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

Children with overweight and obesity may be sick and are often not being appropriately screened for comorbidities.

The algorithm was developed using 2007 Expert Committee recommendations, US Department of Health and Human Services cardiovascular guidelines, and American Diabetes Association guidelines.

The algorithm starts at the well child visit and continues with planned follow-up visits as determined by the patient, family, and provider.

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

The algorithm applies to patients 2 years and older, not addressing the birth to 2 years age group.

For healthy weight children (BMI 5th-84th percentile), providers should screen for genetic dyslipidemia with non-fasting lipid profile at ages 9-11 and 18-21, independent of weight status.

Screening for genetic dyslipidemia is part of cardiovascular guidelines from approximately 3 years ago and should be done on all patients irrespective of weight.

An augmented review of systems for children ≥85th percentile should assess for snoring, sleep disturbances, abdominal pain, menstrual irregularities, hip/knee/leg pain, polyuria, polydipsia, and depression as indicators of potential comorbidities.

Snoring in children with elevated BMI may indicate obstructive sleep apnea.

Abdominal pain in children with elevated BMI may indicate gastroesophageal reflux, constipation, gallbladder disease, or non-alcoholic fatty liver disease.

Polyuria and polydipsia in children with elevated BMI may indicate type 2 diabetes.

Physical exam findings requiring attention in children with elevated BMI include blood pressure (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.

Correct blood pressure cuff size is critically important for children with obesity.

Family history assessment for children with elevated BMI should include obesity, type 2 diabetes, hypertension, lipid abnormalities, and heart disease in first and second-degree relatives.

Children in the overweight category (85th-94th percentile) with positive family history, review of systems, or physical exam findings should receive laboratory screening for comorbidities.

All children with BMI ≥95th percentile should have additional screening and workup for underlying comorbidities regardless of symptoms.

Some providers obtain non-fasting labs for patient convenience, though fasting labs are preferred; this is particularly relevant in rural areas where return visits are unlikely.

Some subspecialty clinics screen for vitamin D deficiency and insulin resistance with vitamin D and fasting insulin levels, but the clinical utility and cost-effectiveness of these tests is yet to be determined.

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

Constipation is a very common comorbidity in children with obesity that is easily treated and improves patients' ability to eat more and be more physically active.

Not every patient is ready for obesity treatment; when patients and families are not ready, providers should avoid using fear tactics and instead keep the door open for future engagement.

There are no quick fixes for childhood obesity; surgical treatment for eligible older children requires many months of behavior modification before surgery.

Motivational interviewing works for behavior change and has been shown to work for obesity management and treatment.

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

In pediatrics, children will continue to grow taller until growth plates fuse, which is an advantage in obesity management.

Stage 1 (Prevention Plus) consists of 15-20 minute themed follow-up visits in primary care focusing on behaviors chosen by patient/family, with possible partnerships with dietitian, social worker, athletic trainer, or physical therapist.

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

Monthly follow-up visits are recommended for Stage 1, though follow-up should be tailored to patient/family motivation and can include text, email, or social media contact.

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

Stage 2 (Structured Weight Management) is delivered by primary care providers with appropriate training, particularly in motivational interviewing, with more intensive support than Stage 1.

Stage 2 follow-up should occur every 2-4 weeks as determined by patient, family, and physician.

Stage 3 (Comprehensive Multidisciplinary Intervention) is delivered by pediatric weight management clinics with multidisciplinary teams that may include endocrinologists, pulmonologists, gastroenterologists, social workers, and dietitians.

Stage 3 includes structured behavior modification with food and activity monitoring and development of short-term diet and physical activity goals.

Stage 4 (Tertiary Care Intervention) is for patients >95th percentile with significant comorbidities, delivered at pediatric weight management centers with obesity expertise.

Stage 4 includes intensive diet and activity counseling with consideration of medications and age-appropriate surgery.

The goal of Stage 4 is BMI decrease because these children are sick and need to reduce BMI, though behavior change remains the initial focus.

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

An empathetic, empowering counseling style such as motivational interviewing should be employed to empower patients and families in behavior change, avoiding fear tactics.