Making the Assessment, Management and Treatment of Obesity Come Alive in Your...

Over the last few years, there has been increased understanding and research that children with overweight and obesity may be sick, and oftentimes those children are not being appropriately screened for comorbidities.

The algorithm relies on existing guidelines: 2007 Expert Committee recommendations, US Department of Health and Human Services cardiovascular guidelines, and American Diabetes Association guidelines.

The algorithm is not a protocol but a suggested course of action that provides guidance to be used with clinical judgment.

The algorithm applies to patients 2 years and older and does not address the birth to 2-year age group.

For all patients irrespective of weight, screening for genetic dyslipidemia should include obtaining a non-fasting lipid profile for children between ages 9-11 and again between 18-21, per cardiovascular guidelines from about 3 years ago.

Positive symptoms in the review of systems that could indicate risk for comorbidities include snoring, sleep disturbances, abdominal pain, menstrual irregularities, hip/knee/leg pain, polyuria, polydipsia, and depression.

Physical exam findings that may indicate comorbidities include pre-hypertension or hypertension (with correct cuff size), acanthosis nigricans, tonsillar hypertrophy, goiter, abdominal tenderness, hepatomegaly, bowing of legs (Blount disease), limited hip range of motion (slipped capital femoral epiphysis), fuzzy optic discs (pseudotumor cerebri), acne, and skin inflammation.

Family history risk factors in first and second degree relatives include obesity, type 2 diabetes, hypertension, lipid level abnormalities, and heart disease.

Patients in the overweight category (BMI 85th-94th percentile) with strong family history, positive review of systems, or positive physical exam should receive further screening for comorbidities, similar to patients in the obese category.

Some providers obtain non-fasting labs for patient convenience, particularly in rural areas where patients travel long distances and are unlikely to return for fasting labs.

Some subspecialty clinics screen for vitamin D and insulin resistance by obtaining vitamin D and fasting insulin levels, but the clinical utility and cost-effectiveness of such tests is yet to be determined, and the costs are very high.

There are no current guidelines on when to start laboratory testing for patients with obesity, but based on patient health risks, some experts may start screening patients as early as 2 years of age.

Constipation is a very common comorbidity in children with obesity that is easily treated, and treating it helps patients feel better, eat more, and be more physically active.

Not every patient is ready for treatment, and when patients or parents are not ready, the appropriate response is to say 'that's OK, when you're ready, I'm ready' rather than using fear tactics.

There are no quick fixes for obesity treatment; even patients eligible for surgical treatment require many months of behavior modification and treatment before surgery.

Small behavior changes can have a profound effect on health and are usually much more sustainable than large changes.

In pediatrics, by and large up until growth plates fuse, children are going to get taller, which is advantageous for weight management.

An empathetic, empowering counseling style such as motivational interviewing should be employed to empower patients and families in behavior change, with no fear tactics.

Stage 1 (Prevention Plus) consists of planned follow-up themed visits of 15-20 minutes in primary care, focusing on behaviors that resonate with the patient, family, and provider, with the patient's preferences coming first.

The goals for Stage 1 are positive behavior change irregardless of change in BMI, and weight maintenance or decrease in BMI velocity.

Children ages 2-5 with obesity should not lose more than 1 pound per month, and older children and adolescents with obesity should not lose more than an average of 2 pounds per week.

Many experts recommend monthly follow-up visits for Stage 1, though follow-up can be tailored to patient and family motivation and can include text, email, or Facebook communication.

After 3-6 months in Stage 1, if BMI and weight status does not improve, consider advancing to Stage 2.

Stage 2 (Structured Weight Management) is the same intervention as Stage 1 but includes more intensive support and structure to achieve healthy behaviors, with follow-up every 2-4 weeks.

Stage 3 (Comprehensive Multidisciplinary Intervention) is often done by a pediatric weight management clinic with a multidisciplinary team including social workers and dietitians, with structured behavior modification including food and activity monitoring.

Stage 4 (Tertiary Care Intervention) is for patients greater than the 95th percentile with significant comorbidities, happens in a pediatric weight management center with providers with expertise in treating childhood obesity, and includes very intensive diet and activity counseling with consideration of medications and age-appropriate surgery.

The goal for Stage 4 is a decrease in BMI because these children are sick and need to get their BMI down, though behavior change is still initially important.

Patients should start at the least intensive stage and advance through stages based on response to treatment, age, BMI, health risks, and most importantly the motivation of the patient and family.