for Patients & Families

Behavioral Programs

See all Behavioral Programs services providers (31) in our database.

Clinics, Other

See all Clinics, Other services providers (67) in our database.

Developmental Evaluation

See all Developmental Evaluation services providers (55) in our database.

Nutrition/Dietary

See all Nutrition/Dietary services providers (53) in our database.

Pediatric Genetics

See all Pediatric Genetics services providers (5) in our database.

Pediatric Metabolic Genetics

See all Pediatric Metabolic Genetics services providers (2) in our database.

Pediatrics, General

See all Pediatrics, General services providers (10) in our database.

Recreation Programs/Activities

See all Recreation Programs/Activities services providers (249) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Author: Amber Baker, DNP/FNP-c - 5/2013
Reviewing Author: Nicole Mihalopoulos, MD, MPH - 5/2014
Content Last Updated: 5/2014

Bibliography

Baker JL, Farpour-Lambert NJ, Nowicka P, Pietrobelli A, Weiss R.
Evaluation of the overweight/obese child - practical tips for the primary health care provider: recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obesity.
Obes Facts. 2010;3(2):131-7. PubMed abstract / Full Text
Simple and practical tools for the identification and management of children with, or at risk of, overweight and obesity in the primary care setting.

Barlow SE.
Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120 Suppl 4:S164-92. PubMed abstract / Full Text
While not a formal practice guideline, these recommendations represented expert consensus when published in 2007. No formal guidelines have been published for children in the US since then.

Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TN, Scott BJ, St Jeor S, Williams CL.
Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment.
Circulation. 2005;111(15):1999-2012. PubMed abstract

Daniels, Stephen.
Consequences of Childhood Overweight and Obesity.
The Future of Children ; (2006) http://www.futureofchildren.org/futureofchildren/publications/journals.... Volume 16 Number 1 Spring 2006. Accessed on Jan. 2014.
Co-morbid conditions associated with obesity; publication of the Woodrow Wilson School of Public and International Affairs at Princeton University and the Brookings Institution.

Dietz WH, Robinson TN.
Overweight Children and Adolescents.
The New England Journal of Medicine. 2005;352(20):2100-9. PubMed abstract

Epstein LH, Dearing KK, Erbe RW.
Parent-child concordance of Taq1 A1 allele predicts similarity of parent-child weight loss in behavioral family-based treatment programs.
Appetite. 2010;55(2):363-6. PubMed abstract / Full Text
Family-based treatments show positive relationships between parent and child weight losses. One mechanism for similar parent-child changes may be a common genetic predisposition to respond similarly to a structured weight loss program. These results show concordance of the Taq1 A1 allele of the DRD2 between parents and children may be one mechanism for the similar response to family-based treatments within families.

Epstein LH, Paluch RA, Beecher MD, Roemmich JN.
Increasing healthy eating vs. reducing high energy-dense foods to treat pediatric obesity.
Obesity (Silver Spring). 2008;16(2):318-26. PubMed abstract / Full Text
Focusing on healthy food choices within an energy-restricted diet may be useful in family-based weight control programs.

Epstein, LH, and Squires, S.
The stoplight diet for children: an eight-week program for parents and children.
1st ed. Boston: Little, Brown; 1988. 0316245755
A family-based pediatric obesity intervention that assigns all foods a color: red, yellow, or green. Red light foods should not be eaten or should be eaten rarely; yellow foods should be consumed in moderation; and green light foods may be consumed in unlimited quantities.

Ford ES.
The epidemiology of obesity and asthma.
J Allergy Clin Immunol. 2005;115(5):897-909; quiz 910. PubMed abstract
Discusses relationship between obesity and asthma and the role of weight management in managing asthma.

Freedman DS, Katzmarzyk PT, Dietz WH, Srinivasan SR, Berenson GS.
Relation of body mass index and skinfold thicknesses to cardiovascular disease risk factors in children: the Bogalusa Heart Study.
Am J Clin Nutr. 2009;90(1):210-6. PubMed abstract / Full Text

Gilles A, Cassano M, Shepherd EJ, Higgins D, Hecker JE, Nangle DW.
Comparing active pediatric obesity treatments using meta-analysis.
J Clin Child Adolesc Psychol. 2008;37(4):886-92. PubMed abstract

Goran MI, Sothern MS.
Handbook of Pediatric Obesity: Etiology, Pathophysiology, and Prevention.
Boca Raton: CRC Press / Taylor & Francis Group; 2005. 1574449125
Features contributions from leading experts on childhood obesity at the social, behavioral, environmental, metabolic, and genetic levels.

Hassink SG.
Evidence for effective obesity treatment: pediatricians on the right track!.
Pediatrics. 2010;125(2):387-8. PubMed abstract

Herrera EA, Johnston CA, Steele RG.
A comparison of cognitive and behavioral treatments for pediatric obesity.
Children's Health Care. 2004;33(2):151-67.

Hughes AR, Reilly JJ.
Disease management programs targeting obesity in children: setting the scene for wellness in the future.
Disease Management & Health Outcomes. 2008;16(4):255-66.

Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS, Strauss RS, Albanese CT, Brandt ML, Hammer LD, Harmon CM, Kane TD, Klish WJ, Oldham KT, Rudolph CD, Helmrath MA, Donovan E, Daniels SR.
Bariatric surgery for severely overweight adolescents: concerns and recommendations.
Pediatrics. 2004;114(1):217-23. PubMed abstract

Janicke DM, Storch EA, Novoa W, Silverstein JH, Samyn MM.
The Pediatric Barriers to a Healthy Diet Scale.
Children's Health Care. 2007;36(2):155-68.

Jelalian E, Wember YM, Bungeroth H, Birmaher V.
Practitioner review: bridging the gap between research and clinical practice in pediatric obesity.
J Child Psychol Psychiatry. 2007;48(2):115-27. PubMed abstract

Jen HC, Rickard DG, Shew SB, Maggard MA, Slusser WM, Dutson EP, DeUgarte DA.
Trends and outcomes of adolescent bariatric surgery in California, 2005-2007.
Pediatrics. 2010;126(4):e746-53. PubMed abstract

Kalra M, Inge T, Garcia V, Daniels S, Lawson L, Curti R, Cohen A, Amin R.
Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery.
Obes Res. 2005;13(7):1175-9. PubMed abstract
Study correlating OSA and extremely overweight adolescents meeting eligibility criteria for bariatric surgery. Significant weight loss after gastric bypass was then associated with a marked reduction in OSA severity.

Latzer Y, Edmunds L, Fenig S, Golan M, Gur E, Hochberg Z, Levin-Zamir D, Zubery E, Speiser PW, Stein D.
Managing childhood overweight: behavior, family, pharmacology, and bariatric surgery interventions.
Obesity (Silver Spring). 2009;17(3):411-23. PubMed abstract

Lönnqvist F, Arner P, Nordfors L, Schalling M.
Overexpression of the obese (ob) gene in adipose tissue of human obese subjects.
Nat Med. 1995;1(9):950-3. PubMed abstract

National Heart, Lung, and Blood Institute Expert Panel.
Integrated guidelines for cardiovascular health and risk reduction in children and adolescents.
National Institutes of Health. NIH Publication No. 12-7486; October 2012. / http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf
Addresses the major population-based risk factors for cardiovascular disease in a single evidence-based set of guidelines.

Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G, Eliakim A.
Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity.
Pediatrics. 2005;115(4):e443-9. PubMed abstract

Nowicka P, Flodmark CE.
Physical activity-key issues in treatment of childhood obesity.
Acta Paediatr Suppl. 2007;96(454):39-45. PubMed abstract
A review of what is known about physical activity in pediatric obesity treatment and practical recommendations, which a health care provider can suggest to obese children and their families.

Ogden CL, Carroll MD, Kit, BK, Flegal KM.
Prevalence of Obesity in the United States, 2009-2010.
Centers for Disease Control and Prevention. 82; January 2012. / http://www.cdc.gov/nchs/data/databriefs/db82.htm

Rao G.
Childhood obesity: highlights of AMA Expert Committee recommendations.
Am Fam Physician. 2008;78(1):56-63. PubMed abstract / Full Text
An American Medical Association expert panel reviewed evidence about how best to manage and prevent obesity. The Committee recommends a four-stage approach to treatment of childhood obesity. Many of these recommendations can be carried out by family physicians.

Resnicow K, Davis R, Rollnick S.
Motivational interviewing for pediatric obesity: Conceptual issues and evidence review.
J Am Diet Assoc. 2006;106(12):2024-33. PubMed abstract

Ross MM, Kolbash S, Cohen GM, Skelton JA.
Multidisciplinary treatment of pediatric obesity: nutrition evaluation and management.
Nutr Clin Pract. 2010;25(4):327-34. PubMed abstract

Ruxton C.
Obesity in children.
Nurs Stand. 2004;18(20):47-52; quiz 54-5. PubMed abstract

Saelens BE, Liu L.
Clinician's comment on treatment of childhood overweight meta-analysis.
Health Psychol. 2007;26(5):533-6. PubMed abstract

Schwartz RP, Hamre R, Dietz WH, Wasserman RC, Slora EJ, Myers EF, Sullivan S, Rockett H, Thoma KA, Dumitru G, Resnicow KA.
Office-based motivational interviewing to prevent childhood obesity: a feasibility study.
Arch Pediatr Adolesc Med. 2007;161(5):495-501. PubMed abstract

Sothern MS, Gordon ST, von Almen TK.
Handbook of Pediatric Obesity: Clinical Management.
Boca Raton, FL: CRC Press/Taylor & Francis; 2006. 1574449133
Compilation of management, medical, nutrition, psychological, and physical activity facts, models, theories, interventions, and evaluation techniques regarding management of pediatric obesity.

Taylor ED, Theim KR, Mirch MC, Ghorbani S, Tanofsky-Kraff M, Adler-Wailes DC, Brady S, Reynolds JC, Calis KA, Yanovski JA.
Orthopedic complications of overweight in children and adolescents.
Pediatrics. 2006;117(6):2167-74. PubMed abstract / Full Text
Discusses how reported fractures, musculoskeletal discomfort, impaired mobility, and lower extremity malalignment are more prevalent in overweight than nonoverweight children and adolescents and may be part of the cycle that perpetuates the accumulation of excess weight in children.

Wilfley DE, Tibbs TL, Van Buren DJ, Reach KP, Walker MS, Epstein LH.
Lifestyle Interventions in the Treatment of Childhood Overweight: A Meta-Analytic Review of Randomized Controlled Trials.
Health Psychology. 2007;26(5):521-532. PubMed abstract / Full Text
Lifestyle interventions for the treatment of pediatric overweight are efficacious in the short-term with some evidence for persistence of effects.