Clinical Consult: Childhood obesity

medical scale apple childhood obesity
(esolla/Shutterstock)

Pediatric obesity has become a national public health crisis over the last decade, with the U.S. Centers for Disease Control and Prevention (CDC) recording rates of childhood obesity as high as 17 percent nationwide. This does not make the individual conversation with families about obesity and its consequences any simpler. In fact, the widespread nature of this problem has served to normalize it in society and often complicates the discussions and motivation for treatment. However, the dire potential consequences of childhood obesity mandate that we as pediatricians work to prevent as well as diagnosis and treat this disorder.

Defining obesity in children

Pediatric obesity is defined by a body mass index (BMI) greater than 95 percent for age and gender, based on CDC growth data. This disorder increases the risk of multiple comorbidities of various organ systems.

Managing obesity in primary care

Primary care pediatricians, using accurate measurements with stadiometers and calibrated scales, can diagnose obesity. Most practices now have systems in place through electronic medical records to indicate patients who have obesity or who are at risk for obesity (BMI > 85th percent for age and gender). Once identified, providers can inform families of the diagnosis and educate them on the potential complications.

childhood_boesity_comorbidities_Lancet
Comorbidities related to childhood obesity. (Ebbeling et al. Lancet 2002)

Once the focus moves beyond issues of appearance and the culture of feeding behaviors to potential medical consequences, families may be more likely to understand the urgency of intervention. Primary care pediatricians can provide lifestyle advice, focusing on nutritional guidance and increasing physical activity to a goal of 60 minutes daily while reducing sedentary screen based time to less than 2 hours daily.

However, often the resources for intensive nutritional counseling and behavioral change support are not available in a busy pediatric practice. Thus, referral to a specialized obesity treatment program may be required to provide this support. However, it is possible that with appropriate resources, and in the absence of additional causative factors or significant comorbidities, many of the children diagnosed with obesity could be cared for within the primary care medical home.

Assessing potential etiologies for increased BMI

The evaluation of obesity must also include an assessment of potential causative factors and resultant comorbidities. If a pediatrician notes:

  • a very rapid and/or unusual pattern of weight gain in a very young child under the age of 2 years, or
  • a decline in linear growth during a rapid rise in weight

additional evaluations for genetic, endocrinologic or metabolic etiologies of the rapid weight gain may be necessary, warranting referral to the appropriate specialist. Providers suspicious of an exogenous cause of the obesity due to other clinical, familial or historical factors, should consider referring their patient to a specialized obesity program for additional evaluation.

Assessing for obesity-related comorbidities

Primary care providers can assess children diagnosed with obesity for related comorbidities. A thorough history and physical examination can evaluate for psychiatric issues, sleep disturbances and other pulmonary factors, as well as musculoskeletal concerns.

ADA diabetes screening guidelines for children
Overweight Children (>85th percent BMI for age and gender) PLUS 2 or more risk factors:

  • Family history of type 2 diabetes
  • Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)
  • Signs of insulin resistance or conditions associated (acanthosis nigricans, hypertension, dyslipidemia, PCOS or small-for-gestational-age birth weight)
  • Maternal history of diabetes or GDM
  • Start testing at 10 years or at onset of puberty

Frequency of screening: every 3 years

The American Diabetes Association recommends screening high-risk patients who meet the outlined criteria for type 2 diabetes (Figure 2). Many children diagnosed with obesity will meet the criteria for screening.

The Children’s Hospital Association Focus on a Fitter Future II, a group with representatives from 25 obesity programs in the U.S., published a consensus guideline statement with guidance on screening, evaluation and treatment for common obesity comorbidities, including lipid abnormalities, liver disease, blood pressure abnormalities and polycystic ovary syndrome (PCOS).

As noted, fasting lipid profile screening can identify patients with additional cardiovascular risk factors, and liver function studies can identify those at risk for steatohepatitis. If abnormal screening results suggest these comorbidities, then referral to a specialized obesity program or to the specific subspecialty service treating the organ system of concern is warranted.

Managing childhood obesity

The primary treatment for pediatric obesity is to alter dietary intake and physical activity levels. Our clinical program, the Optimal Weight for Life (OWL) Program, focuses on implementing a low glycemic index diet in the home through altering purchasing practices, improving the food environment in the home and significantly reducing high glycemic index foods and beverages, including eliminating sugar sweetened beverages. The emphasis is on increasing fruits and vegetables, proteins and healthy fats.

We also offer physical activity consultations and specific programming to provide exercise. A major component is counseling by mental health professionals to facilitate behavioral change in the patient and family unit. Many of these elements of ongoing care could be supported in a primary care setting with appropriate resources. Additional evaluation for etiologies and comorbidities can be done in a subspecialty program in coordination with primary care providers.

Amy Fleischman Optimal Weight for Life Program childhood obesityAmy Fleischman, MD, MMSc, is the medical director of the Optimal Weight for Life (OWL) Program at Boston Children’s Hospital and an assistant professor of pediatrics at Harvard Medical School.

 

 

 

 

Have questions about the management of childhood obesity? Contact Boston Children’s Hospital’s Optimal Weight for Life (OWL) Program.

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