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http://www.uptodate.com/contents/management-of-childhood-obesity-in-the-primary-care-setting?topicKey=PEDS%2F15848&elapsedTimeMs=0&source= 1/33
Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Author
Joseph A Skelton, MD, MS
Section Editors
William J Klish, MD
Martin I Lorin, MD
Kathleen J Motil, MD, PhD
Deputy Editor
Alison G Hoppin, MD
Management of childhood obesity in the primary care setting
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2014. | This topic last updated: Jan 03, 2014.
INTRODUCTION A variety of mechanisms participate in weight regulation and the development of obesity in
children, including genetics, developmental influences (metabolic programming, or epigenetics), and
environmental factors. The relative importance of each of these mechanisms is the subject of ongoing research
and probably varies considerably between individuals and populations. (See "Definition; epidemiology; and
etiology of obesity in children and adolescents", section on 'Etiology' and "Obesity in adults: Etiology and
natural history".)
Among these potential mechanisms, only environmental factors are potentially modifiable during infancy and
childhood. Therefore, prevention and treatment of overweight and obesity in children in the primary care setting
focuses on modifying behaviors that lead to excessive energy intake and insufficient energy expenditure.
Experts who focus on cardiovascular health (rather than obesity per se) recommend very similar health
behaviors, with a slightly different perspective. (See "Pediatric prevention of adult cardiovascular disease:
Promoting a healthy lifestyle and identifying at-risk children".)
This topic review will address interventions to prevent and treat childhood obesity in the primary care setting.
The definitions, epidemiology, and comorbidities of childhood obesity are discussed in separate topic reviews.
Surgical treatment of severe obesity in adolescents also is discussed separately. (See "Definition;
epidemiology; and etiology of obesity in children and adolescents" and "Comorbidities and complications of
obesity in children and adolescents" and "Surgical management of severe obesity in adolescents".)
GUIDING PRINCIPLES Few long-term randomized trials are available to determine which techniques to
prevent or treat obesity are effective. Moreover, several of the techniques that have been addressed in clinical
trials may not be practical for use in a clinical setting. Nonetheless, a number of approaches are recommended
by expert consensus, based on clinical experience, inferences drawn from observing obesity-associated
behaviors, and short-term evidence-based trials [1-6].
Recommendations for primary care providers center on:
Universal measurement of body mass index (BMI) and plotting of results on a BMI chart to track changes
over time
Routine assessment of all children for obesity-related risk factors, to allow for early intervention
Routine brief clinical interventions by the primary care provider, which include:
Messages of obesity-focused education to all children and families
Family-centered communication and interventions, rather than those focused on the child alone
Emphasis on long-term changes in behaviors that are related to obesity risk, rather than relying on
diets and exercise prescriptions, which tend to set short-term goals
Implementing a staged approach to weight management, to address obesity at different ages and levels of
severity
Stimulus control to reduce environmental cues that contribute to unhealthy behaviors. This includes
reducing access to unhealthy behaviors (eg, removing some categories of food from the house or removing
a television from the bedroom) and also efforts to establish new, healthier daily routines (such as making
fruits and vegetables more accessible).
Goal-setting for healthy behaviors rather than weight goals. Goal-setting is widely used for prompting
behavior change. However, the process can be detrimental if goals are not realistic and maintainable.
Appropriate goals are identified by the acronym SMART, where goals should be should Specific,
Measurable, Attainable, Realistic, and Timely.
Contracting for selected nutrition or activity goals. Contracting is the explicit agreement to give a reward
for the achievement of a specific goal. This helps children focus on specific behaviors and provides
structure and incentives to their goal-setting process.
Positive reinforcement of target behaviors. Positive reinforcement can be in the form of praise for healthy
behaviors or in the form of rewards for achieving specific goals. The reward should be negotiated by the
parent and the child, ideally facilitated by the provider to ensure that the rewards are appropriate. Rewards
should be small activities or privileges that the child can participate in frequently, rather than monetary
incentives or toys; food should not be used as a reward.
th
Review of systems (table 4).
Additional assessment may be required in selected children with symptoms or signs of weight-related
comorbidities (table 5). (See "Comorbidities and complications of obesity in children and adolescents".)
Servings of vegetables and fruits, and which of these are regularly offered and accepted. One serving
equals one whole fruit, or cup of vegetables.
Caregiver duties and communication regarding food (eg, who does shopping and who does cooking,
whether food selection is discussed among family members, and whether meals are eaten together as a
family)
How child spends time after school, and who supervises this time
Work schedules of parents or other caregivers
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Other considerations In some cases, economic or cultural factors may limit a familys ability or
willingness to make changes in diet or physical activity. These obstacles can be addressed using a family-
centered approach to counseling, in which families decide when to begin the change process and the intensity
with which they are willing to pursue weight management. To initiate the discussion, the following factors should
be assessed in selected patients:
Activity assessment Similar to the nutritional assessment of children, we suggest that clinicians do a brief
qualitative assessment of physical activity and sedentary activity patterns in children. Both sedentary and active
behaviors (structured and unstructured) should be assessed as outlined in the table (table 7).
In addition, assessment of the following social and environmental factors often helps to identify barriers to
activity and opportunities for increasing physical activity [29]:
Combining a clinical assessment of baseline activity levels with the barriers to increased activity will provide the
clinician with a basis with which to begin behavior changes. Reducing sedentary activities is a particularly
important target for intervention and should be incorporated into any clinical approaches to obesity treatment
and prevention. (See 'Sedentary activity' below.)
GOALS FOR WEIGHT MANAGEMENT
Weight We find that discussion of specific weight loss targets with the patient and family is not usually
helpful and sometimes causes the patient to become discouraged and to withdraw from weight control efforts.
Instead of weight loss goals, we prefer to emphasize behavior goals for specific dietary habits and activities
during discussions with the patient and family. Nonetheless, it is appropriate for the provider to keep weight
targets in mind to ensure that a patients weight trend is safe and realistic.
Weight loss goals are a function of a patients age and degree of overweight or obesity [1,4,6].
Meal location (eg, at dining table, in bedroom, or on couch/ in living room) and emotional climate
(especially arguments about food)
Cultural factors Ask the parents and child what they think of the childs weight. Misperception of the
childs weight status, such as a cultural preference for overweight in children, may affect a familys ability
to effectively address the problem. Conversely, excessive anxiety about the childs weight status also can
interfere with effective management. To address this issue, it is important to explore reasons for the
anxiety in the parent or child. Reasons for excessive anxiety may include an overestimate of the childs
risk for future obesity or a personal history of disordered eating in the parent.
Home Television in bedroom [34]; family physical activity routines [35]; access to and frequency of free
play [36,37]; access to and frequency of organized sports [36-38].
School Physical education classes [38,39]; affordability of activities [36,37]; safety concerns [36,37].
Lifestyle activity Current habits that require walking or use of stairs [38].
For children and adolescents who are overweight or mildly obese, the goal of maintaining current body
weight is appropriate, because this will lead to a decrease in BMI as the child grows taller. If the child is in
a phase of rapid linear growth, merely slowing weight gain is more realistic and often improves weight
status.
At higher degrees of obesity (BMI substantially above the 95 percentile, ie, at the 99 percentile),
gradual weight loss is safe and appropriate, depending on the childs age and degree of obesity.
th th
For children between two and eleven years old with obesity and comorbidities, a weight loss of up to
one pound per month is safe and beneficial but may be difficult to achieve.
A randomized trial in overweight children 4 to 7 years of age in Italy consisted of five group meetings over
one year, providing motivational interviewing [62]. At the end of the intervention, the BMI in children
receiving the intervention had increased by 0.49 kg/m , which was significantly less than the increase of
0.79 kg/m in the control group. Thus, a low-intensity intervention had a significant effect on BMI in this
population.
2
2
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The evidence base in this age group is still small, and the optimal type and timing of intervention remain unclear.
Nonetheless, these findings call for further exploration of early interventions to prevent and treat obesity [50,70].
Research has not determined optimal intervention approaches based on child age groups, though it is believed
that children should be increasingly included in the counseling dialogue and should be given autonomy in
treatment decisions as they mature [4].
Intensity of intervention Most available data suggests that substantial hours of provider contact are
necessary to improve a childs weight status. As an example, a systematic review concluded that behavioral
interventions of moderate or high intensity (defined as 26 to 75 hours or >75 hours of provider contact,
respectively) are effective in achieving short-term (up to 12 months) weight improvements in children [5,22,71].
Unfortunately, interventions at this level of intensity are usually impractical for use in a primary care setting,
unless ample services from dietitians or other specialized counselors are readily available and funded.
Low-intensity interventions (less than 25 hours of provider contact) are feasible in a primary care setting and are
recommended by expert panels, although the evidence base to support this recommendation currently is weak.
Clinical trials suggest that these low-intensity interventions for treatment of childhood obesity have weak or
inconsistent effects [5,72]. It is likely that low-intensity interventions may have important effects on obesity and
health behaviors in individual patients, even if they have little or no measureable effect on the study population
as a whole. Moreover, meta-analyses suggest that lifestyle interventions to prevent and treat obesity in children
are generally effective, even if some of the included studies are too small to show statistically significant
changes in weight status [50,73]. (See "Definition; epidemiology; and etiology of obesity in children and
adolescents", section on 'Environmental factors'.)
Therefore, we and others recommend that providers of primary care consistently provide counseling to all
patients to support healthy eating and activity behaviors in an effort to prevent obesity [2]. In addition, we
recommend that providers engage in brief counseling interventions for their patients with obesity or those with
significant risk factors for developing obesity (such as parental obesity) [1].
For patients who do not respond to a brief clinical intervention or for those with severe obesity, higher-intensity
approaches are needed. These interventions are implemented in stages, and usually require referral to a dietitian
or behavioral counselor, and/or to specialized weight management programs or tertiary care centers. (See
'Staged approach to weight management' above.)
Example and materials Several groups have developed messaging to support this type of brief clinical
intervention as outlined above. Materials to support patient education and practice process improvement are
available at each of the following websites:
A randomized trial in overweight or obese pre-school aged children in the Netherlands consisted of 27
hours of provider contact over four months, including nutritional advice, supervised physical activity, and
parent training [63]. At the end of the four-month program, there were significant decreases in child BMI
and in other anthropometric measures as compared with baseline and a usual care control group. Most
of the improvements were sustained at 12 months follow-up.
An observational study in Sweden evaluated predictors of success for a behaviorally based three-year
treatment program for 643 children 6 to 16 years of age [64,65]. Among participants with severe obesity,
58 percent of the younger children (six to nine years) experienced a clinically significant reduction in BMI
Z-score (-0.5 kg/m ), as compared with only 2 percent of adolescents (14 to 16 years). Among
participants with moderate obesity, younger children also were more likely to be successful than older
children.
2
A randomized trial in 3 to 5 year old children at risk for behavioral issues assessed the effect of an
intervention to promote effective parenting [66]. Although the intervention focused on parenting rather than
nutrition or physical health, the children in the intervention group had lower rates of obesity compared with
controls (24 percent versus 54 percent), after three to five years follow up.
Several studies of lower-intensity interventions in infants and young children report improvements in weight-
related habits, such as television viewing, but did not achieve statistically significant improvements in BMI
outcomes [67-69].
Community resources To assist families in developing an action plan, the practice can collect and
distribute information about resources in the local community, including options for physical activity, active
after-school programs, nutrition counseling services, and sources of healthy food (eg, local sources of
fresh produce).
Breastfeeding Breastfeeding may have a weak protective effect on the development of obesity, but
probably is not a major determinant of obesity risk. (See "Infant benefits of breastfeeding", section on
'Obesity'.)
Establishing a healthy feeding relationship early in life (avoiding overly restrictive and overly permissive
feeding patterns). (See "Introducing solid foods and vitamin and mineral supplementation during infancy",
section on 'Feeding environment'.)
Encouraging a family to eat meals together. (See "Dietary recommendations for toddlers, preschool, and
school-age children", section on 'Eating environment'.)
Universal measurement of body mass index (BMI) and plotting of results on a BMI chart to track changes
over time. (See 'Body mass index' above.)
Routine assessment of all children for obesity-related risk factors, to allow for early intervention. This
includes recording the obesity status (BMI) of the biological parents and assessing key nutritional and
physical activity habits (table 6 and table 7). (See 'Nutritional assessment' above and 'Activity assessment'
above.)
For children with obesity, weight-related comorbidities should be assessed through a focused review of
systems (table 4), physical examination (table 2), and laboratory screening (table 3). (See 'Assessment of
comorbidities' above.)
For all children and their families, routine health care should include obesity-focused education. Key goals
to address are the common diet-related problems encountered in children (table 8), set firm limits on
television and other media early in the childs life, and establish habits of frequent physical activity. (See
'Diet' above and 'Sedentary activity' above and 'Physical activity' above.)
For children who are overweight or obese, we suggest a series of clinical counseling interventions in the
primary care setting (Grade 2C). Each session can be brief (3 to 15 minutes); this brief format is most
For patients who do not respond to a brief clinical intervention or for those with severe obesity, higher-
intensity approaches are needed. These interventions are implemented in stages (table 1) and usually
require referral to specialized weight management programs or tertiary care centers. (See 'Staged
approach to weight management' above.)
To establish a therapeutic relationship and enhance effectiveness, the communication and interventions
should be supportive rather than blaming, and focused on the entire family, rather than on the child alone.
Long-term changes in behaviors that are related to obesity risk should be emphasized, rather than diets
and exercise prescriptions, which tend to set short-term goals. (See 'Theoretical background' above.)
To be effective in managing populations with obesity, primary care offices should develop an efficient office
system for calculating and tracking BMI at each visit and have a wide range of blood pressure cuffs
(including a "large adult" size) and high-capacity scales (ideally up to 500 or 1000 lbs). It is also helpful to
have office furniture that is appropriate for large patients and their families, including sturdy armless chairs
and low examination tables. (See 'Office systems' above.)