2023 - Clinical Practice Guideline For The Evaluation - AAP

CLINICAL PRACTICE GUIDELINE Guidance for the Clinician in Rendering Pediatric Care
Clinical Practice Guideline for the

Evaluation and Treatment of Children
and Adolescents With Obesity
Sarah E. Hampl, MD, FAAP,a Sandra G. Hassink, MD, FAAP,b Asheley C. Skinner, PhD,c Sarah C. Armstrong, MD, FAAP,d
Sarah E. Barlow, MD, MPH, FAAP,e Christopher F. Bolling, MD, FAAP,f Kimberly C. Avila Edwards, MD, FAAP,g
Ihuoma Eneli, MD, MS, FAAP,h Robin Hamre, MPH,i Madeline M. Joseph, MD, FAAP,j Doug Lunsford, MEd,k
Eneida Mendonca, MD, PhD, FAAP,l Marc P. Michalsky, MD, MBA, FAAP,m Nazrat Mirza, MD, ScD, FAAP,n
Eduardo R. Ochoa, Jr, MD, FAAP,o Mona Sharifi, MD, MPH, FAAP,p Amanda E. Staiano, PhD, MPP,q
Ashley E. Weedn, MD, MPH, FAAP,r Susan K. Flinn, MA,s Jeanne Lindros, MPH,t Kymika Okechukwu, MPAu
a
Children’s Mercy Kansas City Center for Children’s Healthy Lifestyles &
Nutrition, University of Missouri-Kansas City School of Medicine, Kansas
City, Missouri; bMedical Director, American Academy of Pediatrics,
Greetings Institute for Healthy Childhood Weight, Wilmington, Delaware;
c
You have in your hands, or at your fingertips, the first edition of the Department of Population Health Sciences, Duke University School of
American Academy of Pediatrics clinical practice guideline for evaluation and Medicine, Durham, North Carolina; dDepartments of Pediatrics and
Population Health Sciences, Duke Clinical Research Institute, Duke
management of children and adolescents with overweight and obesity.
University, Durham, North Carolina; eDepartment of Pediatrics, University
Putting together this guideline was no small task, and the Academy is of Texas Southwestern Medical Center, Children’s Medical Center of Dallas,
grateful to the efforts of all the professionals who contributed to the Dallas, Texas; fDepartment of Pediatrics, University of Cincinnati College of
production of this document. This work is a true testament to their passion Medicine, Cincinnati, Ohio; gChildren’s Health Policy & Advocacy, Ascension;
and dedication to combatting childhood and adolescent overweight and Department of Pediatrics, Dell Medical School at The University of Texas at
obesity. Austin, Austin, Texas; hDepartment of Pediatrics, The Ohio State
University, Center for Healthy Weight and Nutrition, Nationwide
The Subcommittee responsible for developing this guideline comprises a Children’s Hospital, Columbus, Ohio; iCenters for Disease Control and
diverse group of professionals from a variety of disciplines representing both Prevention; Atlanta, Georgia; jDivision of Pediatric Emergency Medicine,
governmental entities and private institutions. Experts all, they are united by Department of Emergency Medicine, University of Florida College of
a common desire to provide the finest, most effective care and treatment to Medicine–Jacksonville, University of Florida Health Sciences
Center–Jacksonville, Jacksonville, Florida; kFamily Representative;
children and adolescents with overweight and obesity. Over the course of l
Departments of Pediatrics and Biostatistics & Health Data Science,
several months, the members of the Subcommittee reviewed the technical Indiana University School of Medicine, Indianapolis, Indiana;
reports produced from the study review, then worked in concert to develop m
Department of Pediatric Surgery, The Ohio State University, College of Medicine,
the Key Action Statements and Expert Consensus Recommendations Nationwide Children’s Hospital, Columbus, Ohio; nChildren’s National Hospital,
contained within this guideline. These were crafted with meticulous care by George Washington University, Washington, DC; oDepartment of
the Subcommittee members, to align with current literature and to place Pediatrics, University of Arkansas for Medical Sciences, Arkansas
Children’s Hospital, Little Rock, Arkansas; pDepartment of Pediatrics,
appropriate emphasis on each statement.
Yale School of Medicine, New Haven, Connecticut; qLouisiana State
While representing such a broad spectrum of perspectives, the members of University Pennington Biomedical Research Center, Baton Rouge,
this committee are all keenly aware of the multitude of barriers to treatment Louisiana; rDepartment of Pediatrics, University of Oklahoma Health
that patients and their families face. These barriers impact not only their Sciences Center, Oklahoma City, Oklahoma; sMedical Writer/Consultant,
Washington, DC; tAmerican Academy of Pediatrics, Itasca, Illinois; and
access to treatment, but their ability to follow prescribed treatment plans. u
American Academy of Pediatrics, Itasca, Illinois
Whereas some patients are able to adopt the lifestyle changes and
habitualize elements of their prescribed treatment plans, so many others This document is copyrighted and is property of the American
struggle to do so for a wide variety of reasons. The members of the Academy of Pediatrics and its Board of Directors. All authors have
Subcommittee understand all of this. To assist with optimizing health equity
and overcoming these barriers, guidance on a number of multilevel factors
related to barriers to treatment have been included in this guideline. During To cite: Hampl SE, Hassink SG, Skinner AC, et al. Clinical
Practice Guideline for the Evaluation and Treatment of
the course of their work, members of the Subcommittee acknowledged that,
Children and Adolescents With Obesity. Pediatrics. 2023;151(2):
although so much has been learned to advance the treatment of children and
e2022060640
adolescents with overweight and obesity, there is still so much we have yet
PEDIATRICS Volume 151, number 2, February 2023:e2022060640 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from http://publications.aap.org/pediatrics/article-pdf/doi/10.1542/peds.2022-060640/1434544/peds_2022060640.pdf
by guest
to discover. The Subcommittee recognizes the importance that future studies
will play in advancing our knowledge and understanding of this chronic
disease, knowledge and understanding that will lead to the development of
new and more effective treatments. Specific discussion about the needs for
future research are included in the guideline.
It is the fervent hope of every member of the Subcommittee that this
guideline and the resources that accompany it will provide you with a more
complete understanding of the issues, factors, and needs of patients
combating overweight and obesity, as well as successful treatment options to
assist them in their battle. This guideline and the resources that accompany
it are not only for you, they are because of you, and all that you do to care
for each and every patient as if they were the most important one. Because,
as we all know, they are.
Be well,
Doug Lunsford, Family Representative
I. INTRODUCTION health (SDoHs, see Definition of “Algorithm for the Assessment and
The current and long-term health of Terms section) on the chronic Management of Childhood Obesity”
14.4 million children and disease of obesity—along with in 2016.16
adolescents is affected by obesity,1,2 heightened appreciation of the
making it one of the most common impact of the chronicity and severity This is the AAP’s first clinical
pediatric chronic diseases.3–5 Long of obesity comorbidities—has practice guideline (CPG) outlining
stigmatized as a reversible enabled broader and deeper evidence-based evaluation and
consequence of personal choices, understanding of the complexity of treatment of children and
obesity has complex genetic, both obesity risk and treatment.8,9 adolescents with overweight and
physiologic, socioeconomic, and Multiple randomized controlled obesity.
environmental contributors. As the trials and comparative effectiveness
environment has become studies have yielded effective This guideline does not cover the
increasingly obesogenic, access to treatment strategies, demonstrating prevention of obesity, which will be
evidence-based treatment has that, despite the complex nature of addressed in a forthcoming AAP
become even more crucial. this disease, obesity treatment can policy statement.
be successful.10,11
A significant milestone in the fight to The CPG also does not include
counter misperceptions about obesity The knowledge and skills to treat guidance for overweight and obesity
and its causes occurred in 1998, when childhood obesity have become evaluation and treatment of children
the National Institutes of Health (NIH) necessities for clinical teams in younger than 2 years. Children
designated obesity as a chronic pediatric primary and subspecialty under the age of 2 were not part of
disease. The NIH made a further care. For more than 2 decades, the the inclusion criteria for the
commitment to necessary research in American Academy of Pediatrics evidence review, because it is
the “Strategic Plan for NIH Obesity (AAP) and its members have had the difficult to practically define and
Research,” released by the NIH Obesity opportunity to collaborate with measure excess adiposity in this age
Task Force in 2011.6 In 2013, on the multiple scientific and professional group. The CPG also does not
basis of accumulating evidence, the organizations to improve the clinical discuss primary obesity prevention,
American Medical Association care of children with overweight as no studies reporting results of
recognized obesity as a complex, and obesity. Notable milestones obesity prevention interventions
chronic disease that requires medical include the 1998 “Expert met the inclusion criteria for the
attention.7 Committee Recommendations,”12 evidence review.
the 2007 “Expert Committee
The scientific and medical Recommendations,”13–15 the Nonetheless, the topics of obesity
community’s understanding of creation of the AAP Section on prevention and evaluation and
obesity is constantly evolving. Obesity and founding of the Institute treatment of children younger than
Increased understanding of the for Healthy Childhood Weight, both 2 years are very important to
impact of social determinants of in 2013; and the Institute’s reduce this threat to children’s
2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

by guest
current and future health. Future stakeholders. It is our hope that this and economic consequences that can
CPGs may include these topics; in CPG will further advance the impact a child’s quality of life.36–39
the meantime, information that may equitable care of children and Because obesity is a chronic disease
assist pediatricians and other adolescents with this chronic with escalating effects over time, a
pediatric health care providers disease. life course approach to identification
(PHCPs) is included on the AAP and treatment should begin as
Institution for Healthy Childhood II. APPROACH early as possible and continue
Weight’s Web site (aap.org/ longitudinally through childhood,
Childhood obesity results from a
obesitycpg). Further information on adolescence, and young adulthood,
multifactorial set of socioecological,
the CPG’s methodology and the with transition into adult
environmental, and genetic
writing committee’s approach is care.36,39–41
influences that act on children and
covered in subsequent sections.
families. Individuals exposed to A. Health Equity Considerations
adversity can have alterations in
The CPG contains Key Action It is not uncommon for the
immunologic, metabolic, and
Statements (KASs), recommendations differences in disease prevalence and
based on evidence from randomized epigenetic processes that increase
outcomes among population groups
controlled and comparative risk for obesity by altering energy
to be described in terms of ethnicity,
effectiveness trials as well as regulation.17–19 These influences
race, gender, and/or age and for
high-quality longitudinal and tend to be more prevalent among
these differences to be referred to as
children who have experienced
epidemiologic studies. The CPG “disparities.”42 Disparity, however,
writing Subcommittee uses the term negative environmental and SDoHs,
only defines differences between
“pediatricians and other pediatric such as racism.20 Overweight and
groups without referring to inequities
health care providers” to include obesity are more common in
that cause these differences among
children who live in poverty,21,22
both pediatric primary and specialty populations (ie, “economic, civil-
care physicians and other medical children who live in underresourced
political, cultural, or environmental
providers as well as allied health communities,23 in families that have conditions that are required to
care professionals, since all will immigrated,24 or in children who generate parity and equality”42).
encounter and can intervene with experience discrimination or Precisely because of the intertwining
children with overweight, obesity, stigma.25–32 As such, obesity does of inequities throughout the life
and obesity-related comorbidities. An not affect all population groups course, health disparities can be
algorithm with these KASs is equally.33 This fact highlights the found from maternal pregnancy
provided in Appendix 1. importance of understanding the outcomes through adolescence and,
role of SDoHs34 as well as the social as such, can have an inevitable
The KASs are supplemented by context of children and their impact on childhood obesity.
Consensus Recommendations that families in the etiology and
are based on expert opinion and treatment of overweight and This distinction between health
address issues that were not part of obesity. disparities and inequities is
the supporting technical reports particularly important when
(TRs). These consensus Children with overweight and considering chronic disease,
recommendations are supported by obesity benefit from health behavior because: (1) obesity risk factors are
AAP-endorsed guidelines, clinical and lifestyle treatment, which is a embedded in the socioecological and
guidelines, and/or position child-focused, family-centered, environmental fabric of children’s
statements from professional coordinated approach to care, lives; and (2) there is a danger of
societies in the field and an coordinated by a patient-centered stigmatizing children with obesity
extensive literature review. medical home, and may involve and their families on the basis of
pediatricians, other pediatric health race and ethnicity, age, and gender
This CPG stands on the shoulders of care providers (such as registered based on the disparities of
the pediatricians, other PHCPs, dietitian nutritionists [RDNs], outcome—with failure to recognize
clinical researchers, and other psychologists, nurses, exercise the systemic challenges that cause
stakeholders who collaborated to specialists, and social workers), and maintain inequities.43,44
create the previous Expert families, schools, communities, and
Recommendations, which have been health policy.35 Obesity is long- Inequities are often associated with
valued sources of guidance for lasting and has persistent and each other45 and result in
health care professionals, clinical negative health effects, attributable disparities in obesity risk and
systems, parents, and other key morbidity and mortality, and social outcomes across the socioecological
PEDIATRICS Volume 151, number 2, February 2023 3

by guest
spectrum. Importantly, they attributable to structural racism have obesity is an important mitigator in
represent neighborhood-, been linked to increased obesity reducing weight stigma.61 Additional
community-, and population-level rates.53 Racism experienced in actions that reduce weight stigma
factors that can be changed.46 everyday life has also been associated include having appropriately sized
Inequities that promote obesity in with increased obesity prevalence.54 office furniture, using appropriate
childhood can have a longitudinal Youth with overweight and obesity capacity medical equipment,
effect leading to disparities in adult have been found to be at increased ensuring that aesthetic and/or
health and contributing to adult risk not only for weight-based instructional images posted in the
obesity and chronic disease.47 harassment but also for sexual office are inclusive, and avoiding
harassment and harassment based on stigmatizing language.28 Accordingly,
The AAP is dedicated to reducing race and ethnicity, socioeconomic the CPG utilizes person-first
health disparities and increasing status (SES), and gender.55 In adults, language (ie, using the term “child
health equity for all children and studies have found positive with obesity, rather than “obese
adolescents.28 Attainment of these associations between self-reported child”) to avoid labeling the child.28
goals requires addressing inequities discrimination and waist This practice is consistent with
in available resources and systemic circumference,56,57 visceral recommendations from the AAP and
barriers to quality health care
adiposity,58 and BMI57 in both non- other national organizations,
services for children with obesity.48
Latino and Latino populations.59 including the Academy of Nutrition
To that end, “practice standards and Dietetics, the Obesity Society,
must evolve to support an equity- C. Weight Bias and Stigma and the Obesity Action Coalition.62
based practice paradigm” and Considerations
payment strategies must promote Individuals with overweight and D. Adverse Childhood Experiences
this approach to care.28 obesity experience weight stigma, Adverse childhood experiences
victimization, teasing, and bullying, (ACEs) are negative experiences
It is our hope that individual clinical
which contribute to binge eating, caused by situations or events in the
encounters with patients and families
social isolation, avoidance of health lives of children and adolescents
will provide opportunities to “screen
care services, and decreased that can pose threats to their
and address the social, economic,
physical activity.28,43 Importantly, current and future physical and
educational, environmental, and
internalized weight bias has been mental health.63,64 These
personal-capital needs of the children
associated with a negative impact on experiences range from family
with obesity and their families.”49 In
addition, understanding the wider mental health.60 Collectively, these turmoil and violence to financial
factors may adversely affect quality hardship, loss of a parent, divorce,
determinants of the chronic disease
of care, prevent patients with abuse, and parental mental illness—to
of obesity will enable pediatricians
overweight and obesity from name a few.65 ACEs have been
and other PHCPs to “raise awareness
seeking medical care, and contribute associated with obesity, both in
of the relevance of these social and
to worsened morbidity and adulthood and in childhood.66–68
environmental determinants of
mortality, independent of excess Children and adolescents who live in
childhood obesity in their
adiposity.28,43,44 poverty have a higher likelihood of
communities.”49
experiencing ACEs, but risk for ACEs
B. Racism Pediatricians and other PHCPs have occurs at every income level.65,69 The
Racism as an SDoH has been defined been—and remain—a source of greater the number of ACEs a child or
as a “system of structuring weight bias. They first need to adolescent experiences, the greater
opportunity and assigning value uncover and address their own the risk for obesity.70 The most
based on the social interpretation of attitudes regarding children with commonly cited mechanisms linking
how one looks (race) that unfairly obesity. Understanding weight ACEs to obesity are social disruption,
disadvantages some individuals and stigma and bias, and learning how negative health behaviors, and
communities (and) unfairly to reduce it in the clinical setting, chronic stress response.71
advantages other individuals and sets the stage for productive
discussions and improved Approach Summary
communities … ”50,51 that “impacts the
health status of children, adolescents, relationships between families and The recommendations in the CPG
emerging adults and their families.”52 pediatricians or other PHCPs. are child-centric and not specific to
Acknowledging the multitude of a particular health care setting and
Inequalities in poverty, genetic and environmental factors are written to inform pediatricians
unemployment, and homeownership that contribute to the complexity of and other PHCPs about the standard

by guest
of care for evaluating and treating height in meters. For children and increase in body fat promotes
children with overweight and teens, BMI interpretation is age- and adipose tissue dysfunction and
obesity and related comorbidities. sex-specific. A child’s BMI category abnormal fat mass physical forces,
To reflect the pediatrician’s and (eg, healthy weight, overweight) is resulting in adverse metabolic,
PHCP’s individual relationship determined using an age- and sex- biomechanical, and psychosocial
with the child and family, the specific percentile for BMI rather
health consequences.”78
Subcommittee refers to “evaluation” than the BMI cut-points used for
(eg, for comorbidities) rather than adult categories.72 Comprehensive obesity treatment:
“screening.” It is anticipated that a Comprehensive obesity treatment
pediatrician’s or other PHCP’s Capacity-building: “Building
(COT) (Fig 1) includes79,80:
setting, training, and expertise may individual competencies and
moderate how elements of the CPG technical expertise, strengthening
Providing intensive, longitudinal
are implemented. Helpful resources organizational capacities, and
treatment in the medical home
can be found in accompanying enabling supportive structural
environments” to maintain or Evaluating and monitoring child
implementation materials. or adolescent for obesity-related
improve health services
delivery.73 medical and psychological
Understanding the underlying
comorbidities
genetic, biological, environmental,
Children with special health care Identifying and addressing social
and social determinants that pose
needs: Children with special health drivers of health
risk for obesity is the bedrock of all
care needs are those who have, or Using nonstigmatizing approaches
evaluation and intervention.
who are at increased risk for, a to clinical treatment that honor
Allowing the family to have a safe
space to understand and process the chronic physical, developmental, unique individual qualities of each
complexity of obesity and its behavioral, or emotional condition child and family
chronicity requires tact, empathy, and who also require health and Using motivational interviewing
related services of a type or amount that addresses nutrition, physical
and humility. Achieving this goal
beyond that required by children activity, and health behavior
enables the patient and family to
generally.74 change using evidence-based
gain the knowledge and
understanding needed to recognize targets for weight reduction and
Chronic care model: The chronic health promotion
risk factors in their environment
care model identifies essential Setting collaborative treatment goals
and behaviors, to honor cultural
elements of a health care system not limited to BMI stabilization or
preferences, and to institute changes
that encourage high-quality chronic
independently as well as under the reduction; including goals which
disease care: the community; the
guidance of a trusted and well- reflect improvement or resolution
health system; self-management
trained advocate—such as of comorbidities, quality of life,
support; delivery system design;
pediatricians and other PHCPs. self-image, and other goals related
decision support, and clinical
to holistic care
information systems.75
Finally, to emphasize important Integrating weight management
goals of treatment—both improved Chronic disease: The Centers for components and strategies across
weight status and reduction or Disease Control and Prevention appropriate disciplines, which
elimination of comorbidities—the (CDC) defines chronic diseases can include intensive health
Subcommittee uses the term broadly as “conditions that last behavior and lifestyle treatment,
intensive health behavior and 1 year or more and require ongoing with pharmacotherapy and
lifestyle treatment (IHBLT) rather medical attention or limit activities metabolic and bariatric surgery if
than “intensive lifestyle or of daily living or both.”76 Obesity is indicated
behavioral modification” or “weight a chronic disease that results in Tailoring treatment to the ongoing
management.” Additional definitions altered anatomy, physiology, and and changing needs of the individual
are listed in the next section. metabolism—all of which adversely child or adolescent, and the family
affect the physical and mental health and community context
III. DEFINITION OF TERMS trajectory of children and
BMI: BMI is a measure used to adolescents.77 The Obesity Medicine Comprehensive patient history: A
screen for excess body adiposity; it Association defines obesity as a comprehensive patient history
is calculated by dividing a person’s “chronic, relapsing, multifactorial, includes a review of systems; family
weight in kilograms by the square of neurobehavioral disease, wherein an history; history of present illness;

by guest
and appropriate nutritional, physical 95th percentile for children and “children with obesity” or “adolescents
activity, and psychosocial history. teens of the same age and sex. with overweight,” not “obese children”
and/or “overweight adolescents.”
Family-based treatment: Family- Pediatricians and other pediatric
based treatment centers on the health care providers: For the Severe obesity: The expanded
role of family at each stage of child purpose of this CPG, pediatricians definition of “severe obesity” includes
development, includes consideration of and other pediatric health care Class 2 and Class 3 obesity.83
the family’s critical role in supporting providers refers to a qualified
child health, and understands the unique primary or tertiary care medical Class 2 obesity ($120% to
contextual elements that affect the patient provider operating within their <140% of the 95th percentile) or
and family and influence treatment. scope of practice and providing a BMI $ 35 kg/m2 to <39 kg/m2,
clinical care to children and
whichever is lower based on age
Intensive health behavior and adolescents. Examples include
and sex
lifestyle treatment: IHBLT educates physicians, nurse practitioners, and
Class 3 obesity ($140% of the 95th
and supports families in nutrition physician assistants. (This document
and physical activity changes that percentile) or BMI $ 40 kg/m2,
also refers to dietitians, licensed
improve weight status and psychologists, exercise specialists, whichever is lower based on age
comorbidities and promote long- and other health care professionals and sex
term health. IHBLT is most often who are not practicing medicine in
effective when it occurs face-to- the same manner.) Social determinants of health
face, engages the whole family, (SDoHs): SDoHs are the conditions
and delivers at least 26 hours of Pediatric medical home: The in the environments where people
nutrition, physical activity, and “pediatric medical home” delivers are born, live, learn, work, play,
behavior change lessons over 3 to accessible, continuous, comprehensive, worship, and age that affect a wide
12 months. IHBLT is foundational patient- and family-centered, range of health, functioning, and
to COT and should continue coordinated, compassionate, and quality-of-life outcomes and risks.
longitudinally. It should be culturally effective health care. In this
SDoHs can be grouped into 5
provided in conjunction with venue, well-trained pediatric physicians
domains: economic stability,
pharmacotherapy and metabolic known to the child and family deliver
education access and quality,
and bariatric surgery if these or direct primary medical care.81
neighborhood and built
treatments are indicated. IHBLT
may be available in the form of a Pediatric obesity specialist or environment, and social and
defined program and may be clinician with expertise: Pediatric community context.8,84,85
offered in pediatrician and other obesity specialists and clinicians
PHCP offices, medical centers or with expertise are health care Treatment intensification:
health systems, or in partnership professionals with additional Treatment intensification occurs
with community organizations. training in pediatric obesity through increased frequency of
medicine. Training may take the contact, increased length of
Longitudinal care: Care provided form of certification programs treatment, or other means of
by a group of health care specific to obesity, fellowship, or a increasing the dose of treatment.
professionals who monitor a focus during specialty training, such
Treatment intensification could
patient’s weight and other health as within endocrinology or
include additional health care
indicators over a length of time gastroenterology specialty training.
professionals and/or additional
sufficient to be associated with It may also take the form of an
informal apprenticeship combined methods, such as physical therapy,
health improvements. Longitudinal
with professional workshops. For psychotherapy, medical nutrition
care is continuous and coordinated
and should include a plan for the purposes of this document, such therapy, pharmacotherapy, or
transition into adulthood. training occurs within the context of metabolic and bariatric surgery.
recognized health care professional
Overweight and obesity: Overweight organizations. IV. METHODOLOGY
is defined as a BMI at or above the
85th percentile and below the 95th Person-first language: According A. Subcommittee Process and
percentile for children and teens of to the CDC, person-first language Support
the same age and sex. Obesity is emphasizes the individual, not their In 2017, the CDC supported the
defined as a BMI at or above the disabilities.82 Hence, this CPG describes AAP’s Institute for Healthy Child

by guest
Weight (the Institute) to conduct an cochair and outstanding issues were B.2. Rationale for KQ2: Comorbidity
evidence review of obesity treatment resolved by group consensus. The Studies
and obesity-related comorbidities. The parent member was an at-large
Previous recommendations have
Institute identified a methodologist member of all the writing groups
included assessments of
and convened an evidence review and reviewed each section.
comorbidities, including HTN,
committee consisting of pediatricians Members’ potential conflicts of
dyslipidemia, glucose, fatty liver
and researchers with expertise in interest were identified and
disease, and others. It is not clear
pediatric obesity etiologies, diagnosis, considered; no conflicts prevented
whether these assessments lead to
and management. This committee, Subcommittee members from
improved treatment strategies or
which met regularly in 2018 to 2019, participating in the CPG
outcomes. Additionally, it is not
followed established methods development process.
clear whether conducting these
(elaborated on below) to create 2 TRs,
B. Scope of the Review assessments would result in an
which capture the evidence review
adverse outcome. We examined
committee’s findings and detail the This review was designed to answer
specific conditions that were
search criteria, systematic review 2 overarching key questions (KQs).
previously recommended or that
process, and research history. One TR KQ1 was: “What are effective
would reasonably require screening:
is on overweight and obesity clinically based treatments for
treatment (https://doi.org/10.1542/ dyslipidemia, HTN, diabetes, fatty
pediatric obesity?” KQ2 was: “What
peds.2022-060643) and the second is liver disease, depression, sleep
is the risk of comorbidities among
on overweight and obesity apnea, and asthma. This is not
children with obesity?”
comorbidities (https://doi.org/ intended to be a comprehensive list
10.1542/peds.2022-060643). of all conditions comorbid with
The Subcommittee developed this
obesity but represents those most
focus based on the needs of
Staff from the Institute and the common and for which screening is
pediatricians and other PHCPs and
AAP’s Council on Quality potentially helpful.
the evidence required to inform the
Improvement and Patient Safety future development of clinical C. Search Strategy
formed a CPG writing practice guidelines. The review did
Subcommittee, comprising the The Evidence Review Subcommittee
not attempt to address treatment
methodologist and several searched PubMed and CENTRAL
strategies for comorbidities
evidence review committee (for trials). The initial search was on
(eg, hypertension [HTN], sleep
members; a range of pediatric April 6, 2018, and an additional
apnea, type 2 diabetes mellitus
primary and tertiary care search was conducted to update the
[T2DM]), as other guidelines and
providers; behavioral health, review, covering the time period
reviews are available to guide such
nutrition, and public health April 7, 2018 through February 15,
treatment.86–90
researchers; a pediatric surgeon; 2020. Both searches followed the
medical epidemiologists from the B.1. Rationale for KQ1: Intervention same procedures, which are
CDC Division of Nutrition, Physical Studies described below.
Activity and Obesity; an
implementation scientist; a parent Pediatricians and other PHCPs are a The Subcommittee combined the
representative; and a trusted source of health information searches for both KQ1 and KQ2
representative from the AAP for parents, including on issues because of their significant overlap to
Partnership for Policy related to nutrition and physical more efficiently review studies.
Implementation. Most activity, which are key components Because the focus was on interventions
Subcommittee members also have of obesity prevention and treatment. that are relevant to primary care, the
other national organization To meet this need, pediatricians and Subcommittee did not search other
affiliations relevant to pediatric other PHCPs need to know the discipline-specific databases, such as
overweight and obesity. strategies that have high-quality ERIC or PsycInfo.
evidence for effectiveness in
The Subcommittee members were preventing and treating obesity. The Subcommittee searched for
identified by the AAP and met Additionally, pediatricians and other studies of children or adolescents,
regularly in 2019 and 2020 and PHCPs need guidance on which with a focus on overweight, obesity,
virtually thereafter. Members were treatments are effective for their or weight status; involving
assigned sections and met virtually population and how to leverage pediatricians, other pediatric health
to complete their sections. Sections available resources for obesity care providers, health care, or other
were reviewed by the chair or treatment efforts. treatment or screening (KQ1); and

by guest
examining common comorbidities 10.1542/peds.2022-060642 and be included in the TR on
(KQ2). For both questions, the https://doi.org/10.1542/ interventions (https://doi.org/
Subcommittee limited only using peds.2022-060643]) to assist in in- 10.1542/peds.2022-060642).
key words, not filters, to ensure the terpretation of evidence within a
inclusion of the newest studies that health equity framework. The tech- D.3. Inclusion Criteria for KQ2 (Comorbidity
had not yet been fully indexed. No nical report authors notated in the Studies)
date limits were placed on searches. “special populations” section of Ap- The Subcommittee included studies
In practice, this meant the pendix 5 when each study specifi-
that had a primary aim of
Subcommittee reviewed studies cally focused on a lower-resourced
comparing comorbidities among
from 1950 to 2020, although fewer population, as well as race and eth-
those with and without obesity or
than 2% of the studies were from nicity distributions for all studies.
by severity of obesity. Obesity and
before 1980.
D.2. Inclusion Criteria for KQ1 the comorbidity had to be measured
(Intervention Studies) contemporaneously to reflect the
The complete search strategies are
included in Appendix 2 of the The primary aim of the intervention practice of clinical screening.
accompanying TRs (https://doi.org/ studies had to be examination of an Obesity had to be categorized using
10.1542/peds.2022-060642 and obesity prevention (intended for a BMI-based measure into accepted
https://doi.org/10.1542/peds.2022- children of any weight status) or categories (ie, healthy weight,
060643). treatment (intended for children overweight, class 1 obesity, class 2
with overweight or obesity) obesity, class 3 obesity). These
D. Inclusion Criteria intervention. The primary intended categories could be based on
D.1. Inclusion Criteria Common to All outcome had to be obesity, broadly percentiles or z-scores and could
Studies defined, and not an obesity use the distributions relevant to the
comorbidity. Studies of obesity
All studies were required to include studied population (eg, World
interventions that reported other
children ages 2 to 18 years. Studies Health Organization [WHO] or the
outcomes were included.
could also include young adults up CDC).91,92
to age 25, if this population was Interventions could involve any
stratified from older adult All studies had to include 1 or more
approach, including screening,
participants, as long as children of the following comorbidities:
counseling, medically managed
younger than 18 years were also lipids, blood pressure (BP), HTN,
weight loss, pharmaceutical
included in the study. Children could treatment, or surgery. Regardless of liver function, glucose metabolism,
have other conditions (eg, asthma), the intervention components, there obstructive sleep apnea (OSA),
as long as these conditions were not had to be some level of outpatient asthma, or depression. These were
known to cause obesity, or be taking clinical involvement in the chosen based on known associations
medications (eg, steroids) other treatment (ie, not just referral to an with weight and potential for
than those known to be significantly outside program), such as screening screening in the primary care
obesogenic. Conditions known to or a clinic follow-up appointment. setting.
cause obesity, such as Prader-Willi Interventions that occurred
syndrome, obesogenic medication completely outside the scope of The complete inclusion criteria are
(eg, antipsychotics), or known health care were excluded. For included in Appendix 3 of the
genetic mutations associated with example, school-based obesity accompanying TR on comorbidities
obesity (eg, melanocortin 4 receptor prevention programs or community- (https://doi.org/10.1542/peds.
[MC4R]) were excluded. based activity programs with no 2022-060643).
pediatrician or other pediatric E. Review Process
All studies had to originate from health care provider involvement
Organization for Economic were excluded. The Subcommittee used Covidence to
Cooperation and Development manage the review process (https://
member countries and be available The Subcommittee did not limit the www.covidence.org/). Covidence is a
in English. search by study design but did program for online collaboration and
report experimental and management of systematic reviews.
The race distribution of the samples nonexperimental studies separately. All abstracts were reviewed by
is reported in the accompanying Although nonexperimental designs 2 independent reviewers on the
technical report evidence overview were included, all studies had to Subcommittee, who assessed the
(Appendix 5 in TRs [https://doi.org/ have a relevant comparison group to study’s inclusion in the full-text

by guest
FIGURE 1
Treatment experience of obesity as a chronic disease (this figure illustrates how longitudinal care is important to help address this chronicity and to ad-
dress and buffer the social and contextual factors that influence a person’s health).
review process. All conflicts were tools. This occurred largely because psychosocial outcomes, mental
discussed and resolved. Articles studies consisted primarily of health, behaviors, and other
excluded at this stage were assigned behavioral interventions without the outcomes (primarily parent BMI
an exclusion reason, with a hierarchy, possibility of blinding. and child cardiovascular fitness).
which is shown in Appendix 4 of the
accompanying TRs (https://doi.org/ All studies, regardless of group, were The Subcommittee categorized the
10.1542/peds.2022-060642 and fully extracted by 2 reviewers, and intensity of interventions in a manner
https://doi.org/10.1542/peds.2022- conflicts were discussed and resolved. consistent with the US Preventive
060643). Intervention studies were categorized Services Task Force (USPSTF) to
into 5 groups for data extraction. allow for comparisons with its
F. Data Extraction and Quality
findings, into interventions with a
Assessment F.1. Group 1 Extraction
dose (number of hours) of <5 hours;
All articles deemed to meet criteria Group 1 articles included 5 to 25 hours; 26 to 51 hours; and 52
for full text inclusion were randomized trials of diet or or more hours. All interventions
categorized into different data “lifestyle” interventions. Extraction
occurred over less than 1 year. The
extraction strategies. Randomized of these articles included:
Subcommittee conducted quality
trials were given a quality sponsorship or funder, design,
assessment for group 1 articles.
assessment using the Cochrane Risk population information, provider
of Bias tool. The Subcommittee type, detailed intervention F.2. Group 2 Extraction
decided not to limit studies based on strategies and intensity, and BMI-
the study quality, because many of based outcomes. The Subcommittee Group 2 articles included
them did not reach “high-quality” also identified outcomes other than randomized controlled trials of
status (ie, at low risk of bias for most BMI, including lipids, glucose pharmaceutical treatments. Similar
or all domains in the Cochrane Risk metabolism, BP, other laboratory information as above was extracted,
of Bias Assessment) using any of the values, other obesity measures, using a brief description of the

by guest
treatment and no categorization of
intensity. These articles also
received a quality assessment.
F.3. Groups 3 Through 5 Extraction

i) Groups 3 Through 5 Articles Group
3 articles included nonrandomized
comparative studies of diet and
“lifestyle” treatments, group 4
articles included nonrandomized
comparative studies of
pharmaceutical treatment, and
group 5 articles included any
surgical studies.
Because of small numbers, the

Subcommittee combined randomized
and nonrandomized surgical studies.
Brief treatment descriptions and BMI-
related outcome data were extracted
from these, but the Cochrane Risk of
Bias tool was not used because these
were observational designs.
F4. KQ2 Extraction (Comorbidity Studies) FIGURE 2

Grading matrix.
All studies were extracted by 2
reviewers who reported prevalence
of comorbidities or mean values of type and design and has reported The Subcommittee reached consensus
laboratory parameters by weight findings for outcomes other than BMI. on the evidence, which was then used
classification. The Subcommittee to develop the clinical practice
The AAP policy statement, “Classifying guideline’s KASs. When the scientific
included healthy weight, overweight,
class 1 obesity, class 2 obesity, and
Recommendations for Clinical Practice evidence was at least “good” in quality
Guidelines,” was followed in and demonstrated a preponderance of
class 3 obesity.
designating aggregate evidence benefits over harms, the KAS provides
Because all classes of obesity quality levels for the available a “strong recommendation” or
severity were not always reported evidence (Fig 2).93 The AAP policy “recommendation.” Clinicians should
in the studies, these classes may statement is consistent with the follow a strong recommendation
include higher groups. For example, grading recommendations advanced unless a clear and compelling
reporting of $95th percentile would by the University of Oxford Centre for rationale for an alternative approach
only be considered class 1 obesity, Evidence-Based Medicine. is present; clinicians are prudent to
although children at higher levels follow a recommendation but are
may be included. (See the TR for a Evidence grades were determined advised to remain alert to new
detailed description of the KQ1 based on the grading matrix in information and be sensitive to
extraction procedures.) Fig 2. Although we included both patient preferences (Fig 2).
trials and observational studies in
G. Data Synthesis and Analysis the technical reports, they are Integrating evidence quality appraisal
The Subcommittee’s primary reviewed separately. Study design with an assessment of the anticipated
method of data synthesis was was considered in the aggregate balance between benefits and harms
narrative. To allow broad inclusion, evidence quality grades, as indicated leads to a designation of a strong
the Subcommittee did not limit to by the matrix. We did not explicitly recommendation, recommendation,
specific designs or measures that use risk of bias scores, but this option, or no recommendation. Once
would facilitate meta-analysis. The information was available and used the evidence level was determined,
Subcommittee has reported on in the Subcommittee’s final an evidence grade was assigned.
studies in each group based on their assessment. AAP policy stipulates that the evidence

by guest
supporting each KAS be prospectively increases continued among certain Disparities exist among children and
identified, appraised, and summarized, populations, including adolescents and youth with obesity, including, but
and an explicit link between quality non-Hispanic Black and Mexican not limited to, lower level of
levels and the grade of American youth.4 A predictive parental education, lower income,
recommendation must be defined. epidemiologic model estimates that if less access to healthier food options
2017 obesity trends hold, 57% of and safe and affordable physical
Possible grades of recommendations children aged 2 to 19 years will have activity opportunities, and higher
range from “A” to “D,” with “A” obesity by the time they are incidence of ACEs.70,98,99 For
being the highest: 35 years of age, in 2050.36 example, among 5345 children 6 to
9 years of age, those whose parents
Grade A: consistent level A studies; Obesity prevalence increases with had lower levels of education had a
Grade B: consistent level B or increasing age.3 For example, in greater odds of having obesity
extrapolations from level A studies; 2015 to 2016, the prevalence of compared with children whose
Grade C: level C studies or obesity in children aged 2 to parents had higher levels of
extrapolations from level B or 5 years, 6 to 11 years, and 12 to education (odds ratio: 1.78; 95%
level C studies; 19 years was 13.9%, 18.4%, and confidence interval [CI]: 1.36 to
Grade D: level D evidence or 20.6%, respectively.3 Among 2.32).100 A cross-sectional analysis of
troublingly inconsistent or incon- children younger than 6 years, there 111 799 children in Massachusetts at
clusive studies of any level; and were no significant trends in obesity the school district level showed that
Level X: not an explicit level of from 1999 to 2018 for those 2 for every 1 percentage point increase
evidence as outlined by the Centre through 5 years of age.4 For in the proportion of children with
for Evidence-Based Medicine. This children 6 through 11 years of age, low SES, there was a 1.17 percentage
level is reserved for interventions significant trends in obesity show an point increase in the prevalence of
that are unethical or impossible to increased prevalence from 15.8% in obesity.101 Furthermore, children
test in a controlled or scientific 1999 to 2002 to 19.3% in 2015 to with disabilities, including those with
fashion and for which the prepon- 2018.4 Similarly, among adolescents intellectual disabilities, are at higher
derance of benefit or harm is over- 12 through 19 years, trends show risk for developing obesity than their
whelming, precluding rigorous increased obesity in the same time peers without disabilities.102
investigation. period from 16.0% to 20.9%.4 The
proportion of children and youth 2 Finally, among 43 864 children and
When it was not possible to identify to 19 years of age with severe adolescents aged 10 to 17 years old,
sufficient evidence, recommendations obesity increased from 4.9% in the presence of 2 or more early
are based on the consensus opinion of 1999 to 2000 to 7.9% in 2015 to ACEs was associated with an
the Subcommittee members. 2016.4,96 The prevalence of severe increased odds of obesity later in
obesity in youth 12 to 19 years of childhood and adolescence (odds
VI. EPIDEMIOLOGY OF CHILDHOOD AND age in 2015 to 2018 was 7.6%.4 ratio: 1.21; 95% CI: 1.02 to 1.44).103
ADOLESCENT OBESITY Together, these disparities highlight
The COVID-19 pandemic has the burden of obesity in children
A. Prevalence of Childhood Obesity significantly affected the lives and from families of lower SES and the
Obesity is a common, complex, and routines of children and adolescents. need to provide strategies to
often persistent chronic disease In 1 analysis, the pandemic period minimize these inequities.
associated with serious health and was associated with a doubling in
social consequences.94 Childhood the rate of BMI increase compared Disparities also exist in obesity
obesity is typically defined as having a with the prepandemic period.97 prevalence across ethnic and racial
BMI of $95th percentile for age and Obesity prevention and management groups. In 2015 to 2018, non-
sex.95 Severe obesity is defined as BMI efforts should routinely include Hispanic Black children and Mexican
$ 120% of the 95th percentile for age health care provider screening for American youth 6 to 11 years of age
and sex. The percentage of US BMI, food security, and social had a higher prevalence of obesity
children and adolescents affected by determinants of health and compared with non-Hispanic white
obesity has more than tripled from increased access to evidence-based children (22.7% and 28.2% vs
5% in 1963 to 1965 to 19% in 2017 pediatric weight management 15.5%, respectively).4 An analysis of
to 2018.2 In 2017 to 2018, the rise in programs and food assistance the Indian Health Services National
obesity prevalence slowed in children resources to mitigate such effects in Data Warehouse showed that in
younger than 6 years of age, but the future.97 2015, the prevalence of overweight

by guest
and obesity in American Indian and obesity; severe obesity during Obesity in childhood and
Alaska Native (AI/AN) children and adolescence increases the risk for adolescence is associated with
adolescents was 18.5% and 29.7%, severe obesity during young health care utilization and costs. For
respectively.104 adulthood.109,110 BMI levels strongly example, the most common primary
track throughout childhood and conditions that cooccur with a
Among children 2 to 5 years of age adolescence and are predictive of secondary diagnosis of obesity and
from lower-income families enrolled high adult BMI.110 may increase costs and utilization
in the Special Supplemental include pregnancy, mood disorders,
Nutrition Program for Women, Obesity puts children and adolescents asthma, and diabetes.121 A modeling
at risk for serious short- and long- study has estimated that the total
Infants, and Children program,
term adverse health outcomes later in lifetime medical costs for 10-year-
recent analyses indicate a modest
life, including cardiovascular disease, olds with lifelong obesity to be in
but significant decline in obesity
including HTN; dyslipidemia; insulin the range of $9.4 to $14 billion for
prevalence from 2010 (15.9%) to that cohort alone.122
resistance; T2DM; and nonalcoholic
2018 (14.4%).106 Among these fatty liver disease (NAFLD).38,96,111–113
children, obesity prevalence ranged Additionally, prediabetes in youth Tracking obesity across the lifespan
across states from 8.5% to 20.2%; with obesity, compared with youth underscores the importance of
disparities persisted by race and with normal weight, has been primary and secondary prevention
ethnicity despite changes in associated with elevated systolic blood and treatment efforts early in life.
prevalence over time.105 pressure and low-density lipoprotein, These efforts include evaluating for
and lower insulin sensitivity.114 obesity using BMI; identifying
In addition, children and youth with children at high risk and adolescents;
special health care needs (CYSHCN) In addition to physical and providing or referring to evidence-
have a higher prevalence of obesity metabolic consequences, obesity in based obesity treatments for
and lower levels of physical activity childhood and adolescence is children, youth, and their families;
compared with children having typical associated with poor psychological and addressing SDoHs.
growth and development.106–108 and emotional health, increased
Among CYSHCN, a metanalysis of stress, depressive symptoms, and VII. DIAGNOSIS AND MEASUREMENT
studies of adolescents with intellectual low self-esteem.115 Several studies Although KAS 1 was not explicitly
disabilities found a pooled odds ratio have determined that children of studied and referenced by the TR,
of obesity of 1.80 compared with some racial and ethnic groups have most of the TR studies implicitly
adolescents with typical a greater prevalence of included measurement of height and
development.102 comorbidities associated with weight and calculation and plotting
childhood obesity, including HTN, of BMI as part of the study
B. Impact of Obesity in Childhood T2DM, hypercholesterolemia, and procedures. Thus, the concept of
Children with obesity commonly depression, compared with non- appropriate measurement,
become adolescents and adults with Hispanic white children.116–120 calculation, charting, and tracking is
KAS 1. Pediatricians and other PHCPs should measure height and wt, calculate BMI, and assess BMI percentile using age- and sex-specific CDC growth charts or growth charts for children
with severe obesity at least annually for all children 2 to 18 y of age to screen for overweight (BMI $ 85th percentile to <95th percentile), obesity (BMI $ 95th percentile), and severe
obesity (BMI $ 120% of the 95th percentile for age and sex).
Aggregate Evidence Quality Grade B

Benefits Easy to use; reproducible; improved identification of severe obesity; and improved ability to monitor
improvements in weight status of youth with severe obesity.
Risks, harms, costs Screening tool with both false negatives and false positives; may misclassify some populations; development,
implementation, and use of separate growth charts for severe obesity requires identification of severe
obesity (electronic health record decision prompts can support this); use of severe obesity growth charts
may confer stigma associated with obesity; interpretation and explanation for families may be challenging.
Benefit-harm assessment Benefit outweighs harm.
Intentional vagueness Growth charts based on reference populations; need to screen or assess adiposity for children among specific
populations (eg, CYSHCN); provider education on use and interpretation of charts; training requirements.
Role of patient preference Patient and family inclusion and discussion is critical to shared decision-making.
Exclusions >21 y
Strength Moderate
Key references 79, 123–130

by guest
implicit in research-based evidence for-age charts.143 The CDC Growth longitudinalchange in adiposity over
included in the TR (eg, Charts provide a historical time among children and adolescents
references123,124,126,130). comparison of children’s weight with obesity.127 The change in z-score,
status relative to a time before the however, may not accurately detect
A. Use of BMI as a Screening and current obesity epidemic during that meaningful changes in weight status
Diagnosis Tool healthier growth patterns or comorbidity risk over time,
The gold standard measurement of predominated; thus, percentiles on particularly for children and
body composition—dual-energy x-ray the Growth Charts do not equate to adolescents with severe obesity
absorptiometry—to identify, locate, and the current population distribution caused by compression of z-scores
quantify body fat, and can be expensive of BMI. The CDC Growth Charts are corresponding to extremely high BMI
and difficult to implement. In clinical recommended for clinically tracking values into a very narrow range.145
practice, BMI is frequently used as both BMI patterns among US children and Consequently, investigators have
a screening and diagnostic tool for adolescents aged 2 to 18 years; proposed and described various
detecting excess body fat because it is although the CDC Growth Charts can alternative options, including using
easy to use and inexpensive. BMI is a be used for adolescents aged 19 to the degree to which, expressed in
validated proxy measure of underlying 21 years, in practice, most percentage, a particular BMI percentile
adiposity that is replicable and can pediatricians and other PHCPs was above the 95th percentile, or the
track weight status in children and transition to adult BMI calculation median, for age and sex (referred to
adolescents.38,131,132 Because of its ease and categorization for patients older as percentage above the 95th
of use, BMI is also frequently used to than 18 years.143 percentile, or percentage above the
follow a child or adolescent’s weight median, respectively).
trajectory over time. The CDC BMI “Overweight” is defined as a BMI at
growth curves are frequently used to or above the 85th percentile and The “extended” method for calculating
visualize BMI trajectory over time. below the 95th percentile for age BMI z-scores and percentiles at
Furthermore, BMI is often used to and sex; “obesity” is defined as a extremely high BMI values was
evaluate the success or impact of BMI at or above the 95th percentile developed to address these limitations.
interventions to improve weight status. for age and sex. “Severe obesity” is This method incorporates data on
defined as a BMI equal to or more children and adolescents with obesity
For most individuals, BMI is than 120% above the 95th from more recent NHANES surveys
generally well-correlated with direct percentile, which approximates the to better characterize the BMI
measures of body fat, including 99th percentile. The CDC Growth distribution above the 95th percentile
skinfold thickness measurements, Charts were not intended to track while retaining the 2000 CDC Growth
bioelectrical impedance, growth of children with extremely Chart BMI distribution below the 95th
densitometry, and dual-energy x-ray high BMI values. Because of limited percentile.
absorptiometry.131,133–139 data on children and adolescents
above the 97th percentile in the The CDC and the AAP recommend
BMI has limitations, however, reference population, higher that weight status in children up to
including high specificity and percentile curves could not 2 years of age be tracked using the
low sensitivity for detecting excess be generated. Caution was WHO’s weight-for-length, age-, and
adiposity.132 BMI does not directly recommended in extrapolation of sex-specific charts.146,147 Specialized
measure body composition and percentiles beyond the 97th growth charts for children and
fat content and may under- or percentile, as this may generate adolescents with certain conditions,
overdetect excess adiposity in unusual or unexpected results.144 In such as trisomy 21, can provide
certain racial and ethnic older adolescents, the adult cut-off useful growth reference information
groups.140,141 Finally, children of a BMI equal to or greater than for special populations. These charts
and adolescents who have high 30 kg/m2 can be used to define may, however, be limited, for
fat-free mass may have a high BMI obesity if this value is less than the example, by the small sample sizes
and, as a result, be incorrectly 95th percentile BMI for age and sex. used in developing them, which may
classified as having overweight or not be representative of all children
obesity.142 Conversion of BMI percentiles to and youth with trisomy 21.148
z-scores (a statistical measure that
The CDC’s 2000 Growth Charts are describes a value’s relationship to a B. The Clinical Utility of BMI
based on NHANES data from the population mean) derived from the BMI is a useful evaluation measure
1960s through the early 1990s and CDC Growth Charts have historically to clinically identify children with
include age- and sex-specific BMI- been used for assessing overweight and obesity for appropriate

by guest
treatment—such as family-based either overweight or obesity clinical tool to screen for excess
behavioral therapy—which can lead to (BMI $ 85th and <95th percentile adiposity and make the clinical
improvements in BMI and related for age and sex). Bright Futures also diagnosis of overweight or
comorbidities.123,124,127–130,149–152 provides implementation tips and obesity. Thus, the BMI must be
guidance for pediatricians and other communicated to the patient and
Following comprehensive systematic family, as it guides next steps for
PHCPs including, for example,
reviews, the USPSTF issued a Grade B comprehensive evaluation and
providing counseling using
recommendation that pediatricians and treatment of obesity and related
motivational interviewing. Bright
other PHCPs screen children and comorbidities. Weight-related
Futures offers guidance to states by
adolescents aged 6 years or older discussions can be uncomfortable
annually for obesity—defined by BMI offering a framework for meeting
for clinicians who want to avoid
percentile—and offer, or refer children national performance standards
stigmatizing children because of
and adolescents to, a comprehensive, under Title V. Finally, Bright Futures
their shape or size. Avoiding this
intensive, family-based behavioral suggests how communities and
discussion may, however, cause
treatment to improve weight status.79 families can support healthier delays or barriers to patients
(A “comprehensive, intensive lifestyles and prevention. This CPG receiving evidence-based care. In
behavioral treatment” was defined as a recommends referral to evidence- addition, obesity stigma can result in
treatment of 26 hours or more over a based weight management patient avoidance of health care and
period of 2 to 12 months.) (See interventions for all children 2 years disruption of clinician-patient
Evaluation and Treatment sections.) and older who have a BMI $ 95th relationships. There is evidence that
percentile for age and sex (see KAS 1, having conversations about obesity
Furthermore, the AAP’s Bright above). can facilitate effective treatment.155–157
Futures recommendations, which are
based on systematic reviews and The practice of annual BMI Three key factors can facilitate a
expert panels, offer prevention measurement at well-child visits is nonstigmatizing conversation about
guidelines including annual recommended and central to the weight with patients and families:
assessment of BMI alongside dietary management and tracking of
nutrition and physical activity overweight and obesity in 1. Ask permission to discuss the
counseling for children and patient’s BMI and/or weight.
children.127,153,154 Limitations to
adolescents starting at 2 years 2. Avoid labeling by using person-
this approach include missed
old127,153(Appendix 2). first language (“Child with
opportunities to track and manage
obesity”; not “obese child” or “my
Appendix 2 describes the USPSTF weight changes that occur in less
patient is affected by obesity; not
recommendations, Bright than a 12-month period.127,153
“my patient is obese”).158
Futures recommendations, and However, other visit opportunities
3. Use words that are perceived as
the recommendations reflected can be used to assess BMI outside neutral by parents, adolescents,
in this CPG’s KAS 1. All 3 sources the well-child visit.153 This CPG’s and children. In several studies
recommend annual screening for KAS on evaluation, based on the inclusive of diverse racial, ethnic,
excess weight using BMI, with the evidence described above, and in and rural and urban populations,
USPSTF beginning at 6 years old and concordance with USPSTF and the preferred words include:
both Bright Futures and this CPG Bright Futures recommendations, “unhealthy weight, gaining too
beginning at age 2 years. For continues to highlight the critical much weight for age, height, or
children or adolescents with a importance of annual evaluation for health, demasiado peso para su
BMI $ 95th percentile for age and excess weight and the provision of, salud (too much weight for his or
sex, the USPSTF provides or referral to, evidence-based her health).” Words perceived as
recommendations for primary care most offensive include: “obese,
interventions, as indicated, to
providers to offer, or refer them to, a morbidly obese, large, fat,
promote the health and well-being
comprehensive, family-based weight overweight, chubby, or sobrepeso
of all children and adolescents.
management intervention. Bright (overweight).”156
Futures recommends that primary C. Communication of BMI and
care providers screen for excess Weight Status to Children and Recognize that discussing BMI with
weight and provide dietary nutrition Parents children, adolescents, and families,
and physical activity counseling for Despite its limitations, BMI is even when using nonstigmatizing
all children and adolescents with currently the most appropriate language and preferred terms, can

by guest
elicit strong emotional responses treatment of the child or adoles- to foods of low nutritional values
including sadness or anger. cent with overweight or obesity. from advertisements; therefore,
Acknowledging and validating those it is not surprising that they
responses, while keeping the focus
A. Policy Factors have preferential increase in
on the child’s health, can help to The larger macroenvironment— consumption of foods of low
strengthen the relationship between including societal attitudes and beliefs, nutritional value.167
the pediatrician or other PHCP and government policies, food industry
patient and family to support practices, and the educational and A.2. Underresourced Communities
ongoing care.159 health care systems—can influence Underresourced communities are
obesity risk.162 It is difficult to make settings in which obesity risk factors
VIII. RISK FACTORS FOR CHILD AND or sustain healthy behavior changes in can predominate over health-
ADOLESCENT OVERWEIGHT AND an obesogenic environment that promoting factors. Children and
OBESITY promotes high-energy intake, families in these settings may be
Obesity is a chronic disease that unhealthy dietary choices, and unable to access fresh fruits and
has a multifactorial etiology. Risk sedentary behavior. vegetables and safe physical activity
factors for overweight and spaces and may suffer from food
A.1. Marketing of Unhealthy Foods insecurity.170–172 Limitations in
obesity—many of which are
SDoHs—include broader policies Marketing of unhealthy food and transportation, cost, affordability,
and systems factors; institutional beverages directed at children tends and availability may reduce access
or organizational (ie, school); to negatively impact their dietary to health care and obesity
neighborhood and community; choices and behaviors.163–166 Foods treatment. Families may be
and family, socioeconomic, and beverages embedded in struggling with poverty, access to
environmental, ecological, genetic, entertainment media have been healthy foods, lack of social
and biological factors (Table 1).21,160 shown to influence eating behavior supports, racism, and/or
These individual, social, and contextual choices of children and also increase immigration status. Understanding
risk factors often overlap and/or consumption of foods during or these contextual factors that impact
influence one another and can operate after exposure to the embedded each child and family is crucial in
longitudinally throughout childhood foods.167 being able to provide compassionate
and adolescence, initiating weight gain and effective obesity treatment.
and escalating existing obesity. A systematic review and meta-
Children and their families interact analysis showed that even short A.2.a. Socioeconomic Status
with their environment at all of these exposure to unhealthy food and Obesity has been shown to
levels and have a unique and beverage marketing targeted to disproportionately affect children
“insider’s” point of view that needs to children resulted in in increased and adolescents who have low
be understood in delivering culturally dietary intake and behavior during SES.173–175 Even though the
sensitive care.161 and after the exposure.168 Both prevalence of obesity has been
younger children and male children stabilizing among US children
Pediatricians and other PHCPs need (sex assigned at birth) tend to be overall, the rates continue to
to be aware of the risk factors for more susceptible to the food and increase among children with low
pediatric obesity to provide early beverage marketing,168 and because SES.173,176 According to the
anticipatory guidance for obesity of their stage of cognitive Children’s Defense Fund, the poverty
prevention, monitor their patients development, younger children are rate among US children is
closely, and intervene early when more likely to be susceptible to alarmingly high.177
weight trajectory increases. advertising and interpret it as
factual.169,170 A longitudinal analysis of
Consensus Recommendation predominantly non-Hispanic white
The CPG authors recommend Currently, marketing to children children in the United States found
pediatricians and other pediatric targets highly palatable relatively that low SES before 2 years of age
health care providers: inexpensive energy-dense foods and was associated with higher obesity
beverages.166 This marketing risk by adolescence in both boys
perform initial and longitudinal occurs via television, websites, and girls; this analysis also indicated
assessment of individual, structural, online games, at supermarkets, and that the effect of early poverty
and contextual risk factors to outside schools.166 Children are, endures later in life.178 Similarly,
provide individualized and tailored unfortunately, frequently exposed another study found that low SES in

by guest
early childhood had a long-term Patterns of childhood overweight obesity in children has been
impact on overweight and and obesity among families that inconsistent when looking at
obesity.179 This study found that the have immigrated vary substantially general child populations. Children
risk of experiencing overweight or by both ethnicity and generational living in households with food
obesity in adulthood was not altered status. Immigrants to the United insecurity have been found,
by either upward or downward States generally originate from however, to have higher BMI z-
mobility of poverty after early countries that have a lower scores and waist circumference
childhood,179 indicating the long- prevalence of obesity, but as measurement and a greater
term effect of poverty-related stress families acculturate to US eating and likelihood of having overweight or
in early childhood. activity patterns, rates of obesity obesity.189 The correlation
may increase. One study found that between food insecurity and
Low SES may also be associated second-generation Hispanic obesity has been found to be
with higher risk for obesity by higher in adolescents, who may
immigrants were 55% more likely
increasing the child’s experience have had more exposure to food
to have obesity than nonimmigrant
with toxic stress. In addition, insecurity over their life-
white children, whereas first-
poverty may limit access to healthy course.190 Female children appear
generation Asian immigrants had a
foods and opportunities for physical to more at risk for obesity in food-
63% lower risk of having obesity.180
activity.180–182 Another study of a insecure environments, compared
large dataset of children followed with male children.191
Several studies have indicated
longitudinally from 9 months of age different patterns of developing
to kindergarten entry showed that Food insecurity is highly associated
obesity in Mexican-origin with poverty, and the cost of fruits
SES played a major role in BMI populations among adults and and vegetables192 and fast food
z-score gaps in Hispanic children, children. Obesity among adults of have been found to influence
whereas rapidity of weight gain in Mexican origin in the United States consumption in low-income
the first 9 months “accounted for has been associated with longer families193,194 and to be positively
much of the disparity between white stays in the United States and with related to overweight in children.195
children and children” of other races being born in the United States Associations between consuming
and ethnicities (other than Hispanic versus Mexico, which are 2 proxies more sugar from sugar-sweetened
children).180 for acculturation. This pattern beverages, and less frequency of
differs in children, in whom eating breakfast and eating dinner
A.2.b. Children in Families That Have
“significantly higher obesity with family have also been noted in
Immigrated
prevalence has been observed for families with food insecurity.190,196
For decades, researchers have first-generation young adult males Family dynamics around feeding
believed that despite poverty and (ages 18–24) and adolescent females may change in situations of food
other negative SES factors, (ages 12–17).”186 insecurity and include pressure to
recently arrived immigrants are eat as well as monitoring and
healthier than their US-born In addition, in some cultures, larger restrictive eating practices.191,197
counterparts. Recent studies, body sizes may be preferred as an Experiences of food insecurity are
however, have examined large indication of health and wealth.187 stressful for children and families
datasets in novel ways and now This cultural factor may make it and may add to the burden of
call this idea into question when it more difficult for parents to chronic stress, which can result in
comes to children in families that understand the gravity of their altered eating patterns in the
have immigrated.183 children’s overweight or obesity. For direction of either restricting intake
this and many other reasons, it is or increasing consumption of
As families who have immigrated try vital to ensure that children and energy-dense foods.190,196
to adjust to a new culture, they may families who have immigrated and
adopt Americanized foodways, who are native-born have access to The AAP and Food Research and
which are high in fat, sugar, and salt. culturally competent health care.188 Action Center’s toolkit, Screen and
This tendency could be heightened Intervene: A Toolkit for Pediatricians
by children’s exposure to media A.3. Food Insecurity to Address Food Insecurity, is
advertising these foods and high- The literature positing an designed to help pediatricians
energy snacks and by reduced association between food identify and address childhood food
physical activity.184,185 insecurity and overweight and insecurity (available at https://frac.

by guest
TABLE 1 Selected Examples of Multilevel Influencers and Contributors to Obesity B. Neighborhood and Community
Example Description Environment Influences or
Contributors to Obesity
A. Policy factors Marketing of unhealthy foods
Underresourced communities Environmental factors play an
Food insecurity important role in obesity
B. Neighborhood and community factors 1. School environment prevalence. Families’ dietary and
2. Lack of fresh food access
physical activity opportunities and
3. Fast food proximity
4. Access to safe physical activity practices (mentioned above) are
5. Environmental health influenced by their neighborhoods
C. Family and home environment factors 1. Parenting feeding style (Table 1).
2. Sugar-sweetened beverages
3. Portion sizes B.1. School Environment
4. Snacking behavior
5. Dining out and family meals Children spend most of their time in
6. Screen time school. Therefore, schools play an
7. Sedentary behavior important role in influencing
8. Sleep duration
9. Environmental smoke exposure children’s food choices and physical
10. Psychosocial stress activity level and, ultimately, their
11. Adverse childhood experiences body weight. For example, the
D. Individual factors D.1. Genetic factors presence of fast foods, vending
a. Monogenetic syndromes and polygenetic
effects machines, and/or sweetened
b. Epigenetic effects beverages in schools may negatively
D.2. Prenatal risk influence children’s food choices.198
a. Parental obesity
b. Maternal weight gain Systematic reviews have shown an
c. Gestational diabetes
association between fast food
d. Maternal smoking
D.3. Postnatal risk outlets and convenience stores
a. Birth weight located near schools and obesity in
b. Early breastfeeding cessation and children.199,200 When analyzed by
formula feeding subgroups, a positive association has
c. Rapid weight gain during infancy and
been seen between fast-food outlets
early childhood
d. Early use of antibiotics and proximity to schools among
D.4. Childhood risk Hispanic, Black, and white children.
a. Endocrine disorders Although the association was seen
b. Children and youth with special health for all grade levels, the effect was
care needs
larger in younger grades.199 This
1. Children with autism spectrum disorder
2. Children with developmental and review also reported a stronger
physical disabilities association between fast-food
3. Children with myelomeningocele outlets and grocery stores located
c. Attention-deficit/hyperactivity disorder near schools and obesity in
d. Weight-promoting appetitive traits
e. Medication use (weight-promoting
socioeconomically underresourced
medications) neighborhoods.
f. Depression
B.2 Lack of Fresh Food Access
A neighborhood’s food environment
org/aaptoolkit). The Toolkit assists food security and improved overall has been shown to have mixed
pediatricians and other PHCPs to: association with children’s BMI.
health of children and their fami-
Although some studies have shown
(1) better identify children living in lies. The toolkit also includes the that a 1.6-km distance or shorter
households struggling with food
“Hunger Vital Sign,” a simple, vali- from a home to a supermarket is
insecurity; (2) sensitively address associated with a lower BMI,201
dated 2-question tool that can be
the topic; (3) connect patients and other studies have found that the
their families to federal nutrition used in the clinical setting to eval-
greater the number of supermarkets
programs and community resour- uate for food insecurity (see link to located near a child’s home, the
ces; and (4) advocate for greater toolkit above). higher the child’s BMI.202 Similarly,

by guest
a systematic review reported mixed association between access to fast- between prenatal exposure to
association, with some studies food restaurants and pediatric bisphenol A and polyfluoroalkyl and
showing a negative association obesity.208 A meta-analysis and recent childhood obesity.214,215
between supermarket accessibility systematic review showed a mixed
and childhood and adolescent association between access to fast- In the postnatal and infancy period
obesity, and other studies either food restaurants and weight-related exposure may occur through
showing a positive effect or no behaviors and weight status in breastfeeding, inhalation, ingestion,
association.203 children and adolescents.209 This or absorption through the skin.
association was shown to be stronger Children get exposed to chemicals
Some of the differences were in populations with lower SES.209 that are used in household products
attributed to variations in including cleaning agents, food
assessment measures and lack B.4. Access to Safe Physical Activity packaging, pesticides, fabrics,
of adjustment for confounding A child’s environment may influence upholstery, etc. Leaching of chemical
variables. Hence, it is not only the the amount of physical activity they products (eg, bisphenols, phthalates,
presence of supermarkets that is get. For example, living in an urban parabens, and other EDCs) has been
important, but also other factors that environment that lacks safe reported in baby feeding bottles,
may impact dietary choices—such as walkable and/or green spaces in clothing, diaper creams, etc.
the type of foods stocked, pricing, which children can play may result Exposure to EDCs during early
etc. Some, but not all, studies have in decreased physical activity levels. childhood can affect programming of
reported a positive association Greater exposure to green space has several systems, including endocrine
between neighborhood poverty and been shown to be associated with and metabolic systems, which may
childhood and adolescent obesity.204 higher levels of physical activity and affect BMI, cardiovascular, and
lower risk of obesity.210 metabolic outcomes later in life.213
It has been suggested that lack of
access to fresh fruits and vegetables C. Family and Home Environment
A recent systematic review of the
may be a risk factor for childhood Factors
literature on the influence of the built
and adolescent obesity, as it may environment and childhood obesity The family’s dietary preferences and
lead to an increased reliance on, found significant association between lifestyle habits have a crucial role in
and consumption of, unhealthy childhood obesity and traffic air influencing the child’s weight.216
foods. The data for this association pollution and indicators of walkability Parenting feeding practices and
have been inconsistent, however. A (which included intersection density modeling of eating behavior and the
recent systematic review showed and presence and amount of park type and quantities of foods and
that, although there was a negative area in the neighborhood).211 beverages in the home have been
association between access to fresh reported to be important influences
fruits and vegetables and healthy In addition to green spaces, other in children’s appetitive behaviors
eating behavior, the association aspects of the environment—including and food preferences.217
between access to fresh fruits and safety—are important in these spaces’
vegetables and overweight and use. A study of low-income preschool C.1. Parenting Feeding Styles
obesity was inconclusive.205 children in New York City reported an Parenting styles differ and may
association of lower obesity risk in have an impact on a child’s risk
B.3. Presence of Fast-food Restaurants neighborhoods with trees alongside for obesity. Four types of parent
Fast-food restaurants generally the streets and a positive association feeding styles have been described:
serve relatively low-priced and between obesity and higher homicide authoritative (responsive and
calorie-rich fast foods with high rates in the neighborhood.212 warm with high expectations);
levels of saturated fat, simple authoritarian (not responsive but
B.5. Environmental Health with high expectations); permissive
carbohydrates, sugar, and sodium.
Because of their easy availability, Exposure to environmental hazards or indulgent (responsive and warm
taste, and marketing strategies, fast during the prenatal period, infancy, but lenient with few rules); and
foods tend to be popular with and childhood can have impacts on negligent (not responsive with few
children and adolescents.206 the health and well-being of children. rules). The 4 parenting styles
Endocrine-disrupting chemicals discussed were initially defined by
Fast-food consumption has been (EDC) can cross the placental barrier Baumrind (1966) and later
associated with weight gain.207 Some, and affect the fetus.213 There are expanded by Maccoby and Martin
but not all, studies have shown an some data that show an association (1983).218,219 (Restrictive feeding

by guest
was not included as 1 of the routines and setting limits, C.6. Dining Out and Family Meals
parenting styles.) was inversely associated with Eating outside of the home has been
obesity.225 This relationship was shown to be associated with higher
Authoritative feeding, where parents present for younger and older energy intake in both children and
respond to the child’s cues of children. Most but not all of the adults.230,231 In the United States,
hunger and satiety, is considered to 32 studies included in the review food eaten outside the home is
be protective against excessive controlled for sociodemographic characterized by higher fat content,
weight gain. Children from factors. larger portions, and greater energy
authoritative parenting homes have
intake.230
been shown to eat more healthy C.3. Sugar-Sweetened Beverages
foods, be more physically active, and A systematic review of 20 In a systematic review of pediatric
have healthier BMI, compared with prospective cohort studies and and adult studies, eating at fast-food
children raised in homes with randomized controlled trials from establishments was associated with
authoritarian, permissive or 2013 to 2015 found that sugar- much higher weight gain, compared
indulgent, or negligent parenting sweetened beverages (SSBs) were with eating at other types of
styles.220,221 positively associated with obesity restaurants.231
in children in all but 1 study
One possible mechanism of (96%).226 Based on this review and Take-away food has also been
parenting style’s influence on a others demonstrating a link associated with high BMI.231 Hence,
child’s weight status is thought to be between SSB and multiple other eating outside of the home—
from interference in the child’s medical and dental diseases, the irrespective of the type of restaurant
ability to self-regulate their dietary AAP published a policy statement establishment visited—is associated
intake. An authoritarian parent, for on SSBs in 2019, calling for broad with higher risk of weight or BMI
example, may not respond to a implementation of policies gain. Conversely, 2 meta-analyses
child’s cues for energy intake, restricting SSB consumption in found that increased frequency of
resulting in poor ability on the part children and adolescents.227 eating family meals was associated
of the child to self-regulate their with lower risk of childhood
own energy intake, and a higher C.4. Portion Sizes obesity.232,233
likelihood of overindulging when Much of the research on the influence
presented with an opportunity to of portion size on children’s intake C.7. Screen Time
eat.222,223 has been performed in laboratory Some, but not all, studies report an
settings providing a single meal association between screen time
A large cross-sectional study to preschool-aged children. A duration, childhood adiposity,234–236
showed that, among preschool- and comprehensive review of this and adult BMI.237 Some studies have
school-aged children, authoritarian research reported that children who shown a dose-response effect of
or negligent parenting is associated serve or are served larger portions of screen time and childhood
with a higher risk of obesity,224 commonly liked energy-dense foods adiposity,235 with screen time
whereas authoritative parenting was typically consume larger amounts but greater than 2 hours per day being
associated with healthy BMI.221 cautioned that long-term studies of positively associated with higher
Among preschoolers, the effect of the effects of larger portions over risk of overweight or obesity.236 A
the parenting feeding style was time on a number of variables, recent meta-analysis reported 42%
found to be modulated by poverty, including body weight, are lacking.228 greater risk of overweight or obesity
with the effect only being seen with more than 2 hours per day of
among children who were not living C.5. Snacking Behavior
television (TV) compared with 2 or
in poverty.224 A recent systematic review of body fewer hours.238
fat and consumption of ultra-
C.2. Family Home Environment Organization There is evidence to support the
processed foods (defined as snacks,
A systematic review of associations fast foods, junk foods, and association between screen time and
between the organization of the convenience foods) in children and consumption of unhealthy diet and
family home environment and adolescents found a positive high energy intake.235 The
childhood obesity found that association but noted that longer- appearance or depiction of food
greater organization of the home term studies examining the items while engaging in screen time
environment, which included association of these foods and may affect a child’s dietary behavior.
practices such as having family obesity are needed.229 A systematic review examining food

by guest
choice and intake showed that food counterparts with longer sleep has been shown to be a risk factor
included in entertainment media duration (12.2 hours). in both pediatric and adult
affects eating behaviors of obesity.251 The association between
children.167 Children and Sleep restriction may be associated depression and obesity could be
adolescents are more exposed to with increased calorie reciprocal, as obesity may increase
food and beverage advertisements consumption.245,246 Additionally, depression risk.
when watching TV.239 Additionally, fatigue and decreased physical
increase in screen time may displace activity has also been associated C.12. Adverse Childhood Experiences
physical activity and interfere with with short sleep duration. It is A number of studies have
sleep.235,240 unclear whether the inverse documented an association between
association between sleep and ACEs and the development of
Although “screen time” includes TV, adiposity is causal or a overweight and obesity. ACEs
computer, video or videogames, consequence of hormonal or impact occurs via toxic stress, which
mobile phones, and other digital metabolic disturbance.247 Although occurs “when a child experiences
devices, the majority of the studies the exact mechanism for this strong, frequent, and/or prolonged
published examined the effect of TV association is unknown, some of the adversity—such as physical or
viewing.235 Male children and consequences of short sleep emotional abuse, chronic neglect,
adolescents tend to spend more duration include hormonal and caregiver substance abuse or mental
time on media screen devices and metabolic alterations—such as illness, exposure to violence, and/or
other Internet technology than increased ghrelin and decreased the accumulated burdens of family
female children and adolescents leptin—which may lead to economic hardship—without
do.236 increased hunger.242 adequate adult support.”252,253
C.8. Sedentary Behavior C.10. Environmental Smoke Exposure
ACEs include a history of physical,
The association between sedentary Children exposed to environmental emotional, or sexual abuse;
behavior and adiposity has been tobacco smoke (ETS) have been exposure to domestic violence;
shown to range from small to found to have higher BMI compared household dysfunction from
inconsistent.241 Studies examining with their nonexposed counterparts, parental divorce or substance abuse;
the effect of sedentary behavior according to a systematic review of economic insecurity; mental illness;
alone on weight using accelerometer ETS exposure and growth outcomes and/or loss of a parent because of
measures have shown no in children up to 8 years of age.248 death or incarceration.69,254–257
association between sedentary
behavior and obesity. Teasing out C.11. Psychosocial Stress A US study found that cumulative
the effects of sedentary behavior Psychosocial stress in the prenatal ACEs doubled the risk of children
alone in treatment studies may be period may have an effect on having overweight or obesity,
challenging, as this is often endocrine function (hypothalamic- compared with their counterparts
confounded with other behaviors pituitary-adrenal axis and with no history of ACEs.258
such as physical activity, screen glucose–insulin metabolism) in the Unresolved stress and emotional
time, or increased intake of child’s life course. A meta-analysis issues may result in maladaptive
unhealthy foods.241 showed that prenatal psychological coping strategies—such as binge
stress was associated with higher eating, eating in the absence of
C.9. Sleep Duration hunger, impulsive eating, and poor
risk of childhood and adolescent
Short sleep duration is associated obesity.249 sleep hygiene—which may result in
with higher risk of obesity in further weight gain.
children.242–244 A meta-analysis of Psychosocial and emotional issues
prospective cohort studies may lead to weight gain through Poverty and associated toxic
demonstrated a dose-response maladaptive coping mechanisms, stresses in utero and early
inverse association between sleep including eating in the absence of childhood have been suggested to
duration and risk of childhood hunger to suppress negative initiate neuroendocrine and/or
overweight and obesity.244 Children emotions, appetite up-regulation, metabolic adaptations that produce
13 years and younger with short low-grade inflammation, decrease in biological phenotypes and
sleep duration (10 hours) had a physical activity, increase in obesogenic behaviors that lead to
76% increased risk of overweight or sedentary behavior, and sleep obesity.259,260 These effects may
obesity compared with their disturbance.154,250,251 Depression persist throughout the lifetime.260

by guest
D. Individual-Level Influences or D.1.a and D.1.b. Monogenetic individual’s phenotype. The
Contributors to Obesity Syndromes and Polygenetic Effects phenotypic effect manifests only in
D.1. Genetic Factors Polygenetic causes of obesity are by the presence of, or in combination
far the most common, and single with, other predisposing factors.
Heritability studies suggest that gene defects are rarer causes of
there is a 40% to 70% genetic obesity. For example, MC4R, a Children with genetic causes of
contribution to an individual’s heterozygous mutation, is the most obesity may present with
obesity risk.261–263 Genome-wide common form of monogenic obesity characteristic clinical features that
association studies have identified and accounts for only 2% to 5% of have historically included findings
32 loci of significance to obesity severe obesity in children.265,266 such as short stature, dysmorphic
predisposition.264 Genetic causes of Polygenic inheritance refers to a features, developmental delay,
obesity include both common and single inherited phenotypic trait that skeletal defects, deafness, retinal
rare genetic variants that involve is controlled by 2 or more different changes, or intellectual disability.
impairment of gene expression or genes. Polygenic variants, on their It is important to note that more
function.264 own, have little effect on an recently discovered genetic
TABLE 2 Genetic Syndromes Associated With Obesity

Genetic Syndrome
Monogenetic disorders
MC4R deficiency Increased lean body mass, accelerated linear growth. Hyperinsulinemia. May have lower
blood pressure.
Leptin deficiency Normal linear growth with reduced adult height. Rapid-onset obesity with hypothalamic
dysfunction (hypogonadotropic hypogonadism, hypothyroidism). Alterations in immune
function. Responsive to leptin treatment.
Leptin receptor deficiency Normal linear growth with reduced adult height. Rapid-onset obesity with Hypothalamic
dysfunction (hypogonadotropic hypogonadism, hypothyroidism). Alterations in immune
function. Not responsive to leptin therapy.
POMC deficiency Accelerated childhood growth. Adrenocorticotropic hormone deficiency, mild hypothyroidism.
Red hair, light skin (in non-Hispanic white individuals).
Proprotein subtilisin or kexin type 1 deficiency Failure to thrive in early infancy. Hypoglycemia, adrenocorticotropic hormone deficiency.
Intestinal malabsorption, diarrhea.
SRC1 deficiency Impaired leptin-induced POMC expression.
Syndromic forms of obesity
Prader-Willi syndrome In neonatal period poor feeding, failure to thrive, and hypotonia. By 4–8 y, hyperphagia with
food impulsiveness. Short stature. Growth hormone deficiency, hypogonadism.
Dysmorphia, intellectual disability, behavioral difficulties.
Alstrom syndrome Short stature. Insulin resistance, T2DM, hypogonadism, hyperandrogenism in females,
hypothyroidism. Visual impairment, hearing loss, cardiomyopathy, hepatic dysfunction,
renal failure.
Bardet-Biedl syndrome Normal stature. Hypogonadism, polydactyly, retinal dystrophy, renal malformation, cognitive
disabilities, polyuria, and polydipsia.
Smith-Magenis syndrome Short stature. Disrupted melatonin signaling. Craniofacial anomalies, intellectual disability,
self-injurious behaviors, sleep disturbance.
SH2B1 deficiency Hyperinsulinemia, delayed speech and language development, aggressive behavior.
Sim1 deficiency Short stature. Hypopituitarism. Neonatal hypotonia, facial dysmorphism, developmental delay.
16p11.2 microdeletion syndrome Developmental delay, intellectual disability, autism spectrum disorder, impaired
communication, and socialization skills.
Brain derived neurotrophic factor deficiency Hyperphagia, impaired short-term memory, hyperactivity, learning disability. Patients with
Wilms tumor-aniridia (WAGR syndrome) have subset of deletions on chromosome
11p.12 including brain derived neurotrophic factor locus.
Albright’s hereditary osteodystrophy Short stature, round face, brachydactyly, subcutaneous ossifications. Some patients may
have mild developmental delay. If inherited from the mother, may be associated with
pseudohypoparathyroidism type 1a.
Cohen syndrome Hypotonia, intellectual disability, distinctive facial features with prominent upper central
teeth, broad nasal tip, smooth or shortened philtrum, thick hair and eyebrows, long
eyelashes, retinal dystrophy, acquired microcephaly, joint hyperextensibility.
Beckwith-Wiedemann syndrome Macrosomia, macroglossia, hemihyperplasia, anterior abdominal wall defects, visceromegaly,
neonatal hypoglycemia, embryonal tumors, renal anomalies. Genetic alteration in
chromosome 11p15.5.
Adapted from Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline.268

by guest
disorders associated with obesity D.2. Prenatal Risk Factors D.2.b. Maternal Weight Gain
are not necessarily characterized by Prepregnancy adiposity and weight
The perinatal environment plays an
these findings in childhood; for gain during pregnancy are
important role in a child’s later
instance, short stature is not a associated with neonatal, infancy,
development of overweight or
hallmark of leptin deficiency in and childhood adiposity.247 The
obesity. The mechanisms by which
children. Table 2 lists selected known effect of maternal weight on
the fetal environment predisposes to
monogenetic causes and syndromes the offspring led the Institute of
associated with obesity. the development of obesity are
Medicine (IOM) to recommend
complex and poorly understood. They different ranges for weight gain
Early onset of severe obesity and the probably include gene-environment during pregnancy, varying from 12.5
presence of hyperphagia are the 2 interactions or epigenetic changes to 18 kg for underweight women to
clinical characteristics that distinguish attributable to several environmental 5 to 9 kg for women with obesity
genetic disorders of obesity. “Early factors, including maternal diet, (BMI > 30 kg/m2).279 Yet, between
onset” refers to the presence of physical activity, and/or other 1997 and 2007, almost half of
obesity before age 5. As noted environmental contaminants.271,272 pregnant US individuals gained
previously, “severe obesity” is more than the weight recommended
defined as BMI $ 120% of the Preterm infants have a greater by the IOM.280
95th percentile for age and sex. likelihood of developing childhood
“Hyperphagia” is the presence of obesity.273–275 Although the exact Excess maternal adiposity has been
insatiable hunger in which the mechanisms for this association suggested to affect fetal metabolic
individual’s time to satiation is are uncertain, several risk factors programing and make the offspring
long, the individual’s duration of have been postulated, including more vulnerable to the obesogenic
satiation is shorter, the individual’s feeding patterns leading to environment and increase the
feelings of hunger are prolonged, accelerated weight gain in preterm risk of obesity. This effect was
and the individual has a severe infants.273 illustrated in metabolic and
preoccupation with food and bariatric surgery studies, in which
experiences distress if denied D.2.a. Parental Obesity children born to mothers with
food.267 Parental weight is a strong predictor obesity after gastric bypass
of pediatric obesity. Children are at surgery had lower prevalence of
D.1.c. Epigenetic Factors macrosomia and severe obesity at
greatest risk of developing obesity
Epigenetic factors can result in adolescence, compared with their
as an adult if at least 1 of their
alterations in gene expression
parents has obesity.276 A meta- siblings born before the mothers’
without alteration in genetic code.
analysis reported an increased risk surgery.247 Fetal or infant
These epigenetic factors may
of adolescent excess adiposity if macrosomia and gestational
modify the interaction of
either parent had overweight or diabetes are some of the
environmental and individual
obesity; the risk increased if both complications associated with
factors in promoting weight
parents had obesity.277 Contributors maternal obesity and serve as risk
gain.269 One of the critical periods
to this association include genetic, factors for later onset of obesity
in the establishment of the
environmental, and behavioral and T2DM in the offspring.281
epigenome is considered to be
during embryonic development.270 factors or the interaction of these
The exact mechanism by which
Prepregnancy maternal or factors, resulting in intergenerational
maternal obesity predisposes to
paternal obesity, for example, may transmission of adiposity. adverse outcomes in the offspring is
influence epigenetic changes unclear. It has been suggested that
during subsequent pregnancy, Maternal BMI is a stronger predictor
the pathways that are affected
increasing the risk of overweight of childhood and adolescent obesity,
control the central regulation of
or obesity in the offspring.269 compared with paternal obesity.247 appetite and insulin sensitivity and
Other risk factors during Maternal obesity more than doubles cardiovascular regulation.281
pregnancy—such as gestational the risk of adult obesity (see below). Alteration of the fetal hypothalamic-
diabetes or maternal excessive Paternal obesity has been associated pituitary-adrenal axis function has
weight gain—may result in with childhood and adolescent been implicated in programming the
epigenetic changes and increase obesity and has an additive effect to metabolic syndrome of the offspring
the risk of obesity in the offspring. maternal obesity.278 of mothers with obesity.282

by guest
D.2.c. Gestational Diabetes D.2.d. Maternal Smoking prepregnancy increasing the risk of
Infants and children of mothers Exposure to ETS has been shown to preterm birth and small-for-
with gestational diabetes mellitus increase the prevalence of childhood gestational-age neonates.300
(GDM) have higher fat mass and and adolescent obesity.292–294 A Maternal pregnancy overweight and
BMI than their counterparts whose systematic review and meta-analysis obesity are significantly associated
mothers did not have GDM.283 reported an association between with large-for-gestational-age
Adjusting for maternal BMI and prenatal ETS and childhood and babies.300
adolescent obesity; children exposed
other potential confounders, GDM
to ETS in utero had about 1.9 times D.3.b. Early Breastfeeding Cessation
was shown to be associated with
greater risk of developing obesity, and Formula Feeding
childhood obesity with odds ratio
compared with their nonexposed Some, but not all, studies have
of 1.6 to 2.8.284,285 The odds counterparts.295 Prenatal exposure to reported decreased risk of
of developing higher waist the risk from tobacco smoke can childhood and adolescent obesity in
circumference ($95th and occur both directly from smoking breastfed infants.247 The majority of
percentile) in children of mothers mothers and indirectly through ETS, evidence is derived from
with GDM was also found to be although maternal smoking was found observational studies and may
higher after controlling for potential to more strongly predict obesity. include confounding effects.247 Some
confounders (OR, 1.55; 95% CI, studies have reported that,
1.03–2.35).285 Sibling studies Children exposed to smoking in compared with bottle-fed infants,
controlling for shared genetics and utero have a dose-dependent breastfed infants are better able to
environment have shown higher increased risk of developing regulate their energy intake and
overweight and obesity.296 have lower risk of childhood excess
BMIs in offspring exposed to
diabetes in utero compared with weight gain.301 Other studies have
D.3. Postnatal Risk Factors
their unexposed siblings.286 also shown that body weight gain is
As with the prenatal environment, slower in breastfed infants.247
Although the exact mechanisms of the postnatal environment is
important to the later development Breastfeeding has been found to be
the effect of GDM are not fully
of overweight and obesity. In inversely associated with
understood, it has been postulated
addition to epigenetic mechanisms, overweight risk in the first year of
that the effect may be mediated
behavioral habits begin to get set at life, independent of maternal BMI
through insulin. Pregnant women
an early age. Acceptance of foods, and SES. Breastfeeding cessation
with GDM have higher insulin availability of high calorie foods, before 6 months was associated
resistance compared with pregnant establishment of the microbiome, with an increased risk of rapid
women without GDM.287,288 It has and early eating habits are only a weight gain and overweight by 12
been suggested that maternal insulin few of the proposed mechanisms for months of age, compared with
resistance and hyperglycemia causes postnatal factors to influence later exclusive breastfeeding.302
fetal hyperinsulinemia, resulting in weight status.297
excessive fetal growth with A systematic review of feeding
associated macrosomia and D.3.a. Birth Weight practices associated with rapid
increased adiposity.287 Maternal Several studies have shown a infant weight gain found that certain
hypertriglyceridemia from insulin U-shaped or J-shaped distribution practices (such as overfeeding,
between birth weight and adult inappropriately concentrating
resistance has also been thought to
lead to increased adiposity and birth BMI.247 Infants with both low formula, placing infants in bed with
(<2500 g) and high (>4000 g) birth a bottle, or adding cereal to a bottle)
size even when glucose levels are
weight have been shown to have may lead to rapid infant weight
well-controlled.289 Additionally,
higher risk of obesity, compared gain.303 In addition, infants fed high-
maternal diabetes is associated with protein formulas are at greater risk
with infants with birth weight
increased leptin synthesis in the
between 2500 and 4000 g.298 A high of elevated BMI later in
offspring.290 Epigenetic changes in BMI and central adiposity are more childhood.247,304
infants of mothers with GDM is prevalent among low-birth weight
another suggested mechanism, infants.299 Maternal prepregnancy D.3.c. Rapid Weight Gain During
affecting gene expression regulation weight and nutritional status are Infancy and Early Childhood
body fat accumulation or other strong predictors of neonatal In resource-abundant countries,
related metabolic pathways.291 outcomes, with underweight rapid weight gain in infancy and

by guest
during the first 2 years of life is development and progression of Furthermore, it is important to
associated with higher risk of overweight and obesity. Similarly, consider that children with
obesity both in later childhood and certain behaviors established in disabilities are at a disadvantage
in adulthood.247,305 A systematic childhood and adolescence can when it comes to obesity treatment
review and meta-analysis found that increase the risk of later strategies that are tailored to their
children who experienced rapid development of overweight and needs. For example, most
weight gain from birth to age 2 obesity. community or school weight
were up to 3.6 times more likely to management, nutrition or physical
have overweight or obesity in D.4.a. Endocrine Disorders activity interventions are not readily
childhood or adulthood, with the Endocrine disorders account for less adapted for children with
relationship being stronger between than 1% of all the causes of disabilities. Therefore, many
rapid infant weight gain and pediatric obesity. These disorders children with disabilities do not
childhood overweight or obesity.306 can be associated with endogenous have the support or strategies that
or exogenous glucocorticoid excess they need to address excess weight.
Therefore, rapid weight gain in Finally, children may face bullying
(eg, Cushing syndrome, use of
infancy and early childhood can be or stigmatization and bias in school.
viewed both as a risk factor for later corticosteroid medications). Short
They may also receive unhealthy
excess weight gain and also as a stature or growth failure and
incentives as rewards from
signal, as mentioned previously, for abnormally high BMI may result caregivers increasing their risk for
pediatricians and other PHCPs to from pseudohypoparathyroidism obesity. These systemic trends and
look for other underlying risk type 1a, growth hormone deficiency, biases make providing adequate
factors and causes for excess weight or hypothyroidism.268,315 care for children with disabilities
gain. For instance, early introduction extremely difficult.
(at younger than 4 months of age) D.4.b. Children and Youth With
of complementary foods has been Special Health Care Needs Impacting D.4.b.2 Children With Autism Spectrum
found to increase the risk of Nutrition and Physical Activity Disorder
childhood obesity in several Children and youth with autism
systematic reviews.307,308 D.4.b.1 Children With Developmental spectrum disorder (ASD) have a
and Physical Disabilities higher risk of developing overweight
D.3.d. Early Use of Antibiotics A survey of data from NHANES, the or obesity. In the United States,
Literature on antibiotic exposure in National Health Interview Survey, children and adolescents 2 to
early life (<2 years) is mixed, with and the National Survey of 18 years of age with ASD have a
some suggestion that it may slightly Children’s Health found that 43.7% greater risk of obesity
increase the risk of childhood and children with disabilities were from compared with their counterparts
adolescent obesity.309–312 The without ASD.325 Although the exact
27% to 59% more at risk for obesity
association is stronger with
than children without disabilities.316 mechanisms through which ASD
repeated antibiotic exposure,313,314 increases the risk for excess weight
exposure within the first 6 months In addition to factors experienced by gain is unknown, a recent meta-
of infancy,314 and broad-spectrum children without disabilities, factors analysis of international studies
antibiotic use.310 With similar that affect children with disabilities showed that positive moderators to
antibiotic exposure, boys appear to this association include children of
that have been implicated in their
be more susceptible to weight gain certain races and ethnicities, female
greater obesity risk are: more
than girls.295 Gut microbiota is biological sex, increased age, and
difficulty breastfeeding,317 disrupted
usually established during the first living in the United States.325 This
appetite regulation,318 weight-gain
years of life; it is hypothesized that meta-analysis did not control for
the effect of antibiotics is mediated promoting medications,319,320 food
other risk factors for obesity,
through the alteration of the gut selectivity and sensitivity issues,321
however, such as use of antipsychotic
microbiome, which plays a role in behavioral disorders,322 physical
medications, food intake challenges,
energy balance. activity limitations,323 and use of
or limited physical activity. Hence,
food rewards.316 A lack of adaptive the variable of race could be
D.4. Childhood Risk Factors physical education or sports,324 and reflective of a negative SDoH.
Various medical conditions that specialized supervision and
present in childhood and instruction324 also play a role in Several etiological factors have been
adolescence are associated with the increasing obesity risk. postulated to contribute to the

by guest
association between ASD and analysis, because the studies were Systematic review and meta-analysis
obesity, including: genetic variants cross-sectional; however, some of adult data showed a positive
(eg, 16p11.2 deletion and prospective studies have shown that association between eating quickly
microdeletion 11p14.1),326,327 ADHD precedes the diagnosis of and higher BMI,349 and in
prenatal exposure to certain obesity.346,347 longitudinal studies, faster eating
infections or medications,328,329 rate was associated with excess
pre and postnatal exposure to Some of the known symptoms of weight gain.349 Similarly, 2 cross-
toxins,330,331 maternal diabetes,332 ADHD may contribute to weight
sectional pediatric studies have
maternal obesity,333 intrauterine gain. For example, binge eating,
reported a positive association
growth restriction and preterm which is a manifestation of
between eating fast and childhood
birth,334,335 food selectivity,336,337 impulsivity in individuals with
and adolescent obesity.350,351 Eating
and physical limitations.338,339 ADHD, may result in increased
quickly has been suggested to result
energy intake. Inattentiveness,
D.4.b.3 Children With Myelomeningocele in greater energy intake.
another symptom of ADHD, may
Several studies report increased lead to lack of planning, or of A recent American Heart Association
rates of obesity of children with following through on a plan, policy statement on caregiver
myelomeningocele,340–342 with resulting in missed meals or the
children having more severe disease influences on young children’s
consumption of unhealthy meals and
tending to have higher BMIs.340 eating behaviors synthesized
snacks.348 Other psychiatric
Children and adolescents with appetitive traits consistently
comorbidities that are often
myelomeningocele have increased associated with child adiposity. In
associated with ADHD—such as
total body fat343 and lower energy depression, anxiety, and circadian
addition to more rapid eating pace,
expenditure,342 compared with these traits include eating in the
rhythm disturbances—may also be
children without myelomeningocele. absence of hunger, high enjoyment of
risk factors for obesity.348
Risk factors for obesity in this food, low responsiveness to satiety,
population include limited ambulation, Dopamine plays an important role in and low level of restrained eating.352
sedentary lifestyle, decreased lean some of the addictive behaviors of
body mass, and reduced resting ADHD and obesity. Functional MRI D.4.e. Medication Use
energy expenditure.344 In addition, studies have identified shared Medications within many categories
children with myelomeningocele may have been associated with weight
neuropsychiatric circuits that are
be less likely to have routine weight gain. The magnitude of risk associated
associated with reward, response
and height, and primary care with medication use is not fully
inhibition, and emotional regulation
providers’ discussions may be lacking
in obesity, ADHD, and abnormal known; therefore, there is an urgent
with respect to addressing healthy
eating behavior.348 need for more research in this area
lifestyles.
as well as mediating strategies.
D.4.d. Weight-Promoting Appetitive Medications implicated include
D.4.c. Attention-Deficit/Hyperactivity
Traits glucocorticoids, sulfonylureas, insulin,
Disorder
Differences in children’s appetitive thiazolidinediones, antipsychotics,
A systematic review and meta-
traits manifest as early as infancy tricyclic antidepressants, and
analysis showed significant
association between attention- (for example, suckling behavior) and antiepileptic drugs.353–356 In particular,
deficit/hyperactivity disorder may become more pronounced second-generation antipsychotics
(ADHD) and obesity among when children get exposed to an (ie, risperidone, clozapine, quetiapine,
unmedicated individuals with obesogenic food environment.217 and aripiprazole) can lead to rapid
ADHD—but not among medicated Although the exact reasons why weight gain and comorbidities such as
individuals.345 The prevalence of some children have better control of prediabetes, diabetes, and
obesity was found to be 40% higher their energy intake is unknown, dyslipidemia.357,358
among children and adolescents interaction between genetic
with ADHD, compared with those predisposition and children’s early A recent review discusses the more
without ADHD. This association is environment may explain some of commonly prescribed medications in
not affected by gender or by study the individual differences in children and adolescents with
setting, country, or quality. Causality appetitive traits. Parent feeding obesity and comorbidities, and
between ADHD and obesity could style, as discussed, has been shown offers suggestions on alternative
not be inferred from this meta- to be of importance.217 therapeutic agents (Table 3).359

by guest
TABLE 3 Selected Examples of Commonly Prescribed Medications and Weight Gain in Pediatric reported data on anthropometry;
Practice359 assessment of symptoms based on
Medication Obesogenic Medications Nonobesogenic Medications self-administered questionnaires;
and not controlling for potential
Allergies and asthma management antihistamines inhaled nasal steroids
steroids (systemic) montelukast confounders, such as family
Antidepressants amitriptyline bupropion history, neuropsychiatric disorders,
nortriptyline imipramine HCL and SES. A more recent study
paroxetine buspirone showed that obesity was a risk
sertraline trimipramine maleate
factor for anxiety and depression
citalopram
protriptyline HCL among children and adolescent
desipramine HCL after adjusting for SES,
trazadone neuropsychiatric disorders, and
venlafaxine family history of anxiety or
doxepin
depression.362
escitalopram
fluoxetine
fluvoxamine The association between obesity and
Antiepileptics carbamazepine felbamate depression and anxiety may be
gabapentin lamotrigine attributable to interactions and shared
pregabalin levetiracetam pathophysiological mechanisms
valproate phenytoin
vigabatrin topiramate
between these conditions.363,364 Some
zonisamide of the shared risk factors include
Antipsychotics aripiprazole molindone genetic, physiologic, and
clozapine pimozide environmental factors. Obesity is
haloperidol associated with subclinical
mirtazapine
olanzapine
inflammation and oxidative stress,
perphenazine which have been shown to be
quetiapine important etiological factors for
risperidone depression, and this has been
sertindole suggested as possible common link
thioridazine
ziprasidone
between obesity and depression.363
Anxiolytics not applicable alprazolam Other factors that can potentially
lorazepam impact the association between
Migraine management amitriptyline lamotrigine obesity and anxiety and depression
atenolol levetiracetam include sleep disturbance, unhealthy
divalproex sodium protriptyline
flunarizine timolol
diet, physical activity, antior bullying of
gabapentin topiramate children/or bullying of children.
imipramin zonisamide
nortriptyline IX. EVALUATION OF THE PEDIATRIC
pizotifen
PATIENT WITH OVERWEIGHT OR
propranolol
Mood stabilizers and antimania carbamazepine lamotrigine
OBESITY
gabapentin topiramate
lithium zonisamide
A. Evaluation of Patients With
valproate Overweight or Obesity
Psychostimulants not applicable amphetamine This evaluation is an important part
methylphenidate
of COT (see COT section in the
dextroamphetamine sulfate
Treatment section). As with all
This is not an exhaustive list; it is included as an example of medications that may result in weight gain and possi-
ble alternatives. chronic diseases, a complete history,
review of systems (RoS), and
physical examination are important
D.4.f. Depression factor for these symptoms.360,361 for treatment. Specific elements of
Children with obesity are more Some earlier research reported both history and physical relating to
likely to have anxiety and bidirectional associations between obesity are of special importance.
depressive symptoms compared obesity and depression and anxiety. Evaluation of the patient and
with their peers of healthy weight. It Limitations of some of the studies family’s readiness to change
is not clear whether obesity is a risk included small samples; self- behavior is critical to effectively

by guest
KAS 2. Pediatricians and other PHCPs should evaluate children 2 to 18 y of age with overweight (BMI $ 85th percentile to <95th percentile) and obesity (BMI $ 95th percentile) for obesity-
related comorbidities by using a comprehensive patient history, mental and behavioral health screening, SDoH evaluation, physical examination, and diagnostic studies.

Benefits Early detection and treatment can reduce future serious sequelae, detection of comorbidity may motivate
treatment engagement.
Risks, harm, costs Increased anxiety, overtesting, time needed for counseling, potential false-negative or false-positive tests, costs
of tests.
Benefit-harm assessment Potential to identify and manage comorbidities that have short and long term serious sequelae exceeds
potential harm especially for high-risk patients.
Intentional vagueness Frequency of evaluation, patient level of risk.
Role of patient preferences Family history, families’ concern about the test, ease and accessibility for testing must be considered.
Exclusions #24 mo old.
Strengths Strong recommendation.
Key references 80, 365
help with obesity treatment (see adolescent with overweight and and nonbiased behavior include
algorithm in Appendix 1). obesity, but this can occur during recognition of the complex genetic
problem-focused visits as well. When and environmental influences on
The early and accurate classification the discussion of weight status is obesity. Recommendations include
of overweight and obesity and normalized and nonstigmatizing, the use of neutral words like “BMI” or
identification of obesity-related family and provider can exit a WCC “excess weight” rather than “fat” or
comorbidities is fundamental to the or other visit with a clear and “chubby,” use of people-first
provision of timely and appropriate practical plan to improve health and language (ie, “a child with high
treatment (see the Comorbidities quality of life. Successfully and weight” or “a child with obesity”
section, below). The routine sensitively treating overweight and rather than “an overweight child” or
classification of weight status allows obesity can be highly rewarding for “an obese child”), an office set-up
for early recognition of abnormal both the family and the pediatrician that accommodates different body
weight gain. This is particularly (or other pediatric health care sizes, and a private weighing
important because patients—including provider), because families suffering station.28 Ongoing successful
children and adolescents—often do from overweight and obesity often communication of support and
not perceive overweight and obesity have experienced previous shaming empathy during obesity treatment is
as a health problem.366 Caregivers, or negative experiences with essential to reduce the effect of
families, pediatricians, other pediatric treatment.28,371 weight bias, because families will
health care providers, and other not continue to seek help if they
health care providers367 can also be Shaming of children with regard to experience stigma.372,373
slow to recognize abnormal weight their weight may happen at school
and even at home in misguided B. Medical History
status, even in the presence of severe
obesity.368,369 efforts to “motivate” the child to Both a complete medical history and
adopt healthier behavior. Overt or physical examination are necessary
Patients and caregivers identify subtle and unintended bias in to evaluate any patient with a
pediatricians and other PHCPs as health care leads to adverse health, chronic disease. Obesity is no
trusted and preferred sources of behavioral, and psychological exception and, like other chronic
information about weight status,370 outcomes.61 In addition, when diseases, requires comprehensive
starting with discussions of feeding feeding practices are identified as evaluation in certain areas of both
practice in infancy and continuing unhealthy, parents may feel the history and physical
with evaluation of healthy nutrition blame. It is important, although examination, which may require
and activity into adulthood. challenging, for pediatricians and additional time to that which is
Pediatricians and other PHCPs are other PHCPs to communicate allocated in a routine visit. The
also uniquely qualified to evaluate support and alliance with children, medical history includes the chief
patients for overweight, obesity, and adolescents, and parents as they complaint, history of the present
related comorbidities. diagnose and guide obesity illness, and family history.
treatment.62
Routine well-child checks (WCCs) in The chief complaint is notable for
the medical home are an opportune In the AAP statement on obesity determining whether overweight
time for the evaluation of a child or bias, steps to provide supportive and obesity is a concern for the

by guest
patient and family. An open- obesity. These prenatal and post- related comorbidities may
ended question such as “What natal causes are described in de- influence both evaluation and
concerns, if any, do you have tail in the Risk Factors section. treatment. Although shared
about your child’s growth and Information about the onset of environment, SDoHs, and stress
health?” can provide a wealth of excess weight gain and consis- can contribute to obesity within
insight on this issue. tency of weight status over time the same family, a family history
The history of the present illness (including a review of the growth of obesity can also provide a clue
provides a more comprehensive curve and previous weight con- to genetic susceptibility to
picture of the trajectory of trol attempts) can provide an un- obesity—especially if the family
overweight and obesity. Starting derstanding of what weight history includes severe obesity
with an inquiry about maternal status represents for the patient. resulting in metabolic and bariatric
weight gain during pregnancy It can also offer clues as to root surgery or severe obesity present
and prenatal factors that predis- causes, necessary diagnostic eval- in multiple family members and
pose to obesity, and then moving uation, and potential therapeutic generations.
on to childhood and later adoles- targets. The medication history should
cent factors that predispose to The family history focuses on be complete and should include
obesity, the pediatrician or other obesity-related comorbidities and medications associated with weight
pediatric health care provider potential genetic causes of gain, such as antipsychotics, espe-
can glean valuable information obesity in addition to other cially atypical antipsychotics; anti-
on causes and therefore manage- family health problems. A family depressants including selective
ment for a particular patient’s history of obesity and obesity- serotonin reuptake inhibitors;
TABLE 4 Special Considerations in the Review of Systems for the Patient With Overweight or Obesity
System Symptom Possible Obesity-Related Causes
General Poor or slowed linear growth velocity Endocrinologic contributor (eg, hypothyroidism, Cushing
syndrome)
Hyperphagia from early childhood, developmental delay, Various genetic etiologies (see Table 2, genetic syndromes
obesity onset under age 5 y, or syndromic features associated with obesity)
Respiratory Shortness of breath Obesity-related asthma phenotype, deconditioning
Snoring, apnea, disordered sleep Obstructive sleep apnea (OSA)
Gastrointestinal Asymptomatic vague abdominal pain NAFLD, NASH
Heartburn, dysphagia, chest pain, regurgitation Gastroesophageal reflux disease
Abdominal pain, enuresis, encopresis, anorexia Constipation
Right upper quadrant pain Gall bladder disease
Hyperphagia Prader-Willi, other genetic causes
Endocrine Polyuria, polydipsia Diabetes mellitus (DM) type 1 or 2
GYN Oligomenorrhea, dysfunctional uterine bleeding Polycystic ovarian syndrome
Orthopedic Hip, thigh, or groin pain, painful or uneven gait Slipped capital femoral epiphysis (SCFE)
Knee pain SCFE, Blount disease
Foot pain Increased weight bearing
Back pain Increased weight
Proximal muscle wasting Cushing syndrome
Mental health Sadness, depression, anhedonia, body dissatisfaction, Depression or anxiety, bullying, sexual, physical, or
school avoidance, poor self-image emotional abuse
Impulsive eating, distractibility, hyperactivity ADHD
Purging, restricting intake, binge-eating, night eating Disordered eating or eating disorders
Flat affect Depression or anxiety
Urinary Nocturia, enuresis DM, OSA
Dermatologic Rash Intertrigo
Darkened skin on flexural surfaces Acanthosis nigricans
Pustules, abscesses Hidradenitis suppurativa
Hirsutism in females PCOS
Flesh-colored striae Rapid weight gain
Purplish striae Cushing syndrome
Skin fold irritation Candida
Neurologic Morning headaches OSA
Daytime sleepiness OSA
Persistent headache Idiopathic intracranial hypertension (IIH)
Adapted from Krebs et al.14

by guest
steroids; anticonvulsants; antihy- into, patients who are most exposed B.2. Nutrition and Physical Activity
pertensives; birth control agents, to negative SDoHs. Given that History
including injected forms; and medi- inequities exist in obesity risk Gathering a nutrition history and
cations used in diabetes mellitus. factors, an SDoH evaluation is physical activity history often takes
important to increase awareness the form of a patient and/or
Table 4 summarizes the RoS and and provide insight in identifying caregiver completing a healthy
provides a valuable framework for
patients who are more vulnerable to habits survey before seeing the
investigating a variety of obesity-
obesity. Assessment of SDoHs is also pediatrician or other pediatric
related conditions.
important to contextualize the health care provider (Table 5).
B.1. Social History patient’s and family’s treatment Electronic health records, waiting
challenges. Standardized tools for room kiosks, and emailed previsit
A thorough social history is helpful
use in primary care exist and surveys can all be used to help
in the evaluation of the child or
include the Safe Environment for gather this information.
adolescent with overweight and
obesity. An understanding of family Every Kid model375 and the
Accountable Health Communities There are many additional tools to
living arrangement will identify
Health-Related Social Needs assess nutrition and physical activity.
resources and barriers that are
Screening Tool.376 These include: 24-hour recalls,
unique to the patient and their
electronic and written food diaries,
family. Factors such as eating
Being alert to and recognizing telephone- and text-prompted diaries,
routines and schedules; eating at
SDoHs are the initial steps in and various smartphone applications
multiple households; and eating
trauma-informed care (TIC). ACEs that track food intake. Pedometers and
environments, such as family meals,
can have a profound impact on other wearable activity monitors can
eating at a table, eating with or
without screens, are all important health over a lifetime and, as noted, assist with physical activity
elements in assessing contributors include stressors as diverse as harsh assessment. Pediatricians and other
to and potential treatment targets parenting, food insecurity, and PHCPs may find some of these
for excess weight gain. Determining parental incarceration. These factors applications and tools at their disposal.
a family’s relationship with food is can trigger physiologic
Cultural dietary habits, limited
also important (eg, Is food a abnormalities that increase a
English proficiency, and limited
common reward? How is food used patient’s risk for obesity, cancer, and
in celebrations? Is there pressure literacy levels may influence the
numerous other diseases. TIC is accuracy of the tool used. In
for the child to eat?). characterized by screening and comparison with adults, physical
recognition of these ACEs, activity assessment is challenging,
Because overweight and obesity
tends to cluster in social groups as responding to them, and working to because children and adolescents
well as families,374 discussions of prevent reexposure to trauma. are less reliable in performing recall
neighborhood, school, and friend Initial recognition of the importance of performed activity.379 And,
groups can guide pediatricians, of ACEs on health occurred in the because of the greater burden of
other PHCPs, and families to field of adult obesity treatment. The overweight and obesity on people of
productive areas for treatment. importance of TIC and addressing certain race and ethnicities, these
Social history can heighten an ACEs in pediatric obesity differences should be acknowledged
awareness of, and provide insight management is ongoing.68,377,378 and any limitations should be
TABLE 5 Assessment Components

Dietary Intake Can Be Addressed by Assessing the Following: Physical Activity Can Be Addressed by Assessing Physical Literacy379:
Eating outside the home Physical literacy: The motivation, confidence, physical competence, knowledge, and
understanding to engage in age-appropriate physical activity for a lifetime. Routine
ambient activity is built into daily living.
Consumption of sweet drinks Sedentary time, especially recreational screen time.
Portion size Moderate activity levels, characterized by a mild increase in pulse and respiratory
rate but still able to talk.
Meal habits, including skipping meals Vigorous activity levels, characterized by increased breathing, elevated heart rate, or
Snack habits sweating.
Fruit and vegetable consumption

by guest
mitigated. An example of a healthy Anxiety Related Disorders Adolescents with Obesity: An
habit survey can be found at https:// assessment.383,384 In addition, ADHD Evidence-Based Review,” by
mainehealth.org/-/media/lets-go/ can be assessed by the Vanderbilt Armstrong et al provides a
files/childrens-program/ ADHD Rating Scales.385,386 thorough explanation of special
pediatric-family-practices/ considerations for patients with or
full-healthcare-toolkit.pdf. Sensitivity As discussed in the AAP clinical at-risk for weight-related illness.365
to cultural, economic, and literacy reports, “Preventing Obesity and Pediatricians and other PHCPs are
barriers is necessary with the Eating Disorders in Adolescents”387 encouraged to reference this AAP-
nutrition history and physical activity and “Identification and published review. The physical
history, as with other assessments. Management of Eating Disorders in exam also requires focused
Furthermore, the presence of eating Children and Adolescents,”388 attention to certain obesity-related
disorders, obsessive-compulsive adolescents with obesity may findings related to physical
disorder, and other mental health engage in unhealthy practices to evaluation (Table 6). These include:
conditions may preclude the use of lose weight. These practices include
certain tools that require intensive skipping meals, using diet pills or Vital signs such as heart rate,
tracking. laxatives, and inducing vomiting. pulse, and blood pressure should
Therefore, it is important for be taken; blood pressure should
B.3. Assessments for Behavioral Health pediatricians and other PHCPs to be measured accurately with an
and Disordered Eating Concerns evaluate the adolescent with appropriately sized cuff.87
Because rates of behavioral health overweight or obesity for these and Other important signs: short
illnesses are greater in patients with other related behaviors, and to stature may be a sign of a genetic
obesity than other patients, it is examine the growth chart for or endocrinologic cause for
important for pediatricians and evidence of more rapid than overweight and obesity. Flat affect
other PHCPs to evaluate the expected decline in BMI. may indicate depression, and
emotional health of children with anxious mood may indicate
As noted in the clinical reports anxiety. Attention-seeking may
overweight and obesity.380 A
above, pediatricians “should be be a signal for underlying
common comorbidity of obesity in
knowledgeable about the variety of distress over overweight and
children is weight-based bullying
and teasing.28,43 If a patient risk factors and early signs and obesity. Syndromic features may
responds affirmatively when asked symptoms of eating disorders in also offer indications of the
if they have ever been teased or both male and female children and presence of an underlying genetic
bullied about their weight, adolescents. Pediatricians should cause for obesity.
pediatricians and other PHCPs can evaluate patients for disordered Skin examination should be
consider provision of resources eating and unhealthy weight-control performed to look for intertrigo
(such as those found at behaviors at annual health and hidradenitis suppurativa
stopbullying.gov) to the child and supervision visits. Pediatricians associated with excess skin folds
parent as well as local counseling should evaluate weight, height, and as well as acanthosis nigricans
referral. BMI by using age- and sex- associated with insulin resistance.
appropriate charts, assess menstrual Flesh-colored striae may be
Various in-office tools can be used status in girls, and recognize the seen on the abdominal wall
to address behavioral health changes in vital signs that may and/or thighs as an indication
disorders seen in greater prevalence signal the presence of an eating of rapid weight gain. The
in patients with obesity. Overall disorder.”388 For more information combination of purplish
behavioral functioning can be on this evaluation, please see the abdominal striae, slowed linear
assessed through the Pediatric AAP clinical report.388 growth, cervicodorsal fat
Symptom Checklist’s parent or teen accumulation, proximal muscle
versions.381 Evaluation for B.3.a. Physical Evaluation wasting, full facies, and hyperten-
depression can be conducted A complete physical examination is sion should prompt evaluation
through the teen version of the necessary in the patient with for Cushing syndrome.
Patient Health Questionnaire 2- or overweight and obesity because of Examination of the head, ears, eyes,
9- question version.382 Assessment the disease’s complex and nose, and throat should occur to
of anxiety by tests such as the multisystem effects. The 2015 look for papilledema associated
General Anxiety Disorder article “Physical Examination with pseudotumor cerebri, tonsillar
assessment or the Screen for Child Findings Among Children and hypertrophy associated with sleep

by guest
TABLE 6 Physical Examination Findings in Children and Adolescents With Obesity
Physical Examination Finding Definition Other Causes and Differential
Vital signs Hypertension SBP or DBP $ 95th percentile on at Numerous, including essential, stress-
least 3 readings induced, renal parenchymal or
vascular disease, cardiovascular
disorders, obstructive sleep apnea
syndrome, substance abuse or
medication side effect,
pheochromocytoma, anemia,
hyperthyroidism, Cushing
syndrome, Williams syndrome,
Turner syndrome
Increased HR Heart rate above upper limit of Numerous, including fever, anemia,
normal for age drugs, anxiety, pain, arrhythmia,
myocarditis, substrate deficiency,
hypovolemic shock, sepsis,
anaphylaxis, toxic exposure,
hyperthyroidism, Kawasaki disease,
acute rheumatic fever,
pheochromocytoma
Anthropometric Changes in height velocity Early height velocity increase True pattern characteristic of obesity,
but early height increases can also
be: familial tall stature, precocious
puberty, gigantism, pituitary gland
tumor
Changes in weight gain Early weight gain before age 5 y Genetic causes, overfeeding
Earlier onset of peak height velocity Slowing of height can be attributable
to medications, inflammatory
bowel disease, hypothyroidism,
hypercortisolism, dysplastic or
genetic syndrome, constitutional
delay, growth hormone deficiency
Slowing of height age 8–18 y
HEENT Papilledema Edema of the optic disc secondary to Intracranial mass lesion,
increased intracranial pressure hydrocephalus, cerebral venous
(Frisen scale) thrombosis, medications,
autoimmune disorders, anemia,
and cranial venous outflow
abnormalities
Dental caries White, brown, or black spots Developmental disease of the tooth
(noncavitary) or eroded areas of and gum, trauma, infection
enamel or dentin (cavitary)
Tonsillar hypertrophy Tonsils occupy at least 50% of the Infectious causes
oropharynx (Brodsky classification
31 and 41).
Chest Gynecomastia >2 cm of breast tissue in biological Hyperaromatase syndrome;
males hypogonadism, hyperprolactinemia,
chronic liver disease, and
medications, particularly H2
antagonists
Cervicodorsal hump Fibrous fatty tissue over the upper Endogenous (Cushing syndrome) or
back and lower neck exogenous corticosteroid exposure,
adrenal carcinoma, adrenal
adenoma; HIV with secondary
hyperinsulinemia
Gastrointestinal Liver enlargement (hepatomegaly) Liver span >5 cm in 5-y-olds and 15 Multiple, including hepatitis, storage
cm in adults or liver edge disorders, infiltrative, impaired
palpable below the right costal outflow, and biliary tract disorders
margin by >3.5 cm in adults or
>2 cm in children
Genitourinary Buried penis Suprapubic fat accumulation leading Trapped penis, webbed penis, and
to the appearance of a shortened micropenis
penile shaft

by guest
TABLE 6 Continued
Physical Examination Finding Definition Other Causes and Differential
Musculoskeletal Gait Collapse into hip (“waddle”), Arthritis, SCFE
Trendelenburg or antalgic gait
(external rotation or out-toeing on
affected side)
Lordosis Trunk sway associated with postural Spondylolisthesis, achondroplasia,
adaptations muscular dystrophy, other genetic
conditions
Hip pain and/or limp Knee or hip pain, subacute onset, Multiple problems present with
pain with external rotation of hip chronic hip, knee, or thigh pain
including slipped capital femoral
epiphysis (SCFE), growing pains,
femoral neck fracture, groin injury,
Perthes disease, osteonecrosis
associated with systemic disease,
juvenile idiopathic arthritis,
reactive arthritis, overuse injuries,
chondrolysis, tumors, osteitis pubis
Genu varum or valgum Genu varum (bow legs) Tibia vara (Blount disease), rickets,
skeletal dysplasia, celiac sprue,
collagen disorder and
hypermobility syndromes (eg,
Marfan syndrome), Loeys-Dietz,
classic Ehler Danlos syndrome)15
Genu valgum (knock-kneed) Physiologic in children under 6 y; in
older children and adolescents,
consider postaxial limb deficiency,
neoplasms, genetic and metabolic
disorders, neurofibromatosis, and
vitamin D–resistant rickets
Pes planus Rigid versus flexible, sometimes with Posterior tibial tendon insufficiency,
pain tarsal coalition, congenital vertical
talus, rheumatoid arthritides,
trauma, neuropathy
Skin Acanthosis AN is thickened and darker skin, Medication side effect, and
occasionally pruritic at the nape of uncommonly, visceral malignancy.
the neck (99%), axillae (73%) and,
less commonly, groin, eyelids,
dorsal hands, and other areas
exposed to friction
Hirsutism or acne Hirsutism: familial, Cushing syndrome,
thyroid disorders
Acne: physiologic, folliculitis, rosacea
Striae Linear, usually symmetrical smooth Pregnancy, Cushing syndrome, and
bands of atrophic skin that initially topical corticosteroid use
appear erythematous, progressing
to purple then white;
perpendicular to the direction of
greatest tension in areas with
adipose tissue
Intertrigo Macerated, erythematous plaques in Inflammatory diseases, metabolic
skin folds disorders, malignancies (rare in
pediatrics), and various infections
by site
Pannus Excess skin and subcutaneous fat Pregnancy, malignancy
below the umbilicus
Adapted from Table 4 and used with permission by Armstrong et al. et al.365 HEENT, head, eye, ear, nose, and throat examination.
apnea and goiter associated with spectrum of impairment that can or tachycardia. Wheezing may be
thyroid disease. be associated with overweight and suggestive of intrinsic or exercise-
A cardiopulmonary examination obesity. Simple deconditioning may induced asthma. Tonsillar hypertro-
should be performed to look for a present with tachypnea, dyspnea, phy may be a sign that increases

by guest
the likelihood of sleep apnea. In behavior (Importance) and their X. COMORBIDITIES OF PEDIATRIC
more severe obesity, congestive belief that they can bring about this OVERWEIGHT AND OBESITY
heart failure may present with bas- change (Confidence). This evaluation
Introduction to Comorbidities
ilar rales or other signs of more is important when discussing
significant cardiac disease. healthy nutrition and activity with Children and adolescents with obesity
Liver size should be assessed by patients who have BMI in the have increased prevalence of
palpation and auscultation. If healthy range; it assumes even comorbidities, and a greater risk for
present, right upper quadrant greater importance with a patient obesity in adulthood, morbidity, and
tenderness should be noted. and family who are struggling with premature death.36,393–395 The risk for
Genito-urinary examination overweight, obesity, or severe obesity-related comorbidities increases
should be performed to assess obesity where health concerns are with age and severity of obesity and
pubertal status and genital elevated. This evaluation of prevalence varies by ethnicity and
appearance looking for signs of readiness to change is central to race.396 For example, there is a higher
endocrine or genetic abnormality. deciding how and when to embark prevalence of NAFLD in Hispanic
Hypogonadism may be present in on obesity treatment. Motivational children and a lower prevalence in
certain syndromes associated interviewing (MI), discussed in the Black children.397,398 AI/AN, Black, and
with obesity or be a result of Treatment section, provides a useful Hispanic youth have higher prevalence
obesity.389,390 More commonly, of prediabetes and diabetes, compared
framework for evaluating and
biological males with abdominal with white youth.399,400 Pediatricians
discussing a patient’s readiness to
and other PHCPs need to recognize
obesity may have a suprapubic change.392
fat pad obscuring the penis, a that the association between ethnicity
and race and obesity and related
so-called “vanishing penis,” and Readiness to change, perceptions of
weight status, health challenges, comorbidities in both children and
need instruction on proper voiding
nutrition habits, and access to adults likely reflects the impact of
and genital hygiene to avoid devel-
physical activity are influenced by epigenetic, social, and environmental
opment of skin breakdown.
factors, such as SDoHs, low SES,
Neurologic evaluation may reveal familial, cultural, and socioeconomic
factors. For this reason, exposure to structural racism,
papilledema, as described above,
understanding these factors is neighborhood deprivation, and
as well as paresthesia.
inadequate built environment in these
Orthopedic findings associated beneficial in forging a productive
subpopulations.399,401–408
with obesity include abnormal relationship with children and their
gait, knee tenderness, pes planus, families. It is also important to
Obesity and related comorbidities
genu valgum (“knock knees”), remember that patients and families
should be evaluated concurrently
genu varum (leg bowing), foot care about their health and their
with an obesity-specific history and
pain, back tenderness, and hip child’s health regardless of race, review of systems, family and social
pain. Obesity may also make ethnicity, and/or SES. Caregivers history, physical examination, and
detection of scoliosis more difficult. should be reminded that the laboratory testing. This evaluation
Neuromuscular evaluation of presence of overweight or obesity is provides pediatricians and other
obesity, as with the orthopedic NOT an indication of poor parenting. PHCPs with an opportunity to assess
evaluation of obesity, includes for both the etiology and
D. Laboratory Evaluation
assessment of bone structure, gait complications of obesity (see the
and pain, but also includes assess- Based on BMI classification—and Evaluation section). Pediatricians
ment for balance, coordination, augmented by findings in the and other PHCPs need to take into
lower limb muscle strength, flexi- history, physical examination, and consideration patient-specific factors
bility and motor skill proficiency. patient readiness to change that may increase the risk for
Patients with obesity frequently assessments—laboratory evaluation comorbidities. For example,
experience impairment in these of the patient represents the next prediabetes and diabetes occur
areas. Such limitations can result important step in evaluation. This more frequently among children
in further reduction of ability to laboratory evaluation and its who are 10 years and older, are in
engage in physical activity.391 connection to the delineation of early pubertal stages, or have a
more common comorbid illnesses is family history of T2DM.399,400,409
C. Assessment of Patient Readiness described in the Comorbidities
to Change section. Other laboratory evaluations There is compelling evidence that
“Readiness to change” refers to a can be performed as clinically obesity increases the risk for
patient’s interest in changing a indicated. comorbidities and that weight loss

by guest
interventions can improve TABLE 7 Inclusion Criteria for Guidelines or Position Statements Reviewed for Comorbidities
comorbidities.80,396,410 Thus, the Inclusion Criteria
recommendations for comorbidity
Clinical guideline or position statement was published in the last 15 y.
evaluation uses input from the
The organization or professional society is recognized as the leading scientific expert in the field.
technical report on comorbidities The clinical guideline or position statement uses an established grading matrix to assess the
for the prevalence, age, and weight evidence.
category396 associated with
comorbidities, and the technical
report on treatment of obesity societies in the field. The inclusion common comorbidities are in
intervention outcomes on criteria for the guidelines and Appendix 3.
dyslipidemia, prediabetes and position statements are in Table 7.
diabetes, HTN, and NAFLD.80 Studies When there was more than 1 A. Laboratory Evaluation of Obesity-
on optimal age, frequency, benefits, guideline from the same Related Comorbidities for
and harms of evaluating for Children With Overweight and
organization or professional
comorbidities for children with Obesity
obesity remain limited. To address society, the most recent guideline
was given precedence. Other The 2007 AAP Expert Committee on
when to begin evaluation, what tests
Child Obesity recommended
to obtain, and frequency of testing, considerations for inclusion were
laboratory evaluation for children
input from other clinical practice guidelines supported by a technical with obesity for dyslipidemia,
guidelines was also report or endorsed by the AAP. prediabetes, and NAFLD starting at
considered.87,88,90,411,412
10 years by obtaining a fasting lipid
The following section is divided into
The KASs in this section are limited panel, fasting glucose, alanine
3 sections:
to comorbidities addressed in the transaminase, and aspartate
technical reports and/or guidelines transaminase levels every 2 years.92
Overall KASs for Laboratory
from professional organizations For children with overweight, the
Evaluation of Obesity-Related
or societies. Consensus recommendation was only for a
Comorbidities for children
recommendations are included to fasting lipid panel unless additional
with overweight and obesity
cover the breadth of relevant (KASs 3–3.1); risk factors were present (such as
comorbidities associated with Concurrent Treatment of Obesity family history of obesity-related
pediatric overweight and obesity and Obesity-Related Comorbidities diseases, elevated BP, elevated lipid
and to provide context for (KAS 4); and levels, or tobacco use).14 KASs 3 and
implementation. Each KAS or Specific Recommendations for 3.1 build on the 2007
consensus recommendation is Evaluation for Common Comorbid- recommendations—taking into
drawn from the technical reports, an ities (KASs 5–8) and Guidelines account recent studies, guidelines,
extensive review of the literature, for Other Comorbidities. and pediatrician and other PHCP
and clinical guidelines or position behaviors—while balancing the
statements from premier Recommendations for reevaluation harm versus benefit of evaluation at
organizations or professional and initial management of the individual and population levels.
KAS 3. In children 10 y and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and
adolescents with obesity (BMI $ 95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI $ 85th percentile to <95th percentile).
Aggregate Evidence Quality Grade B.

Benefits Allows for early detection and management to reduce risk factors for future cardiometabolic disease. Result
will guide treatment. May motivate treatment engagement.
Risks, harm, costs Cost, access, patient anxiety, labeling with chronic medical condition, stress, and time of undergoing treatment.
Benefit-harm assessment Identification and management of cardiometabolic comorbidities in childhood and adolescence exceeds
potential harm, especially for high-risk patients.
Intentional vagueness Age.
Role of patient preferences Parent and patient knowledge, family history, families’ concern about the test, ease and accessibility of testing
should be considered.
Exclusions <24 mo old.
Strengths Strong.
Key references 80, 86, 88, 90, 396, 397, 413–416

by guest
Children $10 Years triglycerides (TG) and low high- history of NAFLD, central adiposity,
To encourage a pragmatic and density lipoprotein (HDL) levels (the signs of insulin resistance,
efficient evaluation strategy, KAS 3 typical pattern of dyslipidemia that prediabetes or diabetes mellitus,
and 3.1 recommend that, for occurs with obesity) have been dyslipidemia, and sleep apnea.88
children with obesity, evaluation for reported in children with obesity as
young as 3 years.395 Considerations for Testing
lipid abnormalities, abnormal
glucose metabolism, and liver Among children with obesity, there
dysfunction be obtained at the same As the risk profile for NAFLD and is clustering of comorbidities, a
time and begin at age 10 years. The diabetes mellitus in children higher risk profile for more severe
expectation is that pediatricians and younger than 10 years is lower disease and/or progression than
other PHCPs will find it easier to (especially in the absence of severe may be commonly or previously
adhere to recommendations when obesity), obtaining tests for recognized.396,421–423 For example,
all tests are obtained at the same abnormal glucose metabolism or regardless of the definition used for
time. They may order fasting liver function is not universally metabolic syndrome, the prevalence
laboratory tests for the evaluation, recommended for this is 0% to 4.7% among children with
because a fasting lipid panel is still population.88,90,415,418 healthy weight and increases to 14.5%
the recommended test to evaluate to 35% among children and
for dyslipidemia for children and Detailed and specific adolescents with obesity.396 In a
adolescents with overweight and recommendations are provided in cohort of 675 children with NAFLD
obesity (see the dyslipidemia the following sections on from 12 clinical centers across the
section, below, for additional dyslipidemia, prediabetes and United States, one-third had T2DM or
information). diabetes mellitus, and NAFLD. prediabetes,422 2 conditions that have
significant morbidity in childhood.
Children 2–9 Years Children With Overweight
Adolescents with severe obesity—who
For children 2 to 9 years of age with For children 10 years and older with have comparable BMI and metabolic
obesity, evaluation for lipid overweight, evaluating for lipid profiles as adults—are more likely to
abnormalities may be considered abnormalities is recommended in present with advanced liver damage
(KAS 3.1). This recommendation the absence of additional risk and severe systemic inflammation,
aligns with the 2011 National Heart factors (KAS 3).86,412 For evaluation suggesting that pediatric NAFLD may
Lung Blood Institute (NHLBI) Expert of type 2 diabetes mellitus (T2DM), be more aggressive.424 Similarly, in
Panel on Integrated Guidelines for additional risk factors need to be T2DM, children have a more rapid
Cardiovascular Health and Risk considered, which include: family rate of progression of islet b cell
Reduction in Children and history, history of gestational failure and dysglycemia compared
Adolescents.86 In population-based diabetes, signs of insulin resistance with adults.425–427
studies, lipid abnormalities occur in (such as acanthosis nigricans), and
children younger than 10 years, use of obesogenic psychotropic Concerns about overtesting and cost
with higher rates among children medication.90,358,419 For NAFLD, are warranted but are balanced by the
with obesity.80,395,417 High additional risk factors include family significant impact of obesity and
KAS 3.1 In children 10 y and older with overweight (BMI $ 85th percentile to <95th percentile), pediatricians and other PHCPs may evaluate for abnormal glucose metabolism and liver
function in the presence of risk factors for T2DM or NAFLD. In children 2 to 9 y of age with obesity (BMI $ 95th percentile), pediatricians and other PHCPs may evaluate for lipid
abnormalities.
Aggregate Evidence Quality Grade C.

Benefits Limit evaluation to populations with increased risk. Allows for early detection and management to reduce risk
factors for future cardiometabolic disease. Result will guide treatment.
Risks, harm, costs Cost, access, patient anxiety, labeling with chronic medical condition, stress, and time of undergoing treatment.
Benefit-harm assessment Identification and management of cardiometabolic comorbidities in childhood and adolescence may exceed
potential harm, especially children at increased risk.
Intentional vagueness Age. Need for testing may vary by condition and individual presentation.
Role of patient preferences Parent and patient knowledge, family history, families’ concern about the test, ease and accessibility of testing
should be considered.
Exclusions <24 mo old.
Strengths Moderate.
Key references 80, 86, 88, 90, 358,396, 397, 413–415, 420

by guest
comorbidities on morbidity and reviewed in the technical report on Children are often seen at least once
mortality. Almost half (43%) of comorbidities396 demonstrate an a year for WCCs, at which the
children and adolescents with obesity association between overweight and/ pediatrician or other pediatric
have at least 1 abnormal lipid level,417 or obesity, severity of obesity, and health care provider reviews the
and 1 in 5 US adolescents have higher prevalence of comorbidities. growth chart, provides anticipatory
prediabetes,423 which are both Studies also report improvement in guidance on growth, feeding,
precursors for future cardiometabolic comorbidities with intensive lifestyle nutrition, sedentary screen time,
disease. Although the prevalence of treatment, weight loss medication, and participation in physical
T2DM in children is low, at and/or bariatric surgery.80,126,438 activity. At a minimum, the WCC can
approximately 1%, the incidence has Specifically, cardiometabolic markers include evaluation for comorbidities
increased from 9 in 100 000 in 2002 improved significantly in children with for children with overweight and
to 13.8 in 100 000 in 2015, a obesity who underwent intensive obesity, and anticipatory guidance
worrisome annual percentage change pediatric obesity treatment of 3 to on risk for comorbidities with
of 4.8%.399 NAFLD is considered one 6 months, which provides an increasing BMI or obesity. It may be
of the most common chronic liver opportunity for clinicians to helpful for pediatricians and other
diseases in children88,397,398,428 and emphasize health outcomes of lifestyle PHCPs to include the diagnosis of
occurs more frequently in male management.80,410,439 Interventions obesity to the problem list to
children, older children, and Hispanic that meet the intensity or “dose” heighten awareness and remind
children.397,429 threshold of 26 hours or more over 2 providers to address weight
to 12 months can lead to clinically concerns at subsequent clinic
Finally, although obesity prevalence significant improvements in BMI,79 encounters.445,446 In a large adult
rates continue to rise, the rate of and decreases in BMI can lead to study, documentation of an obesity
evaluating for obesity or comorbidities clinically meaningful improvements in diagnosis on a problem list was
in practice is low—suggesting that comorbidities.440–444 independently predictive of at least
any concerns about overtesting are 5% weight loss.445 To avoid any
likely to be more theoretical than Guidelines for dyslipidemia, T2DM, harmful effects related to potential
real.3,394,430–432 NAFLD, and HTN all recommend weight bias and stigma, however,
lifestyle treatment of the primary pediatricians and other PHCPs need
See Appendix 3 for information management of the to be mindful of how this diagnosis
on frequency of testing for comorbidity.86–88,90,414,415,419,420 is conveyed to the child and/or
comorbidities. Although the specific dietary caregiver.28
recommendation may differ slightly
B. Concurrent Treatment of Obesity (eg, CHILD-1 and 2 for dyslipidemia, There may also be a potential
and Obesity-Related low-glycemic diet for prediabetes, benefit for improved weight
Comorbidities limiting sugary beverages for NAFLD, outcomes with comorbidity
There is substantial evidence to and a Dietary Approaches to Stop evaluation. In adult studies,
support concurrent treatment of Hypertension [DASH] Diet for elevated identifying obesity-related
obesity and comorbidities to achieve BP), there is overlap between the comorbidities has been shown to be
weight loss, avoid further weight gain, dietary recommendations and all a motivating factor to address
and improve obesity-related comorbidities improve with weight weight concerns.447–449 The
comorbidities. The majority of studies stabilization and reduction.80,410,436 evidence in pediatrics is, however,
KAS 4. Pediatricians and other PHCPs should treat children and adolescents for overweight (BMI $ 85th percentile to <95th percentile) or obesity (BMI $ 95th percentile) and
comorbidities concurrently.
Aggregate Evidence Quality Grade A

Benefits Awareness of relationship between comorbidities and weight status, treating weight improves comorbidities.
Improved continuity of care and outcomes. Provides an opportunity to discuss health.
Risks, harms, costs Anxiety about weight or comorbidities, time needed for education counseling, potential for disordered eating.
Health care costs.
Benefit-harm assessment Benefits exceed potential harm.
Intentional vagueness Pediatricians and other PHCPs may not have access to appropriate subspecialists.
Role of patient preference Increased visit time, patient or parent experience with prior weight-related counseling.
Exclusions <24 mo.
Strength Strong.
Key references 80, 86–88, 90, 396, 410, 414, 415, 419, 420, 433–437

by guest
sparse and inconsistent.434,450 comorbidity management may be laboratory testing, educate patients
Adolescents identify a desire for found in Appendix 3. and families about the long-term
improved health as a primary risks of cardiovascular disease and
motivation for change.451 Another C1. Dyslipidemia provide nutrition and activity
study analyzed clinic records of Children and adolescents with counseling.
4000 youth aged 10 to 18 years overweight and obesity have
with overweight or obesity in an increased prevalence of abnormal This KAS is supported by both the
academic primary care network and lipid levels.396 The combination of 2011 NHLBI Expert Panel on
found that youth who were hypertriglyceridemia and low high- Integrated Guidelines for
evaluated (n 5 2815) with a density lipoprotein (HDL) levels, Cardiovascular Health and Risk
glycosylated hemoglobin (HbA1c) driven largely by underlying insulin Reduction in Children and
had a decrease in BMI-z slope per resistance, is the most common type Adolescents and 2018 American
year after the HbA1c test compared of dyslipidemia seen with Heart Association and American
with similar peers (n 5 2087) who overweight and obesity. Children College of Cardiology Guidelines,
had not been evaluated. Among and adolescents with overweight which recommend evaluation for
those who had an HbA1c test, the and obesity can also have elevated early risk of atherosclerotic
decline in BMI-z slope per year was total cholesterol and low-density cardiovascular disease and
greater for youth with HbA1c in the lipoprotein (LDL) levels.86 NHANES counseling on risk-reduction
prediabetes-range.434 An earlier data from 2011 to 2014 showed behaviors in children and
study with a similar pediatric clinic that prevalence of abnormal lipid adolescents.86,411 Evaluation for
population but a smaller sample size level was 3 times higher among dyslipidemia with obesity is
(n 5 128) did not find a positive children and adolescents with recommended for younger children,
effect on BMI change following obesity, compared with those with a as well as for children 10 years and
cholesterol evaluation.450 There is a healthy BMI (43% vs 14%).417 older. Although data are limited in
need for more studies before young children, 1 population-based
definitive conclusions can be Studies indicate that cardiovascular study showed that 10% of children
reached about whether evaluating risk factors track from childhood with obesity aged 3 to 5 years have
families for comorbidities increases into adult life and that lifestyle elevated TG and low HDL levels.395
engagement, adoption of healthy treatments can improve outcomes
choices, and weight loss or has with respect to these risk In addition to obesity, other risk
unintended negative effects. factors.393,413,452 Being aware of the factors for dyslipidemia include
association of these “silent” cigarette use, HTN, diabetes, and a
C. Specific Guidelines for Initial cardiovascular comorbidities with family history of cardiovascular
Evaluation for Comorbidities overweight and obesity—as well as disease in a first- or second-degree
The following sections provide their persistence into adulthood relative (#55 years for males and
specific recommendations on initial with potential serious health #65 years for females) with a history
comorbidity evaluation. Guidance on consequences—obliges pediatricians of myocardial infarction, sudden death,
repeat evaluation and initial and other PHCPs to perform or HTN.86,437 All of these conditions
KAS 5. Pediatricians and other PHCPs should evaluate for dyslipidemia by obtaining a fasting lipid panel in children 10 y and older with overweight (BMI $ 85th percentile to <95th
percentile) and obesity (BMI $ 95th percentile) and may evaluate for dyslipidemia in children 2 through 9 y of age with obesity.
Aggregate Evidence Quality Grade B: Children $10 y of Age With Obesity. Grade C: Children 2 Through 9 y of Age
Benefits Allows for identification and management of specific cardiovascular risk factors, fasting status limits number of
blood draws. May motivate treatment engagement.
Risks, harms, costs Convenience, cost, access, patient anxiety, labeling with chronic medical condition, stress and time of undergoing
treatment.
Benefit-harm assessment Identification and management of specific cardiometabolic comorbidities in childhood and adolescence exceeds
potential harm of no evaluation, especially for high-risk patients. When obtaining a fasting lipid panel is not
possible, the pediatrician or other PHCP may assess the benefit of evaluating for dyslipidemia with a nonfasting
lipid panel in certain circumstances.
Intentional vagueness None.
Role of patient preference Ease and accessibility of testing; families concern about the test.
Exclusions #24 mo old.
Strength Strong (10 y and older). Moderate (2–9 y).
Key references 80, 86, 395, 396, 410, 411, 417, 453, 454

by guest
TABLE 8 NHLBI Criteria for Lipid Testing Results
Lipid Category Low (mg/dL) Acceptable (mg/dL) Borderline High (mg/dL) High (mg/dL)
Total cholesterol — <170 170–199 $200
LDL cholesterol — <110 110–129 $130
HDL cholesterol <40 >45 —
Triglycerides
0–9 y — <75 75–99 $100
10–19 y — <90 90–129 $130
Non-HDL cholesterol — <120 120–144 $145
Adapted from the Expert Panel on Integrated Guidelines for Cardiovascular Health.86 —, not applicable.
warrant laboratory evaluation and is abnormal (non-HDL $145 mg/dL) 2002 and 2015, the incidence of
may help guide clinical decisions for and/or the HDL level is <40 mg/dL, a T2DM among 10- to 19-year-olds in
assessment of dyslipidemia in younger fasting lipid panel needs to be the United States increased from 9.0
children. Additionally, awareness of an obtained for diagnosis.412 The to 13.8 per 100 000.290,399,458 Based
association of social factors, specifically nonfasting lipid panel is on the 2005 to 2016 NHANES, 1 in 5
ACEs, with cardiovascular risk factors recommended for all children 9 to adolescents (12–18 years) have
is important.455 11 years of age to evaluate for prediabetes.423 Although uncommon,
familial hypercholesterolemia.86 T2DM has been diagnosed in children
C.1.a. Laboratory Tests for Diagnosis younger than 10 years, some as
Estimates are that approximately
of Dyslipidemia young as 4 years of age.459,460 For
25% of children would be referred
The NHLBI expert panel this reason, pediatricians and other
for a fasting lipid panel because of
recommends a fasting lipid panel for PHCPs should consider risk factors
elevated non-HDL lipid
evaluation of dyslipidemia for and symptoms of altered glucose
evaluation.457 Because of the
children with overweight and metabolism in all ages (eg, polydipsia,
obesity.86 Because dietary fats and elevated risk of lipid abnormality
among youth with overweight and polyphagia, polyuria, blurred vision,
carbohydrates (particularly simple
obesity, a fasting lipid panel is unexplained weight loss).
sugars) increase serum TG
concentrations, 8 to 12 hours of fasting recommended. See the
Because obesity is a strong
before testing is recommended.456 implementation guide for predictor for developing
Given that a combination of high TG additional information. prediabetes and T2DM,423,461,462
and low HDL cholesterol is the most pediatricians and other PHCPs need
common pattern of dyslipidemia The cut-off criteria for lipids in the
to have an increased index of
observed in children with overweight 2011 NHLBI guidelines are the same
suspicion when caring for children
and obesity, the recommendation to across different age groups, except for
with obesity, especially in the
obtain a fasting lipid panel is triglycerides, as indicated in Table 8.
presence of other risk factors
important, because nonfasting TG (Table 9).90,408,414,415,463 Both
levels will not be accurate.86 See Appendix 3 for information on
genetics and SDoHs account for
frequency of laboratory testing and
some of the racial and ethnic
For practical purposes, a nonfasting information about initial
disparities observed in the
lipid panel using the non-HDL level management of dyslipidemia.
incidence of T2DM.401,408
may be easier to obtain for routine
evaluation in the primary care setting.
C.2. Prediabetes and Type 2 Diabetes
The pathogenesis of prediabetes and
The non-HDL level is the total Mellitus
T2DM is a peripheral and hepatic
cholesterol minus the HDL cholesterol T2DM is now increasingly diagnosed resistance to insulin accompanied by
level. If the non-HDL cholesterol level in the pediatric population. Between progressive loss of islet cell function.
TABLE 9 Other Risk Factors for Prediabetes and T2DM90,358,415,419

Risk Factors
Maternal history of diabetes or gestational diabetes
Family history of diabetes in first- or second-degree relative
Signs of insulin resistance or conditions associated with insulin resistance (acanthosis puberty nigricans, hypertension, dyslipidemia, polycystic ovary
syndrome, or small-for-gestational-age birth weight)
Use of obesogenic psychotropic medications

by guest
KAS 6. Pediatricians and other PHCPs should evaluate for prediabetes and/or diabetes mellitus with fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test
(OGTT), or glycosylated hemoglobin (HbA1c).a
Aggregate Evidence Quality Grade B.

Benefits Tests sensitive for glucose intolerance have established diagnostic cut-offs.
Risks, harms, costs Cost, access, time, patient anxiety with testing, varying levels of sensitivity and specificity, concordance between
tests is imperfect, HbA1c levels can vary by age, ethnicity, anemia or hemoglobinopathies.
Benefit-harm assessment Benefit outweighs harm.
Intentional vagueness Consideration for patient access and timing of tests.
Role of patient preference Families’ concern about developing T2DM, concerns about the test, ease and accessibility for testing, length of
time for OGTT.
Exclusions Fasting insulin test is not reliable measure of insulin resistance.
Strength Moderate.
Key references 90, 414–416, 464
a
Per KAS 3 and 3.1: pediatricians and other PHCPs should evaluate children 10 y and older with obesity (BMI $ 95th percentile) for abnormal glucose metabolism and may evalu-
ate children 10 y and older with overweight (BMI $ 85th percentile to <95th percentile) with risk factors for T2DM or NAFLD for abnormal glucose metabolism. (Refer to evidence
tables for KAS 3 and 3.1.)
Insulin resistance, when assessed by Diagnostic tests for prediabetes and unpalatable glucose drink—all of
the homeostatic model assessment T2DM are fasting plasma glucose which are factors that can limit its
of insulin resistance test, varies (FPG), 2-hour plasma glucose after use in pediatric outpatient settings
across weight categories, with oral glucose tolerance test (OGTT), as an evaluation test.
highest levels observed among and HbA1c.90 There are several
children with severe obesity.396 clinical guidelines that do not The HbA1c test is easy to obtain as
recommend one test over the other fasting is not required. It provides a
Some children with T2DM have
for evaluation.90,268,415,416,419,420,465 measure of chronic hyperglycemia,
rapidly progressive disease, which
Pediatricians and other PHCPs need and use of the test has been
underscores the need for early
to be aware of the strengths and shown to increase evaluation for
identification and intensive
shortfalls of each test and take
treatment in collaboration with a T2DM in primary care settings.471
patient preferences and test
pediatric endocrinologist.425 It is also the recommended
accessibility into consideration. In
test for monitoring
addition, the concordance between
C.2.a. Laboratory Tests for the all 3 tests is imperfect.416 For prediabetes.90,414–416,418,464,472 The
Diagnosis of Prediabetes and T2DM instance, the FPG is highly sensitivity of HbA1c for diagnosing
Testing for T2DM should always be reproducible; the OGTT, which does diabetes is lower in children473
performed if there is suspicion of not fare as well on reproducibility, when compared with adults.473,474
hyperglycemia in a patient with is effective in identifying Pediatricians and other PHCPs also
symptoms and signs of dysglycemia. This is a good reason need to be aware that HbA1c levels
hyperglycemia, such as new onset to use the OGTT as a confirmation can be 0.1% to 0.2% higher in
thirst (polydipsia), frequent test if the initial test result is individuals with iron deficiency
urination (polyuria) or new onset equivocal.466–470 The OGTT, anemia.475,476
bedwetting, excessive hunger and however, may not be readily
eating (polyphagia), blurred vision, available at some medical settings, Fasting insulin is not recommended
unexplained or unexpected weight requires fasting before the test, lasts for diagnosis of prediabetes or T2DM
loss, or fatigue. at least 2 hours, and includes an because the levels are highly variable
TABLE 10 Criteria for Diagnosing Prediabetes and T2DM90

Prediabetes or Impaired Glucose Tolerance Diabetes Mellitusa
Fasting plasma glucose (FBG) b
100–125 mg/dL $126 mg/dL
2-h plasma glucose (OGTT)c 140–199 mg/dL $200 mg/dL
Random plasma glucose (RBG)d Not applicable $200 mg/dL
HbA1ce 5.7% to 6.4% $6.5%
a
In the absence of unequivocal hyperglycemia, diagnosis is confirmed if 2 different tests are above threshold or a single test is above threshold on 2 separate occasions.
b
Fasting for at least 8 h with no calorie intake.
c
Oral glucose tolerance test (OGTT) using a load 1.75 g/kg of body weight of glucose with a maximum of 75 g.
d
In patients with hyperglycemic crises or classic symptoms of hyperglycemia (eg, polyuria, polydipsia).
e
Glycosylated hemoglobin (HbA1c) is the preferred test for monitoring prediabetes.478

by guest
TABLE 11 Risk Factors for Diagnosis and Progression of NAFLD88,397,433
NAFLD Risk Factorsa
Diagnosis Male sex, $10 y, obesity, sibling with NAFLD, prediabetes or diabetes mellitus, obstructive sleep apnea, dyslipidemia
Progression Adolescent $14 y; higher or increasing alanine transaminase; elevated baseline aspartate transaminase, c glutamyl transferase
(GGT), and LDL cholesterol; prediabetes or diabetes mellitus; obstructive sleep apnea; increasing wt or waist circumference
a
Consideration should be given to groups of certain races/ethnicities with higher rates of NAFLD (eg, Hispanic, Asian), for which higher prevalence can be attributed to genetic,
socioeconomic, and environmental factors.480
and do not reliably correlate with the divided into steatosis (NAFL) and biopsy-confirmed NAFLD who
level of insulin resistance.268,477 steatohepatitis (NASH). In NAFL, the received standardized nutrition and
milder form of the condition, there is exercise counseling consistent with
The cut-off values are similar for fatty infiltration in $5% of the liver, the 2007 AAP Expert
pediatric and adult populations, as with or without fibrosis. In NASH, Recommendations at 12-week
illustrated in Table 10, above. If the there is inflammation, steatosis, and intervals over 1 to 2 years, about
results are unequivocally high and fibrosis with ballooning injury to the half demonstrated any improvement
indicative of T2DM, obtaining a hepatocytes.433 in resolution of NASH or regression
second or repeat confirmatory test of fibrosis. Among children with
is not recommended; instead, The risk profile and natural history borderline or definite NASH,
treatment should be initiated.90,415 of the disorder in the pediatric resolution occurred in about one-
Guideline recommendations for population are still evolving, given third. Adolescents were more likely
tracking glycemic control over time that there are limited long-term to develop worsening steatosis and
use the HbA1c test; however, the studies in children. Pediatric NAFLD less likely to experience any
FPG can be substituted using the may reflect the early onset of a resolution of NASH or regression in
cut-off criteria in Table 10. See the chronic disease with a more fibrosis than younger children.433
implementation guide for further aggressive course, particularly once
discussion on use of OGTT or FBG NASH has occurred.424,479 C.3.a. Laboratory Tests for Diagnosis
tests.90,414,415,419,464 Preadolescent children with NAFLD of NAFLD
have higher rates of mortality over The 2017 North American Society of
See Appendix 3 for more information 20 years, compared with their peers Pediatric Gastroenterology,
on frequency of evaluation and on without NAFLD.479 Children with Hepatology and Nutrition
initial management of prediabetes increasing weight gain; higher levels (NASPGHAN) clinical practice
and T2DM. of alanine transaminase (ALT), c guidelines recommend ALT as the
glutamyl transferase (GGT), and preferred test for NAFLD.88 ALT is
C.3. Nonalcoholic Fatty Liver Disease cholesterol at baseline; worsening more specific for liver disease than
NAFLD is a chronic liver disease levels of HbA1c; and an incident aspartate transaminase (AST), easily
marked by steatosis (fat diagnosis of T2DM are more likely accessible at laboratory centers,
accumulation), inflammation, and to have severe disease or minimally invasive relative to other
fibrosis. The underlying progression (Table 11).433,479 testing modalities for NAFLD, and has
pathogenesis is insulin resistance, However, in a recent study of been used most often in pediatric NAFLD
which alters the process of fat children 8 to 17 years of age with studies. Higher levels of ALT correlate
oxidation in the liver, increasing
oxidative stress and inflammation—
KAS 7. Pediatricians and other PHCPs should evaluate for NAFLD by obtaining an alanine transaminase (ALT) test.a
with resultant liver damage. Among
children with obesity, rates as high Aggregate Evidence Quality Grade A.
as 34% have been reported.429 Benefits Minimally invasive, fair correlation to histology.
Risks, harms, costs Test may not correlate with disease severity.
Three diagnostic terms are used to Benefit-harm assessment Benefit outweighs harm.
Intentional vagueness Future research needed.
describe the histology of the disease
Role of patient preference None.
progression: NAFLD, nonalcoholic Exclusions Not applicable.
fatty liver (NAFL), and nonalcoholic Strength Strong.
steatohepatitis (NASH). NAFLD refers Key references 88, 396, 481
to the whole spectrum of the
a
Per KAS 3 and 3.1: Pediatricians and other PHCPs should evaluate children 10 y and older with obesity (BMI $
95th percentile) for abnormal liver function and may evaluate children 10 y and older with overweight (BMI $ 85th
disorder, from mild steatosis to percentile to <95th percentile) with risk factors for TD2M or NAFLD for abnormal liver function. (Refer to evidence
cirrhosis of the liver. NAFLD is tables for KAS 3 and 3.1.)

by guest
with more advanced liver disease with have abnormal diurnal variation in ethnicity, with highest prevalence
steatosis and fibrosis; however, a normal BP. One-third of children with occurring among non-Hispanic Black
ALT does not definitively exclude obesity have a decreased nocturnal and Hispanic youth.490 SES is also a
NAFLD.429 In a population of children BP dip, increasing the potential risk risk factor for HTN,491 as are
older than 10 years with overweight and for end-organ damage.482 Among adverse childhood experiences, both
obesity who were referred from a children with obesity, additional prenatally and during childhood.87
primary care clinic, an ALT level $80 cardiometabolic risk factors—such These factors may contribute to the
IU/L had a sensitivity of 57% and a as insulin resistance or higher prevalence of hypertension
specificity of 71% for NASH.481 dyslipidemia—may affect BP, observed among non-Hispanic Black
Elevations in AST and GGT, especially at independent of obesity. and Hispanic youth.490
baseline, can be indicative of severe
disease or rapid progression.433,481 Studies indicate that HTN during Pediatricians and other PHCPs
childhood and adolescence increases should obtain a history of salt intake
NAFLD is less common in children the risk for adult HTN and (eg, addition of salt while cooking
younger than 10 years. In an autopsy cardiovascular disease.483–485 More and/or at meals) and sources of
study of 742 children, 3.3% of 5- to 9- concerning, studies have shown that, sodium from processed, frozen, and
year-old children had fatty liver, among children with obesity, HTN is fast foods, because high sodium
associated with vascular changes,
compared with 11.3% in 10- to 14- intake is associated with childhood
increased left ventricular mass, and
year-olds and 17.3% in 15- to 17-year- HTN. Obtaining a history of physical
carotid intima media thickness
olds.397 There is a higher risk for activity and inactivity levels is also
during childhood.486,487 These
NAFLD in young children 2 to 9 years recommended, because decreased
findings support the importance of
of age who have severe obesity, evaluating for HTN early and activity levels are associated with
however.88 Thus, pediatricians and consistently throughout childhood childhood HTN.87 Finally, evaluation
other PHCPs may consider evaluating and adolescence among individuals of sleep duration and disordered
NAFLD by obtaining an ALT level every with overweight and obesity.413,488 breathing are recommended because
2 years in these children. of the association between abnormal
C.4.a. Evaluation for HTN sleep duration and OSA and elevated
See Appendix 3 for more Obesity is the strongest risk factor BP.492,493
information on the frequency of for HTN in childhood.87,488 Elevated
evaluation for NAFLD and on BP is observed in early childhood This KAS aligns with the 2017 AAP’s
managing NAFLD. and prevalence increases with age “Clinical Practice Guideline for
and BMI category.396 A large study Screening and Management of High
C.4. Hypertension conducted in primary care settings Blood Pressure in Children and
The prevalence of HTN among found that 8% of children 3 to Adolescents,” which recommends
children and adolescents with 5 years of age with obesity had evaluation of elevated BP and HTN
overweight and obesity ranges from elevated BP levels; the percentage for children with obesity at every
5% to 30%, with higher prevalence increased to 20% among children clinic visit beginning at 3 years of
with increasing BMI percentile.396 11 to 15 years of age.489 HTN age.87 Frequent monitoring of BP
Children with excess weight also prevalence varies by race and among children with overweight and
KAS 8. Pediatricians and other PHCPs should evaluate for hypertension by measuring blood pressure at every visit starting at 3 y of age in children and adolescents with overweight (BMI $
85 to <95th percentile) and obesity (BMI $ 95th percentile).
Aggregate Evidence Quality Grade C

Benefits Early detection of HTN, opportunity to address weight’s impact on BP and health, prevention of HTN-related
morbidity.
Risks, harms, costs Improper measurement techniques, misclassification, discomfort, time needed, possible inaccuracy during acute
care visits when patient may be in pain.
Benefit-harm assessment Benefits exceed potential harm.
Role of patient preference Increased visit time, discomfort with cuff.
Exclusions <3 y of age.
Strength Moderate.
Key references 87, 396, 413, 453, 488

by guest
TABLE 12 BP Categories by Age and Number of Visits Needed for Diagnosis
BP Category Children 1–13 Years of Age Children $13 Years of Age Number of Visits to Diagnosis
Normal BP < 90th percentile BP <120/80 mm Hg NA
Elevated BP $ 90th percentile to <95th percentile 120/<80 to 129/<80 mm Hg 3
Stage 1 BP $ 95th percentile to <95th percentile 1 12 mmHg 130/80 to 139/89 mm Hg 3
Stage 2 BP $ 95th percentile 1 12 mm Hg $140/90 mm Hg 2
Used with permission and adapted from the AAP HTN CPG,87 Fig 2, and AAP Pediatric Obesity Clinical Decision Support Chart.494 NA, not applicable.
obesity fosters earlier detection of definitions of “elevation,” “stage 1 determine accurate BP

elevated BP. BP,” and “stage 2 BP” (see Table 12). measurement and category. For
This CPG recommended that an diagnosis, BP by auscultation should
C.4.b. Diagnosis of HTN elevated initial BP measurement be repeated with confirmed elevated
In 2017, the AAP published a CPG ($90th percentile), taken either by BP measurements on 3 separate
on HTN that included oscillometry or auscultation, should clinic visits for elevated BP and
recommendations for evaluation for be repeated twice with auscultation stage 1 HTN, and on 2 separate
elevated BP and updated HTN and averaged, at the same visit, to visits for stage 2 HTN.87
TABLE 13 Summary of KASs for Evaluation of Comorbidities Among Children and Adolescents With Overweight and Obesity
KAS # Key Action Statement (KAS) Evidence Quality, Recommendation Strength
A. laboratory evaluation of obesity-related comorbidities
3 In children 10 y and older, pediatricians and other PHCPs should B, Strong
evaluate for lipid abnormalities, abnormal glucose metabolism,
and abnormal liver function in children and adolescents with
obesity (BMI $ 95th percentile) and for lipid abnormalities in
children and adolescents with overweight (BMI $ 85th percentile
to < 95th percentile)
3.1 In children 10 y and older with overweight (BMI $ 85th percentile to C, Moderate
< 95th percentile), pediatricians and other PHCPs may evaluate
for abnormal glucose metabolism and liver function in the
presence of risk factors for T2DM or NAFLD. In children 2 to 9 y of
age with obesity (BMI $ 95th percentile), pediatricians and other
PHCPs may evaluate for lipid abnormalities.
B. Concurrent treatment of obesity and obesity-related comorbidities
4 Pediatricians and other PHCPs should treat children and adolescents A, Strong
for overweight (BMI $ 85th percentile to < 95th percentile) or
obesity (BMI $ 95th percentile) and comorbidities concurrently.
C. Evaluation for diagnosis of dyslipidemia, prediabetes, T2DM, NAFLD, and hypertension
5 Pediatricians and other PHCPs should evaluate for dyslipidemia by B, Strong (10 y and older); C, moderate (2–9 y of age)
obtaining a fasting lipid panel in children 10 y and older with
overweight (BMI $ 85th percentile to < 95th percentile) and
obesity (BMI $ 95th percentile) and may evaluate for dyslipidemia
in children 2 through 9 y of age with obesity.
6 KAS 6. Pediatricians and other PHCPs should evaluate for prediabetes B, Moderate
and/or diabetes mellitus with fasting plasma glucose, 2-h plasma
glucose after 75-g oral glucose tolerance test (OGTT), or
glycosylated hemoglobin (HbA1c).a
7 KAS 7. Pediatricians and other PHCPs should evaluate for NAFLD by A, Strong
obtaining an alanine transaminase (ALT) test.b
8 Pediatricians and other PHCPs should evaluate for hypertension by C, Moderate
measuring blood pressure at every visit starting at 3 y of age in
children and adolescents with overweight (BMI $ 85 percentile to
< 95th percentile) and obesity (BMI $ 95th percentile).
a
Per KAS 3 and 3.1: pediatricians and other PHCPs should evaluate children 10 y and older with obesity (BMI $ 95th percentile) for abnormal glucose metabolism and may evalu-
ate children 10 y and older with overweight (BMI $ 85th percentile to <95th percentile) with risk factors for T2DM or NAFLD for abnormal glucose metabolism. (Refer to evidence
tables for KAS 3 and 3.1.)
b
Per KAS 3 and 3.1: pediatricians and other PHCPs should evaluate children 10 y and older with obesity (BMI $ 95th percentile) for abnormal liver function and may evaluate
children 10 y and older with overweight (BMI $ 85th percentile to <95th percentile) with risk factors for TD2M or NAFLD for abnormal liver function. (Refer to evidence tables
for KAS 3 and 3.1.)

by guest
BP measurements should be taken See Appendix 3 for more sleepiness, inattention and/or
with an appropriately sized cuff; the information on repeat evaluation for learning problems, nocturnal
bladder length should be 80% to HTN and on management of HTN. enuresis, and headaches.
100% of the circumference of the arm, Table 13 lists the KASs for the Examination findings may include
and the width should be at least 40% comorbidities covered in the TR. tonsillar hypertrophy, adenoidal
of the arm circumference.87 (See facies, micro- or retrognathia, high-
D. Other Comorbidities arched palate, and elevated BP.
https://www.cdc.gov/nchs/data/
nhanes/nhanes_07_08/manual_an.pdf.) D.1. Obstructive Sleep Apnea Diagnosis is made by obtaining a
OSA is a sleep disorder polysomnography, the gold
For children and adolescents with standard test, with an apnea-
“characterized by prolonged partial
excess weight, a larger cuff size may hypopnea index of 1 or more
upper airway obstruction and/or
be required to obtain accurate
intermittent complete obstruction episodes per hour in children.496
measurements. For children and that disrupts normal ventilation Because of limited availability of
adolescents with severe obesity, a during sleep.”89 The condition is sleep centers with pediatric
thigh cuff may be needed. associated with cardiovascular expertise, referral to a pediatric
Additionally, for children and complications, neurocognitive otolaryngologist for further
adolescents with obesity, ambulatory impairment, and decreased quality evaluation, diagnosis, and
blood pressure monitoring (ABPM) is of life. Children with obesity have a management may be needed.
recommended to assess HTN severity higher prevalence of OSA: 45%
and identify possible abnormal Consensus Recommendations
among children obesity compared
circadian BP patterns, which with 9% among children with The CPG authors recommend
increases risk for end-organ damage. healthy weight. One study indicated pediatricians and other PHCPs obtain:
ABPM also helps to identify masked that a 1-unit increase in the BMI SD
HTN and/or “white coat” HTN.87 score increased the odds of having A sleep history, including
OSA by a factor of 1.9 independent symptoms of snoring, daytime
Elevated BP in the office setting is of age, sex, tonsillar hypertrophy, somnolence, nocturnal enuresis,
unrecognized in approximately 25% and asthma.441 morning headaches, and inatten-
of cases.495 The AAP’s CPG on HTN tion, among children and adoles-
provides pediatricians and other Evaluation for OSA is based on cents with obesity to evaluate for
PHCPs with practical tools to assist history of symptoms and OSA.
with identification of elevated BP examination. Children with obesity, A polysomnogram for children
and HTN. Improved identification of tonsillar hypertrophy, craniofacial and adolescents with obesity and
children at high risk and youth anomalies, trisomy 21, and at least 1 symptom of disordered
allows for a thorough evaluation, neuromuscular disorders are at breathing.
treatment, and follow-up, with the higher risk for OSA. Common
goal of decreasing long-term symptoms include frequent snoring, See Appendix 3 for more
cardiovascular morbidity and gasps or labored breathing during information on the initial
mortality. sleep, disturbed sleep, daytime management of OSA.
TABLE 14 Definitions and Criteria for PCOS

Definition Diagnostic Criteria
National Institutes of Health Requires the presence of:
1. Hyperandrogenism (clinical and/or biochemical)
2. Ovarian dysfunction
American Society of Reproductive Medicine (Rotterdam) Requires the presence of at least 2 criteria:
2. Ovulatory dysfunction
3. Polycystic ovarian morphology
American Endocrine Society Requires the presence of hyperandrogenism (clinical and/or biochemical) and either:
1. Ovulatory dysfunction
2. Polycystic ovarian morphology
Androgen Excess and Polycystic Ovary Syndrome Society Requires the simultaneous presence of:
2. Ovarian dysfunction (ovulatory dysfunction and/or polycystic ovarian morphology)
All of the diagnostic criteria for PCOS require the exclusion of other disorders of adrenal excess, such as nonclassic or late-onset congenital adrenal hyperplasia, Cushing syn-
drome, hyperprolactinemia, hypothyroidism, acromegaly, premature ovarian failure, a virilizing adrenal or ovarian neoplasm, or a drug-related condition.

by guest
D3. Polycystic Ovarian Syndrome prolactin, free thyroxine, thyroid significant reduction in depressive
Polycystic ovarian syndrome (PCOS) is stimulating hormone, and insulin. symptoms following structured
a heterogeneous disorder characterized Interpretation of laboratory results pediatric obesity treatment. Notably,
by hyperandrogenism and disordered should be made in the context of age- no adverse mental health outcomes
ovulatory function and is often appropriate reference ranges; were reported.505 Additionally, the
associated with obesity and insulin therefore, referral to a laboratory that interventions technical report
resistance. The condition increases risk can perform ultrasensitive pediatric indicates that obesity treatment may
for infertility, T2DM, cardiovascular assays is recommended. Routine improve psychosocial outcomes for
disease, and cancer.497 ovarian imaging is not indicated for youth with obesity, including quality
the diagnosis of PCOS in of life.80 Further research in this
Four different sets of criteria have adolescents.498,502 An algorithm for area is needed; however,
been published for diagnosis of evaluation is provided in the pediatricians and other PHCPs
PCOS in adults as outlined by implementation materials from should be aware that obesity
differing professional organizations previously published consensus treatment interventions have not
(Table 14).498 Establishment of recommendations.503 been associated with increased
diagnostic criteria for PCOS in symptoms of depression.80
adolescence has been difficult, See Appendix 3 for more
because characteristic features of information on the initial Evaluation for depression includes
PCOS can be normal physiologic management of PCOS. awareness of symptoms and risk
events during early adolescence.499 factors. Symptoms include
Consensus Recommendation irritability, fatigue, insomnia,
International pediatric and
adolescent specialty societies have The CPG authors recommend excessive sleeping, decline in
made recommendations for pediatricians and other PHCPs: academic performance, family conflict,
diagnosis specific to adolescents, and weight changes. Risk factors
which include the following: Evaluate for menstrual irregularities include personal or family history of
(1) evidence of clinical or and signs of hyperandrogenism depression, substance use, trauma,
biochemical hyperandrogenism, (ie, hirsutism, acne) among female frequent psychosomatic complaints,
and (2) persistent irregular adolescents with obesity to assess psychosocial stressors, and other
menstrual cycles (<20 days or >45 risk for PCOS. mental health conditions. The AAP
days) 2 years after menarche.500 CPG for depression recommends
D4. Depression evaluating adolescents 12 years and
Limited data are available on
prevalence of PCOS in adolescents. The relationship between pediatric older for depression annually using a
Estimates range from 3% to 11%, obesity and depression is less well formal self-report tool, such as the
depending on the criteria for understood than the physical Patient Health Questionnaire-9.506
diagnosis.501 comorbidities; however, Additionally, routine monitoring of
identification of depression is an psychosocial function and using an
Evaluation for PCOS in an adolescent important component of the evaluation tool when a patient
requires first excluding other medical assessment and management of presents with symptoms of
conditions that may cause menstrual pediatric obesity, given its potential depression is recommended.
dysfunction (oligomenorrhea or impact on treatment outcomes.
amenorrhea) and/or signs of A systematic review and meta- If initial evaluation for depression is
androgen excess (acne, hirsutism, or analyses conducted in 2019 showed positive, evaluation with a
alopecia). Additionally, for that children 18 years and younger standardized depression tool should
adolescents, evaluation should occur with obesity have a 32% increased be conducted. Assessment for
2 years after menarche, because odds of having or developing depression should also include
irregular menstrual cycles are not depression compared with children direct, separate interviews with the
uncommon during this timeframe. of healthy weight, with the highest patient and family members to
Laboratory testing may include: odds (44%) among females with include functional impairment at
17-hydroxyprogesterone, total obesity.504 home, school, and peer settings and
testosterone, free testosterone, sex safety and/or suicide risk.506 The
hormone-binding globulin, Studies are limited on the effect of implementation materials include
dehydroepiandrosterone sulfate, treatment of pediatric obesity on additional information and
androstenedione, luteinizing hormone, depression. A recent meta-analysis resources, including tools for
follicle-stimulating hormone, estradiol, of 36 studies found a small but pediatricians and other PHCPs, in

by guest
addition to an assessment and present with knee pain alone or in See Appendix 3 for more
management algorithm.506 addition to hip pain. The pain can information on the initial
happen only with weight bearing or management of SCFE.
See Appendix 3 for more be constant. On physical
information on the initial examination, there is external D.5.b. Blount Disease
management of depression. rotation with passive hip flexion, Blount disease is a growth disorder
limitation of internal rotation and that primarily affects the proximal
Consensus Recommendation
antalgic gait. Pain can also be medial tibial physis and
The CPG authors recommend epiphysis.510,511 It often presents as
elicited passively with internal
pediatricians and other PHCPs: a triad of asymmetric tibia vara,
rotation of the hip. SCFE is
tibial torsion, and precurvatum. As
Monitor for symptoms of characterized as stable if the child
with SCFE, excess weight is a risk
depression in children and can bear weight with or without
factor, because it increases
adolescents with obesity and crutches and as unstable when
mechanical stress on the physis.
conduct annual evaluation for weight-bearing is not possible.509
Blount disease disproportionately
depression for adolescents Because SCFE can be bilateral, the
affects non-Hispanic Black or
12 years and older with a pediatrician or other pediatric Hispanic children.510,511 The reason
formal self-report tool. health care provider needs to for this predilection is unclear, but it
remember to obtain a history and may reflect epigenetic, social, or
D5. Orthopedic Comorbidities exam for the contralateral leg. The cultural factors that affect early
D.5.a. Slipped Capital Femoral Epiphysis history and examination should also ambulation, growth, or obesity.
Slipped capital femoral epiphysis exclude differential diagnoses for Other risk factors include a family
(SCFE) is the most common hip hip pain (eg, infections, history of Blount disease and
disorder in the adolescent period. It inflammation or autoimmune ambulation before 12 months of
occurs between 9 and 16 years of conditions, neoplasms, and trauma). age.510,511 Symptoms and signs
age, spanning periods of rapid linear include leg pain, abnormal gait with
growth. There is a 1.5:1 male-to- As the pathophysiologic process bowing of the lower legs, and leg-
female ratio, and SCFE occurs more continues, the child is at greater risk length discrepancy.
often in Black, Hispanic, and AI/AN for increased morbidity, including
children.507,508 SCFE is bilateral in avascular necrosis. Thus, the Blount disease is classified into 2
25% to 80% of cases.507 Weakening importance of early diagnosis categories: (1) infantile or early-
of the proximal femoral physis cannot be overemphasized. Once onset, and (2) late-onset or
(growth plate) causes a slip in the SCFE is suspected, pediatricians and adolescent Blount disease, based
physis, with a corresponding other PHCPs should confirm the whether the onset occurred before
displacement of the epiphysis diagnosis and place an emergent or after age 10 years, respectively.
(femoral head). Risks such as referral to the orthopedic surgeon. Infantile Blount disease is bilateral
obesity exert mechanical stress on The mainstay for diagnosis is plain but asymmetric, occurs more often
the physis, whereas metabolic radiographs of the hip and pelvis in males, and often includes a
conditions (eg, hypothyroidism, (Table 15). Ultrasonography and preceding history of early
hypopituitarism) weaken the computerized tomography are not ambulation. For young children,
physis, creating the ideal setup for useful. In cases with equivocal pediatricians and other PHCPs
a slip. radiography results and a high index should exclude physiologic bowing
of suspicion, MRI, which is more typically seen during toddlerhood,
The common presentation is hip sensitive at assessing the physis, can which is bilateral but symmetrical
pain, although many children may be obtained. and resolves by age 3 or 4 years. In
TABLE 15 Recommended Imaging for Slipped Capital Femoral Epiphysis and Blount Disease
Condition First-Line Imaging Additional Tests
SCFE Bilateral hip (anteroposterior and lateral), frog-leg radiographs If SCFE is unstable, cross-table lateral radiograph. MRI for
equivocal imaging results, or assess blood supply to
femoral head.
Blount Long leg (anteroposterior and lateral), knee (anteroposterior MRI of the knee to delineate level and extent of deformity,
and lateral) radiographs assess blood supply to physis.a
a
Additional tests are determined by orthopedic surgeon.

by guest
the adolescent subtype, the tibia population-based study in Olmstead headaches. There should also be a
vara deformity is milder, unilateral, County, Minnesota, the incidence of high index of suspicion for IIH with
and predominantly associated with IIH among adult females aged 15 to new-onset headaches and significant
severe obesity.510–513 44 years with obesity was 3.5-fold weight gain (5% to 15% of body
higher than that of all females in weight), particularly when it occurs
Plain radiographs are the initial that age group.517 in the prior 12 to 18 months.518,520
imaging of choice (Table 15). When
used, MRI provides a more sensitive The pathogenesis is unclear, hence Initial evaluation for IIH involves
investigation of the deformity. the name; however, 3 hypothesized conducting comprehensive evaluation
mechanisms are increased venous by the neurologist and ophthalmologist
See Appendix 3 for more pressure, decreased cerebrospinal or at an integrated IIH clinic.
information on the initial fluid (CSF) drainage, and increased
management of Blount disease. CSF production. Other factors See Appendix 3 for more
associated with for IIH include information on the initial
Consensus Recommendations medications (eg, doxycycline, management of IIH.
The CPG authors recommend tetracyclines, retinoic acid,
Consensus Recommendation
pediatricians and other PHCPs: sulfonamides), autoimmune
disorders (eg, systemic lupus The CPG authors recommend
Perform a musculoskeletal pediatricians and other PHCPs:
erythematosus), and hormonal
review of systems and physical
disorders (eg, Cushing disease,
examination (eg, internal hip Maintain a high index of
Addison disease). A higher
rotation in growing child, gait) as suspicion for IIH with new-
prevalence of IIH has also been
part of their evaluation for obesity.
reported in females with PCOS.519 onset or progressive headaches
Recommend immediate and in the context of significant
complete activity restriction, Typical symptoms are persistent weight gain, especially for
nonweight-bearing with use of headaches, pulsatile synchronous females.
crutches, and refer to an orthopedic tinnitus, and visual changes or loss,
surgeon for emergent evaluation, if although the history can be variable. D.6. Summary
SCFE is suspected. PHCPs may Physical examination includes a In summary, a thorough history and
consider sending the child to an fundoscopy for papilledema and a physical examination is invaluable in
emergency department if an thorough neurologic evaluation for guiding pediatricians’ and other
orthopedic surgeon is not available. cranial nerve deficits such as sixth PHCPs’ assessment for comorbidities.
nerve palsy. The presence of altered This section of the CPG, the algorithm
D.5.c. Idiopathic Intracranial Hypertension consciousness or neurologic deficit in Appendix 1, Appendix 3, and the
Idiopathic intracranial hypertension with localized peripheral findings accompanying implementation
(IIH) (previously known as should prompt pediatricians and resources provide a framework for
pseudotumor cerebri) is a other PHCPs to consider another evaluation, reevaluation, and initial
neurologic condition with serious etiology. The serious sequelae for management. Obesity is a linchpin
long-term morbidity.514,515 It occurs IIH is vision loss. Thus, a review of disorder with attendant comorbidities,
most often in females of child- system should be obtained to some of which are not covered in this
bearing age, and obesity is a well- evaluate any child with obesity who section or in the technical report (eg,
established risk factor.516–518 In a has significant or progressive pes planus). For these comorbidities,
KAS 9. Pediatricians and other PHCPs should treat overweight (BMI $ 85th percentile to <95th percentile) and obesity (BMI $ 95th percentile) in children and adolescents, following the
principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers.

Benefits Early intervention, reduction of comorbidities, long-term health care cost savings, efficiency with coordinated care.
Risks, harms, costs Time, resources, and cost to family, provider, and clinical practice. Stigma felt by patient and parent.
Benefit-harm assessment Benefits outweigh the harms.
Intentional vagueness Frequency of monitoring and duration of longitudinal care not solidified by scientific literature.
Role of patient preference Family and patient’s willingness to discuss weight, attend weight-related visits, undergo obesity-related clinical and
laboratory evaluation.
Exclusions None.
Strength Strong.
Key references 521

by guest
pediatricians and other PHCPs are status. Nonetheless, it is important high risk for weight fluctuation and
encouraged to seek resources to recognize that the following disordered eating patterns,
available through the AAP and other recommendations will require participation in structured,
professional societies. adaptation based on the patient’s supervised weight management
unique medical, family, programs decreases current and
XI. TREATMENT OF CHILD AND developmental, social, and future eating disorder symptoms
ADOLESCENT OVERWEIGHT AND environmental factors. No evidence (including bulimic symptoms,
OBESITY exists, however, to exclude children emotional eating, binge eating, and
with special health care needs, drive for thinness) up to 6 years
A. Obesity is a Chronic Disease complex disease, or developmental after treatment.378,505,523 The
Obesity is a chronic disease and limitations from the treatment structure and underlying principles
should be treated with intensive and options outlined below, except of the primary care-based and
long-term care strategies, provision where specifically noted. intensive health behavior and
of ongoing medical monitoring and lifestyle programs described here
treatment of associated The evidence for pediatric obesity share multiple similarities with
comorbidities and ongoing access to treatment that is presented in this eating disorder programs. These
obesity treatment. As noted CPG shows that several treatments
include a focus on increasing
previously, obesity is associated are effective in treating both obesity
healthful food consumption,
with increased prevalence of and related comorbidities. It is
participating in physical activity for
comorbidities, including abnormal important to note, however, that in
enjoyment and self-care reasons,
lipids, glucose dysregulation and all of these studies, if the treatment
and improving overall self-esteem
other endocrinopathies, abnormal is discontinued, children tend to
and self-concept. Structured and
liver enzymes, and elevated BP. A regain weight and lose the attendant
professionally run pediatric obesity
key component of treating obesity is health benefits. There is limited
treatment is associated with
to concurrently monitor and treat longitudinal evidence about
reduced eating disorder prevalence,
the comorbidities (see Comorbidities durability of weight change after
risk, and symptoms.505,523
section). treatment. The natural course of
obesity across the lifespan is C. Motivational Interviewing
The chronic care model requires characterized by responses to
MI (also discussed in the Evaluation
care to be delivered within the treatment and relapse when
section) is a patient-centered
context of individual patient factors, treatment ends.77 Therefore,
taking into consideration the child’s counseling style that identifies and
continuous coordinated care is
household and familial influences, required to support ongoing obesity reinforces a patient’s own
access to healthy food and activity treatment throughout childhood and motivation for change—in contrast
spaces, and other SDoHs.522 adolescence into young to the more traditional approach in
Recommendations for obesity adulthood.503 which a provider prescribes
treatment should be integrated behavior change. MI guides families
within existing community and B. Evidence-based Pediatric Obesity to identify a behavior to change,
social systems.521 The medical home Treatment Reduces Risks for based on what the parent(s) or child
Disordered Eating feels is important and can be
model is the preferred standard of
care for children who have chronic In the field of pediatric nutrition, in accomplished.524
conditions,522 and the child’s the treatment of both obesity and
medical home should serve as a care eating disorders, concerns have MI does not impose a particular goal
coordinator in the treatment of been raised as to whether diagnosis but is successful when the family
children with obesity, coordinating and treatment of obesity may changes the selected behavior—
with subspecialists, including inadvertently place excess attention which could be nutritional, such as
obesity treatment specialists, and on eating habits, body shape, and reducing sugar-sweetened
community resources. body size and lead to disordered beverages; increasing physical
eating patterns as children grow activity; or engaging in other
Treatment of obesity varies based into adulthood. The literature behaviors, such as eating meals
on individual-level factors. No refutes this relationship, however. together or improving sleep hygiene.
specific studies were found that Cardel et al refer to multiple studies The target of MI is the person who
compare different treatments by a that have demonstrated that, is responsible for the behavior
patient’s underlying condition, although obesity and self-guided change. Pediatricians and other
special needs, or developmental dieting consistently place children at PHCPs focus on parent motivation

by guest
when patients are preadolescent or families are ready. And regardless of pediatricians and other PHCPs may
younger, and transition to patient their readiness to engage in more have better traction discussing what
motivation, usually combined with “active” obesity treatment, all the patient hopes to accomplish
parent motivation, when patients patients need follow-up, physically than attempting to incite
reach adolescence. encouragement, and monitoring of concern about potential future
health status. disease. Likewise, encouraging a
MI consists of 4 processes: engaging, very self-conscious patient to
focusing, evoking, and planning. The MI process of focusing furthers exercise in a public setting may
These processes, described below, respect for the autonomy of the come across poorly. Taking time to
are particularly salient when patient and family. Behavior change evaluate individuals’ values, goals,
discussing weight status and is the patient’s and family’s decision,
and barriers is a critical piece of
devising a change plan.524 not the pediatrician’s or other
assessing readiness to change.
PHCP’s. Identifying behaviors to
The MI process of engaging is change is a collaborative process. With regard to the MI process of
facilitated by the existing medical Caregivers and pediatricians (or planning, pediatricians and other
pediatrician-patient relationship. other pediatric health care PHCPs can evaluate a patient’s
Through engaging, MI can help providers) tend to feel that the locus
knowledge of what is necessary for
answer the question of whether to of control for pediatric behavior
a particular strategy and what
attempt behavior change. Attempts change resides with the caregiver
resources and support are available
at obesity treatment often fail longer than it actually does,
to them. As a consultant,
because of a disconnect between however. Between 6 and 12 years of
pediatricians and other PHCPs play
pediatricians and other PHCPs who age, a steady shift of control occurs
see impending health problems with a crucial role providing support and
from caregiver to patient. By the
regard to weight status and a guidance for the patient’s
early teen years, the vast majority of
caregiver who sees a thriving, behavioral decisions reside in the collaboratively chosen course of
growing child. The presence of other patient—not the caregiver. action. Because obesity treatment is
challenges—such as financial Therefore, the patient should characterized by frequent setbacks
constraints and other SDOHs, mental increasingly be the target of the and relapses, pediatricians and
illness, or competing health readiness to change assessment and other PHCPs can also serve as
considerations—may make obesity focusing as they age. valuable experts who can assess
treatment a low priority. why behaviors may have reverted
The MI principle of evocation and what strategies might be
An evaluation of these factors is advances the autonomy of the appropriate for patients who seek to
necessary before any action. The patient and family. Pediatricians and “get back on track.”
longitudinal nature of many other PHCPs can evaluate values
pediatrician-family relationships can that are important to the patient Table 16 summarizes MI processes
enable ongoing monitoring of and family. Speaking to an as a way of evaluating and
weight, health status, and family adolescent patient who is more responding to patient readiness to
challenges. More focused obesity concerned about athletic change. Note that the MI tools are
treatment efforts can ensue when performance than health, suggestions; in practice, each tool
TABLE 16 Possible Use of MI to Evaluate and Respond to Readiness to Change392

MI Process Phase of Evaluation Goal Possible MI Tool
Engaging Early, getting to know patient Establishing collaborative role, Open-ended questions, affirmations,
understanding patient issues nonjudgmental graphics, empathic
reflections
Focusing Early and when desire to change Identifying appropriate and productive Readiness ruler, elicit-provide-elicit,
weight status is expressed strategies to change weight status healthy habits survey, identifying and
responding to change talk and sustain
talk
Evoking When behavior change is desired Triggering internal motivation, empowering Values statement, double-sided and
change amplified reflections
Planning When embarking on change Carrying out effective change plan, dealing Readiness ruler, action reflections,
with relapse summarization, teach back, SMART
goals (specific, measurable,
achievable, realistic, and timely)

by guest
KAS 10. Pediatricians and other PHCPs should use motivational interviewing (MI) to engage patients and families in treating overweight (BMI $ 85th percentile to <95th percentile) and
obesity (BMI $ 95th percentile).

Benefits Improvement in BMI, including in low-intensity interventions.
Risks, harms, costs Minimal. Use of MI can add some time to the standard visit.
Benefit-harm assessment Benefit outweighs risk.
Role of patient preference Patient preference is central.
Exclusions Patients who are not responsible for their behavior change, such as children who are young or with developmental
or cognitive impairment. In these situations, MI should target the parent or other caregiver.
Strength Moderate.
Key references 525
may find utility in every phase of low-intensity studies (not aimed at Although much more work is
evaluation. MI evaluation), 1 included MI in needed to examine the optimal
both arms529 and 1 did not use characteristics that might moderate
C.1. Motivational Interviewing and Weight MI.530 MI’s impact, like training, fidelity to
Status the MI process, potential patient
Prospective studies specifically Approximately 23 low-intensity characteristics, as well as target
examining MI have demonstrated studies were ineffective, of which 14 behaviors, the success of the studies
that the approach has positive effect included MI.531–551 These programs in which MI was the core treatment
on weight status, compared with varied in participant age, sample size, supports this KAS.
controls.525–528 The outcomes duration, and other components.
included greater decline in BMI D. Intensive Health Behavior and
percentile or BMI SD score (also Among moderate-intensity Lifestyle Treatment
known as z-score), and less of an interventions (5–25 hours), about
IHBLT is the foundational approach
increase in BMI. These studies were one-third of the approximately 20
to achieve body mass reduction or
all low-intensity treatments (ie, less effective interventions used
the attenuation of excessive weight
than 5 hours) that were delivered in MI.552–574
gain in children. It involves visits of
pediatric primary care practices by
Conversely, approximately one- sufficient frequency and intensity to
medical providers and dietitians who
quarter of the ineffective programs facilitate sustained healthier eating
successfully learned and used MI.
used MI.123,125,150,151,567,575–611 and physical activity habits.79 IHBLT
MI is a tool used with many typically involves engagement with,
different strategies aimed at Use of MI in high-intensity programs and participation of, families in
encouraging nutrition and physical is more difficult to interpret, discussions of necessary treatment
activity change, and so the use of MI because many of these studies based on the severity of disease.
does not guarantee effect. Tables 2 resulted in several publications at It also involves interaction with
and 3 in the technical report on different outcomes points, with pediatricians and other PHCPs
interventions (https://doi.org/ discrepant effects. Some used MI in who are trained in lifestyle-related
10.1542/peds.2022-060642) both study arms.439,610,612–614 An fields and requires significantly
provide an overview of all the estimated one-quarter of the more time and resources than
programs, including impact and use effective high-intensity programs are typically allocated to routine
of MI. Of the 2 additional effective used MI, however.439,612,613,615–622 well-child care.623
TABLE 17 Treatment Intensity and BMI Reduction in Randomized Controlled Trials

Authors Study Population BMI Outcomes Duration
Wilfley (2017) 615
US; ages 7–11; OW/OB; n 5 172 Not reported; “ 6.71 percent overweight” at 8 mo 26–51 h per 8 mo
Butte (2017)642 US; ages 2–12; OW/OB; n 5 549 0.42 at 12 mo; only effective in ages 6–8 >52 h per 12 mo
Nemet (2005)621 Israel; ages 6–16; OB; n 5 46 2.2 at 12 mo 26–51 h per 3 mo
Savoye (2007)439 US; ages 8–16; OB, n 5 174 3.3 at 12 mo, 2.8 at 24 mo >52 h per 12 mo
Vos (2011)617 Germany; ages 7–15; OB; n 5 73 0.2 (BMIz) at 12 mo 26–51 h per 3 mo
Weigel (2008)612 Germany; ages 7–15; OB; n 5 73 4.3 at 12 mo >52 h per 12 mo
Reinehr (2010)643 Germany; ages 7–15; OW/OB; n 5 66 1.5 at 6 mo >52 h per 6 mo
OW, overweight; OB, obese.

by guest
There are known limitations for years of age.625 Although not 26 or more hours: The major
families to access and participate in universally available, treatment factor driving the effectiveness of
IHBLT. These limitations include the programs that provide engaging, IHBLT is the intensity (or dose)
relative scarcity and distribution of group-based physical activity and of the intervention, measured in
such treatment programs and nutrition programming are currently hours of face-to-face patient
pediatricians or other pediatric available in various forms across the contact. The number of hours, or
health care providers with
United States.222,626 Some IHBLT are “dose,” delivered is directly
experience and/or training in proportional to the likelihood a
housed in academic medical centers
pediatric obesity treatment, family child will experience a reduction
transportation challenges, loss of or community hospitals, some are in
in BMI (Table 17). Although a
school or work time to attend primary care offices or obesity
threshold effect was observed at
multiple recurring appointments treatment specialty clinics (ie,
26 or more hours over a 3- to
during what are typically working weight management clinics), and
12-month period, interventions
hours, SDoHs, competing health others are delivered through
that delivered $52 hours of con-
issues for children or family partnerships with local community
tact over the same duration dem-
members, and mismatched entities such as the YMCA627 or onstrated the most consistent and
expectations between the family parks and recreation significant reduction in BMI and
(who may expect significant weight departments.628 Clinic-community cardiometabolic comorbidity
loss) and pediatricians or other partnerships in particular have improvement.625 As described in
pediatric health care providers.624
demonstrated implementation the technical report, 28% of
IHBLT is appropriate for typically
developing children and adolescents
feasibility and are engaging to low- treatments <5 hours,525–527,529,
income and racially diverse 531–535,537–540,546–549,630
as well as CYSHCN, although will 38% of
require modification based on the populations.629 Pediatricians and treatments 5 to 25 hours,527,537,554,
555,557,559,560,563,567,568,570,572,573,
patient’s unique health conditions other PHCPs should investigate local
575–583,602
and developmental factors. programs in the area and become and 75% of treatments
familiar with the referral $26 hours290,554,555,557,559,
560,563,567,568,570,572,573,575–583,602,
The most consistently effective requirements and processes to
604–606,612,617,618,621,631
IHBLT programs deliver 26 or more connect patients with this treatment led to
hours of face-to-face, family-based option (Fig 3). significant improvements in BMI
counseling on nutrition and physical among pediatric participants.80
activity over at least a 3- to 12- Each of the components of the KAS Hence, pediatricians and other
month period, for children aged for below are supported by evidence PHCPs should look for programs
children 6 years and older with that is detailed in the technical that engage families often and
overweight and obesity, with more report on interventions and frequently. No studies directly
limited evidence for children 2 to 5 summarized here: compare the same intervention
Intensive Health Behavior and Lifestyle Treatment (IHBLT)

WHO: WH E N : WH AT: W H ER E: D O SA G E: FORMAT: CHANNEL:
Patient and Promptly for Health education Healthcare setting Longitudinal Group, Face-to-face
family in child or and skill building treatment (strongest
partnership adolescent with on multiple topics across 3-12 evidence)
with a overweight or months with
multidisciplinary obesity ideally > 26
treatment team* Community-based contact hours Individual, or
setting with linkage
Behavior
modification
to medical home
+ Virtual
(growing
and counseling Both evidence)
* PCPs and/or PHCPs with training in obesity as well as other professionals trained in behavior and lifestyle fields such as dietitians, exercise specialists and behavioral health
practitioners
FIGURE 3
Intensive health behavior and lifestyle treatment.

by guest
over a shorter versus longer guided self-help for families.578 summer camp, after school).633
period of time, however. Although there is promising For adolescent populations, the
Face-to-face: Most of the studies evidence that these strategies may evidence and best practices for
included interventions where be successful, more research is including parents in obesity
IHBLT occurred in group settings needed to understand the target treatment is less clear.634 Several
where families gathered together population, effectiveness on health studies measure parental BMI as
in a health care or community outcomes, and implementation a treatment outcome, along with
location, or in a family’s home as potential. adolescent BMI, although none
part of a home visit. Sessions were Family-based: In all effective included in the technical report
led by a variety of individuals or studies, the parent or the family have demonstrated significant
combinations of individuals, unit was included in the treat- reduction in parent BMI.549,566,
568,569,578,563,606,628
including community health ment. Prior evidence has demon- Obesity tends
workers, nutritionists, exercise strated that parent involvement to affect families; thus, family-
physiologists, physical therapists, is associated with early success based treatment has the potential
and social workers. Fewer studies in child obesity treatment632 and to improve the health and weight
evaluated the effectiveness of treat- that family-based interventions status of other household mem-
ment that did not take place in a are more effective in achieving bers, including siblings, although
face-to-face setting, including and sustaining child BMI reduc- no data are available to support
mobile health tools for parents or tion than interventions that tar- this outcome.
adolescents,530,632 telemedicine- get the child without including Multicomponent: Nearly all of the
delivered counseling sessions,557 or the family (ie, school-based, evidence for effective treatment
FIGURE 4
Facilitators for successful health behavior lifestyle treatment (this figure highlights some of the factors that are associated with successful health behavior
and lifestyle treatment).

by guest
of childhood obesity includes Programs often address other preferences, and self-image.
components that focus on components of health as well, Intensive behavioral interventions
healthy eating and physical activ- including getting enough sleep, should be tailored to the child’s
ity. The specific nutritional and reducing sedentary screen time, and developmental abilities and
exercise content varies widely addressing stigma and weight bias. learning skills.
among studies, and is delivered Although these additional elements
in different combinations, so no are generally recognized as positive D.1. Evidence for Effectiveness
one unified approach has demon- and are consistent with anticipatory The 2017 USPSTF recommendation
strated superiority over another. guidance, they do not have evidence for pediatric obesity treatment is
for additional benefit in the context based on high-quality randomized
The physical activity component is of IHBLT. and nonrandomized studies that
more effective when children are demonstrate a significant BMI
engaged in a combination of aerobic Over a 3- to 12-month period: The reduction and were published
and nonaerobic physical activity,635 criteria for the evidence review through January 2016 (n 5 42).79,625
compared with physical activity required a weight-specific out- The evidence review to inform this
counseling. Noncompetitive, come at least 3 months after the CPG additionally included a
intervention started. The ratio- systematic evidence review of
cooperative, fun activities that build
nale for excluding shorter-term randomized and nonrandomized
motor skills as well as self-confidence
lifestyle treatments was to en- interventions leading to BMI
are more engaging for children.
sure that pediatricians and other reduction (March 2020; 214 total
Several studies have noted adaptations
PHCPs focus on treatments that intervention studies of all types; of
for children with obesity, including a have a more-sustained treatment these, 126 were randomized lifestyle
preference for water-based activities effect and that reinforce with pa- studies).
and nonweight-bearing activities rents that obesity does not have
(ie, cycling) and considerations for a “quick fix,” but requires long- The evidence review is additive to
physical therapy or conditioning or term and ongoing attention. the USPSTF review, as it includes
training if a child has a low level of Treatments with duration longer new studies since January 2016 as
fitness. than 12 months are likely to well as studies with a comparative
have additional and sustained effectiveness design. Dose is clearly
Nutrition skill-building sessions that treatment benefit. There is lim- the factor most strongly correlated
involve direct meal preparation or ited evidence, however, to evalu- with treatment outcomes, as
tasting are more effective in ate the durability of effectiveness evidenced by a selection of trials
increasing children’s acceptance of and the ability of long-term treat- that deliver “high intensity” and
new foods and increasing parent ments to retain family “comprehensive” contact over a
confidence to prepare meals at engagement. 2- to 12-month625 or 3- to 12-month
home, compared with nutrition For children 2 to 18 years of age time period.80
education.636 Specific nutritional with overweight and obesity: The
content included in treatment varies USPSTF identified evidence for In research settings simulating
as well. Several studies relied on intensive “lifestyle” treatments clinical practice, intensive behavioral
published guidelines (ie, NHLBI- starting at age 6 years.79 This intervention has evidence for
supported CHILD-1diet), whereas KAS includes children down to effectiveness in lowering child BMI,
others used specific dietary age 2, recognizing that several reducing comorbidities, and
approaches, such as the reduced- recent studies show treatment improving quality of life.
glycemic load diet553,564,574 or using effectiveness in preschoolers 2 to Interventions that provide more
meal replacements.591 5 years of age.565,566,569,570,618, $26 hours of treatment are
631,638,640
Treatment studies de- associated with a reduction in BMI
Several of the more-intensive livered care differently depend- z-score between 0.10 and
programs that demonstrate ing on the child’s age. For 0.50530,565,569,570,612,618,622,641 or a
effectiveness also included a focus example, studies targeting pre- range of 1.6 to 8.1 kg (3.5 to
on mental health and parenting schoolers more often involved 18 lb) weight loss over 1 year.
skills; thus, evidence exists to home visits and focused on Interventions that meet the intensity
support the addition of these parental skills training. Studies or “dose” threshold of 26 hours or
components to increase targeting adolescents more often more over 3 to 12 months can lead
effectiveness.613,618,619,622,637–639 focused on the teen’s autonomy, to clinically significant

by guest
improvements in BMI, systolic and BMI reduction. In randomized D.2. Referral Strategies
diastolic BP, insulin, and glucose studies, effective behavior change Limiting factors to IHBLT
levels and to clinically meaningful uses a family-focused approach.615 effectiveness include lack of
improvements in comorbidities such Parents are taught self-manage- engagement or participation by
as asthma, obstructive sleep apnea, ment for their own behaviors (eg, families and high attrition rates.
and NAFLD.440–444 Interventions role modeling), as well as positive Thus, when referring to more
lasting less than 3 months did not parenting strategies and contin- intensive treatment, pediatricians
demonstrate effectiveness. gency management. Children learn and other PHCPs should inform
goal-setting, body acceptance, and patients and their family members
High-intensity: Greater contact strategies to manage bullying. Ef- about the reason for the referral,
hours lead to greater treatment fective interventions, for example, encourage families to actively
effect. In all of the studies, inter- deliver moderate-to-vigorous phys- participate in the treatment, and
vention dose is most strongly as- ical activity for at least 50 minutes schedule follow-up visits to monitor
sociated with weight outcomes. twice a week for 6 months and progress in the treatment.
Although weight management 40 minutes of nutrition counseling
interventions above a threshold weekly for 6 months.439,645 Nutri- One factor in early attrition may be
of 26 contact hours are generally tion content includes a nondiet, mismatched expectations for weight
effective in reducing excess lifestyle modification approach loss.648 Families can best make
weight (mean BMI z-score reduc- that teaches families to set goals decisions about IHBLT participation
tion 0.2), higher-dose interven- for meal preparation, grocery after providers inform them of
tions with contact time $52 shopping, and learning skills in- commitment and likely outcomes.
hours demonstrate a stronger cluding portion size and label Pediatricians and other PHCPs are
and more consistent BMI reduc- reading.439,612,643 encouraged to help to set
tion effect.625 The mean differ- reasonable expectations for these
ence in change of BMI z-score There is no evidence that obesity outcomes among families, as there is
between controls and interven- treatments harm patients’ quality of a significant heterogeneity to
tions with $52 hours of contact life. Among the studies that included treatment response and there is
is 0.31 (95% CI, 0.16 to quality of life measures, none currently no evidence to predict
0.46), and absolute BMI z-score showed worsening; about one-third how individual children will
reductions in the pooled inter- showed improvement to quality of respond. Many children will not
vention groups is 0.05 to 0.34.625 life.535,555,615,642 More study on experience BMI improvement,
This treatment effect is observed treatments’ impact on mental health particularly if their participation
in children 2 to 16 years of age is needed, however. Few studies falls below the treatment threshold.
but most consistently in children examined mental health impact; As described in the Health Behavior
6 to 12 years of age.642 Savoye although none showed worsening and Lifestyle Treatment section,
showed effective treatment in mental health, all of the studies those who do experience BMI
those 8 to 16 years of age but excluded subjects who had improvement will likely note a
less effectiveness among those established mental health disorders modest improvement of 1% to 3%
13 to 16 years of age,439 and BMI at baseline.553,579,646 BMI percentile decline.396
reduction is driven by the youn-
ger age groups in the Weigel612 The prevalence of eating disorders is D.3. Prompt IHBLT
and Reinehr643 studies. A high not well-characterized in patients A key distinction from prior
dropout rate in obesity treatment participating in obesity treatment,647 recommendations is for
is a known threat to delivering but disordered eating patterns may pediatricians and other PHCPs to
actual treatment hours. In re- be more common among youth with refer as soon as possible to IHBLT.
search settings, attrition rates of obesity compared with youth at a Current practice patterns involve
40% are common439; in real- healthy weight.387 Therefore, counseling in primary care practices,
world settings working with low- pediatricians and other PHCPs often for months to years, before
income families, attrition rates should evaluate patients before, referring to more intensive
can be as high as 60%.644 during, and after intensive behavioral programs. Although providing
Comprehensive: Interventions intervention for the presence of patient-centered and
that include behavior, physical disordered eating (as discussed in nonstigmatizing nutrition and
activity, and nutrition compo- the evaluation section) as well as for activity counseling is important for
nents are associated with child greater-than-expected weight change. children of all weight classifications,

by guest
KAS 11. Pediatricians and other PHCPs should provide or refer children 6 y and older (Grade B) and may provide or refer children 2 through 5 y of age (Grade C) with overweight (BMI $
85th percentile to <95th percentile) and obesity (BMI $ 95th percentile) to intensive health behavior and lifestyle treatment. Health behavior and lifestyle treatment is more effective with
greater contact hours; the most effective treatment includes 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-mo period.
Aggregate Evidence Quality Grade B: Children $6 y of Age. Grade C: Children 2 Through 5 y of Age.
Benefits BMI reduction, quality of life improvement, comorbidity improvement or resolution is associated with 26 or more
hours of face-to-face, family-based, multicomponent treatment over 3 to 12 mo.
Risks, harms, costs Minimal risk or harm. Participation is time-intensive and requires repeated visits. Treatment is costly to administer
and inconsistently paid.
Benefit-harm assessment Benefit outweighs risk.
Intentional vagueness Impact is inconsistent in studies with significant heterogeneity of treatment response. Increasing dose of treatment is
associated with more BMI improvement.
Role of patient preference Patient preference is central.
Exclusions Patients not responsible for their behavior change, such as children who are young or with developmental or
cognitive impairment.
Strength Moderate.
Key references 625
there is no evidence to support is most effective. Thus, RDNs, health On the strength of the literature, the
either watchful waiting or behavior specialists, and exercise USPSTF gives the evidence for
unnecessary delay of appropriate professionals should be part of the intensive “lifestyle” treatment of
treatment of children who have health care team and have critical childhood obesity a “B” rating,
already developed obesity. Many skills for IHBLT. They can work which means that health plans
children are only referred to within a multidisciplinary obesity should cover this care.79,625 The
treatment programs when their treatment clinic, be embedded within USPSTF is authorized by Congress to
obesity has become more a medical home organization so that assign grades to the state of the
severe.529,626 A delay in care they coordinate with pediatricians
evidence regarding treatment
ultimately reduces the likelihood of options for diseases. Under the
and other PHCPs, and participate in
treatment success for the child.649 Affordable Care Act, grades of “A” or
care through referrals. Given the
“B” are mandated to be covered
Similarly, no evidence supports number of children who meet criteria
with no deductibles, copayments, or
selectively referring patients to for treatment, and the current cost-sharing.653 A large gap
obesity treatment programs based on limitations on number of pediatricians currently exists, however, between
those who meet certain criteria, such and other PHCPs who deliver IHBLT, this expectation and the actual
as obesity severity, presence of a significant effort toward medical policies in state Medicaid and
comorbidities, and/or readiness or home capacity-building will be commercial health plans. Health care
motivation to change. Although there needed to achieve equitable access for systems should build the capacity
is currently limited evidence for all children. Current programs are necessary to deliver this evidence-
obesity treatment in children 2 generally located in cities, and often based level of care (see the
through 5 years of age, excess weight in academic centers.651 An individual Implementation Barriers section for
gain in early life predicts future center may or may not offer the more discussion).
obesity650; therefore, future studies entire range of intensive treatment,
should examine treatment in this age E. When Intensive Programs Are Not
including intensive lifestyle, Available
group. Pediatricians and other PHCPs pharmacotherapy, and surgery.
are advised to prioritize the most Pediatricians and other PHCPs are
Providers should be familiar with the
effective treatment available for on the frontline of identifying
treatment programs at local centers;
patients with obesity and encourage overweight and obesity. Consistent
their knowledge of the child and
patients and families to use these success in behavior-based obesity
family, along with awareness of treatment is highly related to
programs at the time of obesity
available options, can guide treatment
diagnosis.555,615,642 treatment intensity. Both individual
direction. Rural communities need and systemic barriers may, however,
It is necessary to provide IHBLT resources and programs, especially keep many families from receiving
within various sites of health care ones that accommodate the distinct the recommended moderate- to
delivery. Face-to-face time with challenges of rural living, including high-intensity multicomponent
pediatricians and other PHCPs cannot transportation and economic and obesity treatment. In addition,
realistically achieve the intensity that cultural factors.652 pediatricians and other PHCPs

by guest
should be aware that pediatric When an IHBLT is not available, noncompetitive, cooperative, fun,
patients who seek bariatric surgical pediatricians and other PHCPs can aerobic and nonaerobic activities.
treatment may encounter significant increase the intensity of weight Behavior goals related to physical
disparities in access to care based management support through activity include aiming for the
on demographics, SES, and collaboration and by connecting physical activity guidelines of
insurance type.654 families with community resources 60 minutes perday of moderate to
to support nutrition and address vigorous physical activity635,642 and
Availability of IHBLT or other
food insecurity (eg, food provision reducing time spent in sedentary
treatments is generally poor, as
programs), physical activity (eg, behavior.656 Physical activity
described in a Children’s Hospital
local parks, recreation programs), limitations, such as joint pain related
Association report in 2013.655
and other SDoHs. Pediatricians and to musculoskeletal comorbidities or
Differences in access based on
other PHCPs should familiarize increased work of breathing related
demographics and similar factors
have not been well studied. A themselves with resources and to severe obesity, should be
consortium of academic centers actively collaborate with other considered, and a stepped care plan
with pediatric weight management specialists and community for a gradual increase in physical
programs reported a high proportion programs. activity can be made. Medicaid and
of publicly insured patients and other insurance plans may restrict
racial and ethnic diversity626; For example, pediatricians and other coverage to specific medical
however, these sites are safety-net PHCPs should assess the availability conditions which do not include
medical centers in larger cities and, and pediatric expertise of local obesity or risk factor reduction.
as such, are a small sample of the dietitians and offer referrals to Providers can search for community
children in the United States with patients where possible. RDNs can programs that follow a philosophy of
obesity. Pediatricians and other assess a child’s nutritional needs, noncompetitive, fun activities, ideally
PHCPs are encouraged to pay including appropriate food groups engaging the whole family. See Figure
attention to difference in care access and portion sizes, and provide 4 for facilitators of successful health
and seek mechanisms to mitigate guidance for specific diet needs and behavior lifestyle treatment.
these challenges.654 preferences, including cultural
patterns. Some RDNs have received
Consensus Recommendations
Although the health care and special certification in pediatric and
payment systems often limit the adolescent obesity, and the Academy The CPG authors recommend that
time and resources available within of Nutrition and Dietetics offers pediatricians and other PHCPs:
the primary care office, families can RDNs additional learning
benefit from guidance outside of opportunities in pediatric and Deliver the best available inten-
intensive programs, including pre adolescent obesity and encourages sive treatment to all children
and postprogram participation. training in patient-centered with overweight and obesity.
Several successful studies have been counseling techniques. RDNs can Build collaborations with other
conducted in the primary care complement the care of medical specialists and programs in their
setting, with less than 5 hours of providers and may be the most communities.
treatment and using individual visits widely available specialist with
rather than group visits. These whom pediatricians and other F. Specific Health Behavior
treatments varied in their approach PHCPs can work to provide more Recommendations
and included clinical decision intensive behavioral intervention.
Many pediatricians and other
support built into electronic health Behavioral health specialists, ideally
PHCPs, especially those in primary
records (EHRs), MI, and a self- integrated into primary care, can
guided curriculum for teens and care, have an important role in
focus on the process of behavior
parents.525,529,591 Strategies that recommending specific health
change, including parenting skills,
may help pediatricians and other role modeling, and consistent behaviors to improve energy
PHCPs include use of EHRs to reinforcement techniques. balance. The following specific
remind and streamline care during health behavior recommendations
office visits, MI training to Implementation tools can help do not form a KAS, because
effectively encourage families to address actions in low-resourced randomized controlled trial (RCTs)
take action, and resources for settings. Exercise specialists can that test each in isolation do not
families to use outside of office provide counseling and training to exist and are unlikely to be
visits. engage children and families in performed.

by guest
Effective programs described in the Pediatricians and other PHCPs gardens, and school wellness
technical report incorporated many should present these specific policies.
nutrition, physical activity, and strategies in the context of MI,
behavior change strategies helping families to identify their Parents and caregivers have a
simultaneously, an approach that is own goals and to determine steps to crucial role to play in obesity
responsive to the multiple behaviors overcome barriers in making treatment through strategies such as
that contribute to energy imbalance. change. The AAP’s Next Steps: A parental monitoring, limit setting,
Single-component interventions, Practitioner’s Guide of Themed reducing barriers, managing family
such as physical activity alone, were Follow-up Visits to Help Patients conflict, and modifying the home
generally not successful, and the Achieve a Healthy Weight provides environment.15,684,685 A systematic
multicomponent studies were not step-by-step strategies for the review of parental involvement in
designed to isolate the impact of one pediatrician or other PHCP on childhood obesity treatment studies
component over another. If the content and delivery of each theme, found that medium- to high-intensity
study target were too narrow (for including portion sizes, screen time parental involvement was associated
example, consumption of 5 fruits and sleep, meal patterns and snacks, with weight-related measures of
and vegetables a day), any impact and bullying and teasing.657,658 treatment effectiveness.686 Parents
on weight or BMI would likely be can serve as role models and provide
too small to detect. Table 18 lists specific behavior support in obesity treatment. In
strategies endorsed by major addition, an enhanced parent-child
Most of the successful interventions professional and public health relationship functions as a mediator
described in the technical report organizations. Some systematic in development of healthier
described nutrition counseling reviews are cited, which include behaviors and further weight
without a structured diet. many association studies, but a control.687 Parents themselves and
(Exceptions were a small study that family relationships may also benefit
comprehensive search for studies
found both low and modified from children’s obesity treatment.
and reviews was not performed.
carbohydrate diets were better than
A recent systematic review found
control,572 and a study that found a Table 19 presents strategies that are
that certain common features
focus on only beverages and a focus common but have not at this time
involving parents in obesity
on multiple nutrition changes were been addressed by the AAP or other
treatment interventions with their
both superior to control but not major health organizations. For
preadolescent children were
different from each other.571) Two some, rigorous systematic reviews
successful in producing nutrition
effective studies of adolescents provide information about potential
and physical activity behavior
implemented caloric restriction of benefit as well as harm or lack of
change. These features include
1300 to 1550 calories per day, but harm. Brief mention of existing
promotion of intrinsic motivation
the interventions also included literature is included, but extensive and self-efficacy through
additional components, such as searches for publications were not empowerment of parents and
physical activity promotion and performed. children and fostering shared value
behavior change strategies.563,591 and whole-family ownership. The
Two small studies found benefit When actively intervening to treat
activities most commonly associated
from interventions that reduced overweight and obesity in the
with positive behavior change
glycemic load.564,574 primary care setting, pediatricians
included parental leadership in goal
and other PHCPs should also
setting, problem solving, social
Despite the lack of evidence for evaluate and address the modifiable support, demonstrating desired
specific strategies on weight risk factors for obesity that are behaviors, and restructuring the
outcomes, many of these strategies described in the Risk Factors home environment. It is encouraging
have clear health benefits and were section. These include parenting that the majority of studies that
components in RCTs of intensive feeding styles, frequency of dining included low-income populations in
behavioral intervention. Many out and eating fast food, and ACEs, this review found favorable
strategies are endorsed by major among other household risk factors. results.688
professional or public health Awareness of supports and barriers
organizations. Therefore, in the patient’s community will also Adolescence can present substantial
pediatricians and other PHCPs can help guide the family to resources challenges to family-based care,
appropriately encourage families to outside the home, such as parks and because this period is marked by a
adopt these strategies. recreation programs, community developmentally normative period of

by guest
TABLE 18 Behavior Strategies
Strategy Description References
Reduction of sugar-sweetened beverages (SSBs) Higher intake of sugar-sweetened beverages Systematic review ; AHA SSB660; AAP sports
659
(carbonated beverages, sweetened beverages, and energy drinks661; AAP fruit juice662
soda, sports drinks, and fruit drinks) is
associated with greater wt gain in adults and
children. The American Heart Association
(AHA) recommends not more than 25 g (6 tsp)
each day of added sugar and not more than 1,
8-oz serving of SSB per week. The AAP
discourages the consumption of sports drinks
and energy drinks for children and
adolescents. The AAP statement on fruit juice
notes that it is a poor substitute for whole
fruit because of its high sugar and calorie
content and pediatricians should advocate for
elimination of fruit juice in children with
excessive wt gain.
Choose My Plate MyPlate is the US Department of Agriculture’s USDA choosemyplate.gov
(USDA) broad set of recommendations for
healthy eating for Americans. These
recommendations include multiple healthy diet
goals: low in added sugar, low in concentrated
fat, nutrient dense but not calorie dense,
within an appropriate calorie range without
defined calorie restriction, and with balanced
protein and carbohydrate. The principles can
be adapted to different food cultures. There is
a surprising dearth of literature on the
impact of these guidelines on health and BMI
outcomes and on the most effective education
practices.
60 min daily of moderate to vigorous physical Aerobic exercise, especially for 60 min at a time, Systematic reviews664–667; AAP physical activity;
activity is associated with improved body weight in Guidelines for Americans379,635
youth although its effect may be small and
variable. It is also associated with better
glucose metabolism profiles. High-intensity
interval training in youth with obesity may
improve body fat, weight, and cardiometabolic
risk factors, although the effect is variable.663
The Physical Activity Guidelines for Americans
recommends 60 min per day for children and
adolescents.
Reduction in sedentary behavior Reduction in sedentary behavior, generally AAP media and young minds170; systematic
defined as reduced screen time, has review656
consistently shown improvement in BMI
measures, although impact is small. Early
studies focused on reduced television, a
discrete activity that is simpler than current
multifunctional electronic devices. The AAP
recommends no media use under age 18 mo,
a 1-h limit for ages 2–5 y, and a parent-
monitored plan for media use in older
children, with a goal of appropriate, not-
excessive use but without a defined upper
limit.
increased desire for independence paradigms for parent involvement in optimize treatment. Further research
and autonomy, despite continued adolescent obesity treatment and detailed reporting are needed to
reliance on parents for many needs. demonstrates mixed findings regarding inform clinical guidelines for optimizing
Given these challenges, the research the ideal level of involvement and the the role of parents in adolescent
investigating specific clinical specific parenting strategies that can obesity treatment.634

by guest
TABLE 19 Common Strategies
Strategy Description References
Avoidance of breakfast skipping Breakfast skipping among children is associated Systematic review668
with overweight and obesity and with lower
quality of dietary intake throughout the day.
Traffic Light Diet This approach to teaching healthy eating has Evidence summary can be found on the
shown consistent success within the context Academy of Nutrition and Dietetics Web site:
of moderate- to high-intensive multicomponent https://www.andeal.org/topic.cfm?cat=1429&
programs, in which experienced providers evidence_summary_id=250033&highlight=
help families learn and use the diet. traffice%20light%20diet&home=1.
5210 This messaging emerged from a consortium of Scant literature on weight or BMI impact.669,670
primary care pediatricians as simple, Attainment of 5-2-1-0 behaviors is low.671
memorable, and feasible (www.mainehealth.
org/Lets-Go/Childrens-Program). Each
component of 5-2-1-0 messaging aligns with a
major recommendation or guideline: 5 fruits
and vegetables a day is consistent with the
USDA ChooseMyPlate recommendations, 2 h or
less of screen time is consistent with earlier
versions of AAP policy; 1 h or more of
moderate to vigorous physical activity is
consistent with Physical Activity
Recommendations for Americans, and 0 (or
nearly no) sugar-sweetened beverages aligns
with USDA, AHA, and AAP.
645,672–683
Use of screen-based physical activity (exergames) Video games that require physical activity can
reduce children’s body wt. Players can reach
levels of light-to-moderate intensity physical
activity during exergame play, especially
games that involve whole-body movement.
Systematic reviews have shown that children
can lose body weight or attenuate weight gain
when playing exergames over a sustained
period of time. Specific setting in which
exergaming resulted in weight, adiposity, or
BMI z-score improvement included home, part
of a structured physical activity program, and
part of a multicomponent obesity treatment.
Children experienced modest reductions in
weight, adiposity, or BMI z-score when
exergames were provided in the home, within
a structured physical activity program, and
within an obesity treatment program. There is
less evidence to date for newer technologies
like smartphone apps and wearables, but
these are promising tools to engage and
sustain youths’ interest in healthy behaviors.
Appropriate amount of sleep for age Obesity is associated with shorter sleep duration, Systematic review243–247
and the association appears to be driven by
increased calorie consumption, decreased
physical activity from fatigue, and potential
hormonal and metabolic alterations such as
increased ghrelin and decreased leptin
leading to hunger.
G. Self-Management chronic disease, the patient and unique challenges to overcome

Obesity is a complex chronic disease family have to manage the demands based on the severity of their
with biologic, environmental, and of the disease and evidence-based disease and the adversity of their
other causative factors that are treatment in the context of these environments. Effective obesity
systemic and operate at the local, factors. This means that individual treatment helps patients and
regional, and global level. As with all patients and their families will have families develop self-management

by guest
strategies that are critical for tailored resources”695 while children with typical development.
chronic disease management in this mitigating barriers, such as This includes assessing health
context. inadequate knowledge or skills or behaviors, identifying community
lack of time.696 For young children resources and policies, sharing
Self-management has been defined and children with disabilities, “self- appropriate resources, and promoting
as “the development of a range of management” may apply to healthy behaviors.697,698 Pediatricians
attitudes, health behaviours and caregivers on behalf of or in and other PHCPs are encouraged to
skills to help minimize the impact of conjunction with the patient. assess risks contributing to obesity in
their condition on all aspects of life collaboration with families and
for themselves and their families The complex environment in which interdisciplinary teams (specialists,
and caregivers.”689 Self-management children and adolescents with psychologists, primary care providers,
has also been described “as a obesity and their families live needs mental health professionals, social
dynamic, interactive, and daily to be acknowledged in the way workers, physical therapists, and
process in which individuals engage providers individualize and tailor dietitians), providing their patients
to manage a chronic illness,”690 and self-management supports. (CYSHCN) and their families with
“the ability of the individual, in essential skills and resources to
conjunction with family, community, H. Treatment Considerations for manage obesity.
and health care professionals, to Children and Youth With Special
manage symptoms; treatments; Health Care Needs In addition, it is critical to recognize
lifestyle changes; and psychosocial, CYSHCN are those who have, or who that CYSHCN may have physical,
cultural, and spiritual consequences are at increased risk for, a chronic emotional, and/or cognitive
of health conditions.”691 For physical, developmental, behavioral, condition(s) preventing them from
example, dietary change is an or emotional condition and who also engaging in community or clinical
important treatment strategy in the require health and related services activities that are available for their
self-management of many chronic of a type or amount beyond that peers with typical development.699
diseases692,693 and is about required by children generally.74 Therefore, creative solutions for
“tailoring support to improve promoting physical activity and
knowledge, skills and confidence”694 It is important that management of healthy nutrition and behavior
by promoting facilitators such as obesity for CYSHCN includes similar change are vital for this special
“location, language, incentive and protocols and processes as those for population. Solutions come from
FIGURE 5
The ICF framework and the F-words.705 Used with permission.

by guest
guidance and supervision from disorders (Table 2) have added associated with attainment of
families, health care providers, and obesity risk and may need healthier weight status.709
community recreation staff for additional supports in obesity
appropriate physical activities and treatment.316 I. Use of Pharmacotherapy
consumption of healthier food
options.700–702 Hyperphagia can be particularly Consensus Recommendation
challenging to manage in CYSHCN. A The CPG authors recommend
It is essential to emphasize the combination of specific behavioral pediatricians and other PHCPs:
numerous benefits of recreational techniques within the context of
activities for CYSHCN to include family-based behavioral treatment May offer children ages 8
improve socialization, fitness level, and the use of pharmacotherapy through 11 years of age with
and motor and movement may be necessary.700 obesity weight loss pharmaco-
skills.703,704 Additional nutrition, therapy, according to medication
Prader Willi syndrome is a complex indications, risks, and benefits, as
physical activity, and sedentary time
genetic disorder affecting 1 in an adjunct to health behavior
recommendations can be found in a
15 000 to 1 in 30 000 people and and lifestyle treatment.
recent report from the Healthy is associated with obesity and
Weight Research Network, an hyperphagia.706,707 Specific
interdisciplinary group of clinical Although IHBLT has the largest
recommendations for health
investigators and experts providing body of evidence meeting the
supervision and multicomponent
evidence review’s high-quality
obesity treatment of children with care can help pediatricians and
evidence for effectiveness criteria, it
autism and other intellectual and/or other PHCPs institute a longitudinal
is important to consider the use of
developmental disabilities.697 treatment approach to care.
pharmacotherapy for children and
The International Classification Hypothalamic obesity is a adolescents who require an
neuroendocrine disorder resulting additional treatment option to
of Functioning (ICF), Disability,
from damage to the hypothalamus, manage their obesity. In particular,
and Health model and AAP
disrupting the body’s energy children with more immediate and
recommendations are appropriate
regulatory system, which requires life-threatening comorbidities, those
frameworks related to assessing
intensive multicomponent who are older, and those affected by
pertinent health conditions and more severe obesity may require
treatment.708
contextual factors affecting additional therapeutic options. For
CYSHCN to aid in planning to treat ADHD is associated with obesity, children younger than 12 years,
obesity, as seen in Fig 5. The ICF and symptoms such as deficits in there is insufficient evidence to
framework can be used to alertness and attention that are provide a KAS for use of
organize approaches in the caused by sleep-disordered pharmacotherapy for the sole
management of childhood obesity. breathing attributable to obesity can indication of obesity. There are,
overlap with those of ADHD. however, specific conditions
Children with obesity-related Impulsivity in ADHD may contribute outlined below for which use of
genetic syndromes, behavioral to dysregulated eating and weight medication may be indicated.
difficulties, developmental gain. Effective treatment of ADHD in Additionally, although the evidence
disabilities, and hypothalamic children with obesity can be is insufficient at the time of this
KAS 12. Pediatricians and other PHCPs should offer adolescents 12 y and older with obesity (BMI $ 95th percentile) weight loss pharmacotherapy, according to medication indications, risks,
and benefits, as an adjunct to health behavior and lifestyle treatment.

Benefits BMI reduction as an adjunct to lifestyle treatment.
Risks, harms, costs Varies by pharmacotherapeutic agent.
Benefit-harm assessment Benefit and harm are individualized by patient, must weigh the side effects and potential benefit of the medication
and patient-specific factors.
Role of patient preference Significant; must determine appropriate timing and duration of treatment, monitor for side effects.
Exclusions Medication-dependent exclusions.
Strengths Moderate.
Key references 710

by guest
evidence review, the use of daily, with gradual increases up to a treatment, and use in children or
pharmacotherapy to aid BMI maximum total daily dose of 2500 mg. adolescents with more severe
reduction in children is a rapidly Adverse effects are dose-dependent, obesity and/or a secondary
evolving field; new evidence may and include bloating, nausea, flatulence, diagnosis, such as prediabetes or
lead to additional options for and diarrhea. Lactic acidosis is a PCOS. Given the modest and
children younger than 12 years in serious but very rare complication in inconsistent effectiveness,
the future. pediatric populations.711 metformin may be considered as an
adjunct to intensive health behavior
Studies Included Metformin has not been approved as and lifestyle treatment and when
At the time of the evidence review a weight-loss drug. A 2020 meta- other indications for use of
for this CPG, 27 randomized studies analysis of metformin studies in metformin are present.
met the inclusion criteria for review, adults with obesity showed modest
and an additional 8 observational (<5%, or 1 BMI unit) weight Orlistat is an intestinal lipase
studies were also considered. The reduction with metformin when inhibitor that blocks fat absorption
majority of the studies evaluated the used as an adjunct to lifestyle; through inhibition of pancreatic and
efficacy of metformin either alone however, the effectiveness is gastric lipase. It is currently
(n 5 16 randomized, 7 observational) inconsistent across different approved for children 12 years and
or in combination with other populations.712 The evidence for older at a dose of 120 mg, 3 times
medications (n 5 7 randomized). effectiveness of metformin for per day. Adverse effects include
weight loss in pediatric populations steatorrhea, fecal urgency, and
Other studies evaluated orlistat
is similarly conflicting. One small flatulence; these adverse effects
(n 5 2 randomized), exenatide
study randomized 39 teens 13 to greatly limit tolerability, and thus,
(n 5 2 randomized), or other
18 years of age with obesity orlistat is uncommonly used in
medications with only 1 study cited
participating in a lifestyle modification pediatric obesity treatment. Orlistat
(phentermine, mixed carotenoids,
program to either metformin is FDA approved for long-term
topiramate, ephedrine, and
hydrocholoride XR 2000 mg, or treatment of obesity in children
recombinant human growth
placebo once daily for 48 weeks.713 12 years and older.729,730
hormone). Since the evidence review,
Adolescents taking metformin reduced
additional high-quality evidence has Glucagon-like peptide-1 receptor
BMI by approximately 1 kg/m2 as
been published to define the safety agonists, such as liraglutide,
compared with a slight increase in
and efficacy of novel agents exenatide, dulaglutide, and
BMI among teens in the lifestyle-only
(setmelanotide, liraglutide, and the semaglutide, decrease hunger by
program.
combination phentermine or slowing gastric emptying and by
topiramate) and are included in this Another well-designed randomized acting on targets in the central
discussion. study of 100 children 6 to 12 years of nervous system. Depending on the
age with severe obesity (mean BMI medication, the formulation is either
Medication Use and Mechanisms of
Action 34.6 kg/m2) showed a BMI reduction oral or a daily or weekly
of approximately 1 kg/m2 at a dose of subcutaneous injection. Two small
Metformin is an antidiabetic agent used 1000 mg twice daily for 6 months, studies of exenatide (weekly
in T2DM among patients 10 years and also as an adjunct to lifestyle injection) among children as young
older. Metformin also has several treatment.714 Gastrointestinal as 8 years showed BMI reduction
indications not approved by the US symptoms limited the tolerated ranging from 0.9 to 1.18 U but with
Food and Drug Administration (FDA), maximum dose in nearly 20% of significant adverse effects. Exenatide
including prediabetes, PCOS, and patients, however, and no additional is currently approved in children 10
prevention of weight gain when used BMI reduction was noted with to 17 years of age with T2DM. A
with atypical antipsychotic treatment beyond 6 months. Of the recent randomized controlled trial
medications. Metformin is a biguanide 16 studies of metformin that met found liraglutide (daily injection)
drug that reduces blood glucose levels quality inclusion criteria for the more effective than placebo in
by decreasing blood glucose evidence review, about two-thirds weight loss at 1 year among patients
production in the liver, decreasing showed modest BMI reduction.713–724 12 years and older with obesity who
intestinal absorption, and increasing One-third showed no benefit.725–728 did not respond to lifestyle
insulin sensitivity. It comes in treatment.710 The magnitude of the
immediate- and extended-release The effective studies typically difference was approximately 4.5 kg
formulations; the recommended included higher metformin doses, body weight lost, or 5% BMI
starting dose is 500 mg, once or twice more intensive lifestyle adjunct reduction. The starting dose is 0.6 mg

by guest
per day up to a maximum dose of centrally through largely unknown to demonstrate safety or efficacy for
3.0 mg per day, by subcutaneous mechanisms. The major adverse the indication of obesity in children.
injection. Adverse effects include effect is cognitive slowing, which
nausea and vomiting, and among can interfere with academic Prescriber Qualifications
patients with a family history of concentration or other activities of Weight loss medications require the
multiple endocrine neoplasia, a daily living. In addition, topiramate same oversight and expertise in
slightly increased risk of medullary is a potential teratogen and requires management as other medications
thyroid cancer.710 Liraglutide is FDA counseling and reliable birth control used in pediatric care. To
approved for long-term treatment of for patients able to become adequately inform patients and
obesity (with or without T2DM) in pregnant. Typical dosing for parents about the risks and benefits
children 12 years and older. headache prevention ranges from of off-label or experimental use of
25 mg a day to 100 mg a day in new therapies, pediatricians and
Melanocortin 4 receptor (MC4R) other PHCPs who prescribe weight
twice daily doses. Although
agonists, such as setmelanotide, act loss medications should have
topiramate has an indication for
on the MC4R pathway to restore knowledge of the patient selection
normal function for appetite treatment of binge eating disorder
criteria, medication efficacy, adverse
regulation that has been disrupted in adults (age $ 18), only 1 study
effects, and follow-up monitoring
because of genetic deficits upstream has evaluated the use of topiramate guidelines. In addition, injectable
of the MC4 receptor. MC4 receptors in children, and it did not differ medications may require additional
in the brain regulate hunger, satiety, from placebo. Topiramate is teaching for families that is not
and energy expenditure. The daily currently FDA approved for children available in all primary care offices.
dose is 1 to 3 mg daily, given 2 years and older with epilepsy and Pediatricians and other PHCPs may
subcutaneously, and results in for headache prevention in children choose to refer to pediatric obesity
weight loss of 12% to 25% over 12 years and older. experts or treatment centers for
1 year in a small, uncontrolled study prescribing weight loss medication.
of patients with these rare deficits. Phentermine and topiramate as a
Common adverse effects include combination medication is approved No current evidence supports
injection site reaction and nausea. for weight loss in adults. Recent weight loss medication use as a
Setmelanotide is FDA approved for data show that among adolescents monotherapy; thus, pediatricians
patients 6 years and older with 12 to 17 years of age with and other PHCPs who prescribe
proopiomelanocortin (POMC) documented history of failure to weight loss medication to children
deficiency, proprotein subtilisin or lose sufficient weight or failure to should provide or refer to intensive
kexin type 1 deficiency, and leptin maintain weight loss in a lifestyle behavioral interventions for patients
receptor deficiency confirmed by modification program (mean age, and families as an adjunct to
genetic testing. 14 years; mean BMI, 37.8 kg/m2), medication therapy.
BMI percent change at 56 weeks
Phentermine is a central was -10.44 (high dose; 15 mg/ J. Pediatric Metabolic and Bariatric
norepinephrine uptake inhibitor but 92 mg) and 8.11 (mid dose; Surgery
also nonselectively inhibits 7.5 mg/46 mg) as compared with It is widely accepted that the most
serotonin and dopamine reuptake placebo.731 Treatment also improved severe forms of pediatric obesity (ie,
and reduces appetite. Recommended HDL and TG cholesterol profiles. $class 2 obesity; BMI $ 35 kg/m2,
doses include 7.5 mg, 15 mg, 30 mg, Adverse events reported were not or 120% of the 95th percentile for
or 37.5 mg, and adverse effects more common than placebo in the age and sex, whichever is lower)
include elevated BP, dizziness, high- or mid-dose range. represent an “epidemic within an
headache, tremor, dry mouth, and epidemic.” Moreover, severe obesity
stomachache. Adverse effects are Lisdexamfetamine is similar in is a harbinger of the establishment
dose-dependent; however, mechanism to phentermine and is a and cumulative progression of
effectiveness does not always stimulant-class medication approved numerous related comorbidities,
increase with increasing dose. for children 6 years and older with diminished long-term health status,
Phentermine is FDA approved for ADHD. It has an indication for and shortened life expectancy.654,739
short-course therapy (3 months) for treatment of binge eating disorder
adolescents 16 years or older. in patients 18 years and older; thus, For adults, the evidence supporting
it is used off-label for children with the clinical indications and
Topiramate is a carbonic anhydrase obesity. However, no evidence is associated recommendations on the
inhibitor and suppresses appetite available at the time of this review use of metabolic and bariatric

by guest
KAS 13. Pediatricians and other PHCPs should offer referral for adolescents 13 y and older with severe obesity (BMI $ 120% of the 95th percentile for age and sex) for evaluation for
metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers.
Aggregate Evidence Quality Grade Ca

Benefits Referral for evaluation to a comprehensive pediatric metabolic and bariatric surgery center may result in the
determination of eligibility for laparoscopic Roux-en-Y gastric bypass or vertical sleeve gastrectomy, which are both
associated with significant and sustained weight loss, accompanied by improvements and/or resolution of
numerous related comorbid conditions, remission of certain cardiometabolic risk factors, and improvements in
weight-related quality of life.
Risks, harms, costs Minor perioperative risks may occur in up to 15% of patients, and major perioperative risks may occur in up to 8%
of patients. Subsequent related procedures may be required in 13% to 25% of patients up to 5 y following surgery.
Vitamin deficiencies are common and need long-term monitoring and potential intervention. Health care costs and
costs to families (eg, time, recovery).
Benefit-harm assessment Perioperative risks considered within acceptable tolerances compared with other elective surgical abdominal
procedures. Benefit and harm are patient-specific with generally accepted safety profiles within the context of
perceived long-term post-procedural benefits (ie, reduction in comorbid disease burden), resulting in improved
health status and quality of life.
Intentional vagueness This action statement does not recommend surgery for all who have severe obesity but rather the opportunity for
children, adolescents, and families to consider and undergo evaluation.
Role of patient preference Significant; must determine appropriate timing of intervention and comprehension of treatment plan.
Exclusions Not applicable.
Strength Moderate.
Key references 126, 654, 732–738
a
This KAS was given a Grade C recommendation, as available evidence is from observational and case-controlled studies. As described in the methods section for the evidence re-
view, only randomized and comparative effectiveness studies were included for the CPG. The Evidence Review Panel made the decision to include observational and case-control
studies specifically for surgical interventions only, because of ethical considerations and practical challenges to randomization.
surgery is founded on a body of adjustable gastric band procedures, significantly lower magnitude of
literature that has been expanding approved by the FDA only for efficacy of intensive behavioral
since the early 1960s.740 patients 18 years and older, have interventions—compared with
Corresponding analyses related to declined in use in both adults and larger and more durable
the use of various surgical weight youth because of worse long-term improvements in BMI and
loss procedures in pediatric effects as well as higher-than- comorbidity resolution after
populations have been primarily expected complication
metabolic and bariatric surgery—
established in the last 20 to rates.647,652,654,655,706,732–736,739–744
has led to a significant increase in
30 years. Large contemporary and
well-designed prospective Similar to the adult experience, an pediatric bariatric surgical case
observational studies have expanding body of data shows that volume since the early 2000s.126
compared adolescent cohorts pediatric bariatric patients also
experience durable reduction in The majority of complications following
undergoing bariatric surgical
BMI,152,744–748 as well as significant metabolic and bariatric surgery in the
treatment versus intensive obesity
improvement and/or complete pediatric population are minor (15%),
treatment or nonsurgical controls.
amelioration of several obesity-related occur mostly in the early postoperative
These studies suggest that weight comorbid conditions. These timeframe, and consist of a
loss surgery is safe and effective for include HTN, T2DM, dyslipidemia, combination of postoperative nausea
pediatric patients in comprehensive cardiovascular disease risk factors, and and/or dehydration, although major
metabolic and bariatric surgery weight-related quality of life.152,654,734 perioperative (30-day) complications
settings that have experience have been reported in 8% of
working with youth and their Furthermore, recent evidence individuals.654,733 Subsequent related
families. Laparoscopic Roux-en-Y showing that adolescents had a procedures may be required in 13% to
gastric bypass and vertical sleeve higher probability of remission of 25% of patients up to 5 years
gastrectomy are both commonly certain cardiometabolic risk factors following metabolic and bariatric
performed in the pediatric age (T2DM and HTN) compared with surgery.744,746,747 In addition, recent
group and result in significant and adults highlights the argument that data showing multiple micronutrient
sustained weight loss, accompanied earlier surgical intervention may deficiencies following metabolic and
by improvements and/or resolution impart specific advantages related to bariatric surgery serve to highlight the
of numerous related comorbid the cumulative impact of chronic need for routine and long-term
conditions.732 Laparoscopic obesity-related diseases.736 The monitoring.

by guest
TABLE 20 Criteria for Pediatric Metabolic and Bariatric Surgery733
Weight Criteria Criteria for Comorbid Conditions
Class 2 obesity, BMI $ 35 kg/m or 120% of the 95th percentile for age
2
Clinically significant disease; examples include but are not limited to
and sex, whichever is lower T2DM, IIH, NASH, Blount disease, SCFE, GERD, obstructive sleep apnea
(AHI >5), cardiovascular disease risks (HTN, hyperlipidemia, insulin
resistance), depressed health-related quality of life.
Class 3 obesity, BMI $ 40 kg/m2 or 140% of the 95th percentile for age Not required but commonly present.
and sex, whichever is lower
AHI, apnea-hypopnea index.
Although the determination of use disorder, and pregnancy. recommendations can be made for
eligibility for metabolic and Important elements include the children 12 years and younger.
bariatric surgery relies heavily on a ability to determine the patient’s and
multicomponent and individualized family’s capacity to understand the Age is not the sole determinant of
approach between members of the risks and benefits of metabolic and eligibility for metabolic and bariatric
metabolic and bariatric surgery team, bariatric surgery and adhere to surgery. The pediatrician or other
the patient, and the patient’s parents required lifestyle modifications PHCP should take into account the
or guardians, initial steps toward leading up to and following such patient’s physical and psychosocial
consideration should be provided, intervention. The evaluative process needs. Evaluation for metabolic and
when appropriate, within the medical is rooted in a framework of bariatric surgery should include a
home. Specifically, pediatricians and thoughtful, shared decision making holistic view of the patient and
other PHCPs should be familiar with between the patient, parents(s) and/ family, including individual and
recent and clearly defined clinical and or guardian(s), and medical and social risk factors. Families should
anthropometric benchmarks, which surgical providers and ideally be fully informed of the benefits and
serve as a prompt for the initiation of includes coordinated and ongoing risks of metabolic and bariatric
these discussions with the patient communication with the patient’s surgery, and their preferences are
and family and ongoing bilateral medical home.654,733 paramount. As highlighted in a
communication between the medical recent AAP policy statement, the
home and surgical center654,733 A referral to a comprehensive decision to continue care with a
(Table 20). In addition to knowledge of metabolic and bariatric surgery pediatrician or pediatric medical or
indications for metabolic and bariatric center with experience and surgical subspecialist should be
surgery, pediatricians and other PHCPs expertise in treatment of patients made solely by the patient (and the
should build and maintain skills in younger than 18 years does not family, as appropriate).749
discussing this topic with families in a necessarily mean the child will
nonbiased and sensitive manner. ultimately have surgery. This Insurance authorization is a key
Pediatricians and other PHCPs should referral provides the family with consideration for individuals
also seek to establish a local and/or important information and considering metabolic and bariatric
regional referral mechanism to additional evaluation of risks and surgical intervention regardless of
qualified facilities that offer pediatric- benefits for use in making an age; however, data highlight a
focused metabolic and bariatric informed decision. In the case of significant disparity regarding benefit
surgical services. younger children, recommendations coverage when comparing pediatric
for referral to a comprehensive versus adult populations.126 Efforts
Individual determination of eligibility multidisciplinary obesity treatment to determine coverage availability,
status at the time of referral to a center with surgical capability including potential mitigation
center that offers metabolic and should be considered on a case-by- strategies designed to address
bariatric surgical intervention for the case basis. coverage gaps, should be the focus of
pediatric population involves a early discussions between the family,
comprehensive and multidisciplinary Although data addressing surgical medical home, and metabolic and
assessment of longitudinal BMI and intervention in the younger age bariatric surgical specialty providers.
comorbidity status as well as group are limited, recent Children and adolescents who are
physiologic and psychosocial comparative analysis show referred for evaluation for metabolic
assessment, including the sustained efficacy and similar safety and bariatric surgery should have
determination of potential profiles when compared with this referral visit covered, and those
contraindications such as correctable adolescents.737,738 Additional who are deemed eligible for
causes of obesity, ongoing substance research is needed before broad metabolic and bariatric surgery

by guest
should have their preparation visits, Tailoring treatment to the can also benefit children with
the surgery itself, hospitalization, ongoing and changing needs of obesity include the following:
postoperative visits, and ongoing the individual child or adoles-
cent and the family and A. Provision of Evidence-based Care
care covered.
community context All care provided to children and
K. Comprehensive Obesity Treatment youth with obesity and their
(COT) for Children and Adolescents Who delivers COT? Ideally, primary families should be evidence based
care teams and pediatric weight where possible; where evidence-
The essential components of COT of
management specialty teams will based approaches do not exist, care
children and adolescents include
partner to provide COT for children should be evidence informed and/or
treatment of the obesity as a chronic
and adolescents with obesity. based on promising practices.
disease and evaluation and
Primary care providers evaluate for
management of comorbidities. This As pediatric obesity becomes an
obesity, evaluate for comorbidities,
treatment is delivered by primary increasing public health issue and
and provide patient-centered and
care providers and their teams, in evidence-based nutrition and recognizable chronic disease, it
collaboration with pediatric obesity physical activity guidance, using MI. becomes critical to rely on evidence-
specialists, allied health providers, Some primary care practices may based medicine and or expert
community partners, and metabolic also be able to provide IHBLT and recommendations to establish
and bariatric surgery teams. pharmacotherapeutic options. prevention, assessment, and
IHBLT, regardless of where it is treatment of obesity. To date,
COT: COT includes79,80: delivered, requires the allocation of several guidelines have been
significantly more time and developed and updated to address
Providing intensive, longitudinal obesity in children. Examples
resources than are typical in the
treatment in the medical home provision of routine well childcare. include “Pediatric Obesity—
Evaluating and monitoring child Coordination in the medical home Assessment, Treatment, and
or adolescent for obesity-related with additional professionals, such Prevention: An Endocrine Society
medical and psychological as dietitians, exercise specialists and Clinical Practice Guideline,” and
comorbidities behavioral health practitioners, will “Expert Committee Recommendations
Identifying and addressing social depend on the child’s COT plan and Regarding the Prevention,
drivers of health available resources. Pediatric health Assessment, and Treatment of Child
Using nonstigmatizing ap- care providers can augment COT and Adolescent Overweight and
proaches to clinical treatment with referral to community Obesity.” These guidelines have been
that honor unique individual resources and programs (see critical in moving forward with the
qualities of each child and family algorithm in Appendix 1). prevention, assessment, and
Using MI that addresses nutri- treatment of obesity in children as
tion, physical activity, and health new research is conducted and more
XII. SYSTEMS OF CARE FOR CHILDREN
behavior change using evidence- new evidence becomes available. This
WITH OVERWEIGHT AND OBESITY
based targets for weight reduc- CPG adds to this body of
Obesity is a chronic disease—similar knowledge.15,268,685
tion and health promotion to asthma and diabetes. Children
Setting collaborative treatment and adolescents with obesity have B. Partnership With Children and
goals not limited to BMI stabiliza- the potential to benefit from the Families
tion or reduction, including goals foundational standards for systems Children and families of children
that reflect improvement or reso- of care designed for children and and youth with obesity should be
lution of comorbidities, quality of youth with special health care active and core partners in decision
life, self-image, and other goals re- needs.153,750 CYSHCN are defined as making in all levels of care.
lated to holistic care “those who have or are at increased
Integrating weight management risk for a chronic physical, Patient-centered care involves not
components and strategies across developmental, behavioral, or only an understanding of the family’s
appropriate disciplines, which emotional condition and who also social and cultural context but also an
can include intensive health require health and related services appreciation for their desires as
behavior and lifestyle treatment, of a type or amount beyond that decisions are made about obesity
with pharmacotherapy and required by children generally.”74 treatment. Family desire for treatment
metabolic and bariatric surgery if The principles of the chronic care should not be assumed despite
indicated model and the medical home that attendance at primary care or

by guest
specialty weight management visits. growth charts in educating about plan has been shown in children
Pediatricians’ and other PHCPs’ use of obesity.754 with diabetes mellitus, sickle cell
MI techniques can, however, reinforce disease, and congenital heart
the importance of family-driven D. Medical Home disease.468,756–762 Specifically,
treatment decisions and foster Children With Obesity Should be Cared transition of care plans have been
families’ internal motivation that can for in a Medical Home shown to improve knowledge and
sustain treatment. As a relationship is self-efficacy and help to integrate
The benefits of a medical home for
built with the family, MI can form the the young adult into a new medical
children and youth with obesity
foundation for shared decision making home or neighborhood.757,761,763,764
include streamlined care, efficient
between pediatricians (and other use of resources (home-, school-,
PHCPs) and families about treatment The transition of care literature for
and community-based services),
continuation and intensification.751 childhood obesity is limited but
expanded expertise and
growing.752,765,766 In general,
competence for the involved
The advent of parent and patient transition of care for obesity
providers, establishment of a forum
EHR portals has enabled involves the development of specific
for problem solving, and improved
bidirectional communication goals and a timeline for the
satisfaction for the patient, family,
between families and health care
and provider. Primary care transition.759 This also includes the
teams and can facilitate shared development of a registry type
providers can help identify children
decision making in obesity treatment. system to track and alert
early as obesity is developing and
Additional facilitators may include pediatricians and other PHCPs when
base intervention efforts on family
tools featuring direct input from a child reaches the age of 12 years
dynamics and reduction in high-risk
families, such as care plans and care
dietary and activity behaviors.755 so that outreach to the family to
coordination agreements.752 start the transition process can
Linkages should also be established
A patient decision aid to promote occur.468,762,763 It is generally
between primary care practices and
shared decision-making about
obesity treatment clinics to understood that timing of these
options for adolescent severe obesity
coordinate care with obesity discussions and the actual transition
treatment was found to be feasible
specialists when necessary (eg, of care to an adult primary care
and acceptable by pediatricians (and
psychologist, dietitian, physician). provider(s) or team depends on the
other pediatric health care
The medical home also provides an individual needs of the patient and
providers) and families.753
effective model for implementing family as well as developmental and
C. Provision of Health Care That successful transitions to adult- neurocognitive abilities. It is also
Recognizes Cultural Values oriented systems to treat obesity. understood that these discussions
All services and supports for E. Transition to Adult Primary Care should be ongoing, at least annually.
children and youth with obesity and Providers It is highly recommended that the
their families should be providers and teams should be in
Children and adolescents with obesity
implemented and delivered in a direct communication with each
should have a plan for a transition of
linguistically appropriate and other. Peer support groups are also
accessible manner that recognizes
care to adult primary care providers. highly recommended to assist the
cultural values. Transition of care for children with patient and family and to provide a
obesity to adult primary care peer network as part of the medical
All written materials provided providers is an important field for home.752,767
to children and youth with which evidence and
obesity and their families should recommendations have been The complex nature of obesity
be culturally appropriate and in a developing. Generally, the concept of management and care, including the
manner and format appropriate transition of care highlights the structured changes involved in
for children and their parents or importance of the collaboration of behavioral strategies, the connection
caregivers who have limited the primary and/or subspecialty with community-based programs,
English proficiency, lower levels of pediatric, adolescent, or family and the need for medication therapy
literacy, or sensory impairments. medicine care team, with the adult and surgery for a number of
With families with limited provider who is preparing to children and adolescents with
English proficiency, vigilance assume the role of primary care obesity highlights the importance of
is needed to also provide a provider for a young adult. The a coordinated transition plan,
trained interpreter and use importance of a formal transition frequent communication with the

by guest
patient and family, and between treatment programs. Differences in deduction for companies advertising
providers and teams early payment policies between public unhealthy foods to children; and
on.752,765,766,768,770 and private insurers and restrictive (3) improving nutrition standards
provider networks can make it for food and beverages sold in
XIII. BARRIERS AND challenging for pediatricians and schools outside of meals. Another
RECOMMENDATIONS FOR CPG other PHCPs to achieve consistent simulation study projected that an
IMPLEMENTATION management practices. The overall excise tax on SSBs, banning child-
Pediatricians and other PHCPs and lack of financial support from either directed advertising of fast food, and
families face numerous barriers to insurance companies or families’ providing after-school physical
promoting healthy, active lifestyles inability to pay for treatment activity programs would all reduce
and to supporting obesity treatment programs disincentivizes the obesity prevalence while also
among children. The successful expansion of their availability, and reducing disparities.773
implementation of this CPG into there have not been robust studies
routine practice requires careful on best practices for scaling up and Implementation Consensus
sustaining effective treatment Recommendation 1: The
consideration of barriers and
programs. subcommittee recommends that
facilitators at the policy, community,
practice, and provider level that can the AAP and its membership
For patients and families, efforts to strongly promote supportive
modify implementation,
implement the recommendations for payment and public health policies
effectiveness, and sustainability.
behavior change are also associated that cover comprehensive obesity
A. Policy Level with indirect costs (such as time
prevention, evaluation, and
and costs associated with healthier
At the forefront of the policy-level treatment. The medical costs of
foods and exercise) and are heavily
barriers to the implementation of untreated childhood obesity are
impacted by policies at the federal,
these guidelines are both direct and well-documented and add urgency
state, and local level. These policies
indirect costs that are associated to provide payment for
include agricultural subsidies, school
with recommended evaluation and treatment.122 There is a role for
nutrition, and physical activity
effective treatment of obesity. In AAP policy and advocacy, in
standards and curricula, zoning and
2010 and again in 2017, the USPSTF partnership with other
public spaces to promote safe
designated a grade B classification organizations, to demand more of
physical activity, tax deductions for
for evidence of effectiveness of our government to accelerate
direct advertising of unhealthy foods
childhood obesity screening and progress in prevention and
to minors, and nutrition
high-intensity, family-based treatment of obesity for all children
labeling.771–773 As the recent AAP
behavioral treatment.79 Although a policy statement on the role of
through policy change within and
grade B designation should secure racism in child health and well- beyond the health care sector to
reliable insurance payment under being notes, the long-standing improve the health and well-being
the statutes of the Affordable Care structural racism that has plagued of children. Furthermore, targeted
Act , the lack of payment by insurers these policies manifests in the form policies are needed to purposefully
remains a major barrier to of limited access to high-quality address the structural racism in
childhood obesity treatment.769,770 education, safe neighborhoods for our society that drives the
There is currently no consistent active play, healthy food, and health alarming and persistent disparities
coverage of other evidence-based care for people of certain races and in childhood obesity and obesity-
treatment strategies not explicitly ethnicities.52,774 related comorbidities.
included in the USPSTF
B. Community and Population Level
recommendation. One simulation-based cost
effectiveness analysis of multiple At the community and population
Direct costs to families include interventions for childhood obesity level, SDoHs can limit the
payment for obesity evaluation and found that 3 policies were estimated implementation and prioritization of
treatment that insurers do not pay to be cost-saving; in other words, health behavior recommendations
for, as well as insurance plans with they would save more in health care (including counseling on nutrition,
high deductibles or copays. These costs through reduction in obesity physical activity, sleep, and screen
cost barriers make it difficult for prevalence than it would cost to time) for both pediatricians (or
families to access care, obtain implement.771 The policies are: other PHCPs) and families. These
laboratory testing, attend follow-up (1) implementing an excise tax on SDoHs include food security, safe
visits, and initiate and/or complete SSBs; (2) elimination of the tax neighborhoods and housing, health

by guest
literacy, weight-related parenting to evidence-based pediatric care that will yield improved health
skills, household chaos, and access obesity treatment programs and outcomes for children with obesity.
to transportation. to increase community resources The recent AAP policy statement on
that address social determinants weight stigma highlights the
Many communities lack access to of health in promoting healthy, detrimental effects of weight bias and
evidence-based, high-intensity active lifestyles.521 ineffective approaches to the diagnosis
weight management programs for and management of obesity.28
treatment, either in clinical or C. Practice and Provider Level
community-based settings.775,776 At the practice and provider level, Implementation Consensus
Telehealth and mobile technologies classic barriers to implementation of Recommendation 4: The
are emerging as a potential means guidelines include the lack of time, subcommittee recommends that
to close this access gap, but little is resources, knowledge, awareness, medical and other health
known about the effectiveness of self-efficacy (confidence in one’s professions schools, training
pediatric weight management ability to perform a behavior), and programs, boards, and professional
treatments via these modalities.777 outcome expectancy (the belief that societies improve education and
The well-described digital divide a recommended behavior will lead training opportunities related to
may also limit their utility among to a specific effect).781 Evidence obesity for both practicing providers
populations disproportionately indicates that clinical decision and in preprofessional schools and
impacted by obesity.778,779 A failure support (CDS) can be delivered residency and fellowship programs.
to consider these factors could lead through EHR systems to help Such training includes the
to worsening disparities. overcome some of these practice- underlying physiologic basis for
and provider-level barriers and weight dysregulation, MI, weight
The recent iteration of the Obesity
improve evaluation and effective bias, the social and emotional
Chronic Care Model proposes an
management. Evidence-based CDS impact of obesity on patients, the
integrated framework for the
tools include assessment need to tailor management to
prevention and treatment of
components (ie, flagging abnormal SDoHs that impact weight, and
obesity.521,780 The framework
heights, weights, and BMIs) and weight-related outcomes and other
discusses the importance of
provision of suggestions for obesity emerging science.
coordinating and integrating
approaches to address obesity treatment, such as order sets for
across clinical and community recommended laboratory tests or XIV. EVIDENCE GAPS AND FUTURE
systems as well as stakeholders. other follow-up actions.529,782–784 RESEARCH DIRECTIONS
In doing so, an integrated approach Most pediatric providers currently Research in the field of pediatric
strives to identify and address use EHRs that calculate and plot overweight and obesity has rapidly
barriers to equitable implementation, BMI; however, limitations of EHR increased over the past decade and
access to healthier options, and data systems hinder rapid dissemination supports the evidence-based
sharing. An important part of and implementation of innovations recommendations and guidelines
integration includes the identification to support practice.785–787 contained in this CPG on the
of an integrator or convener that assessment and management of
brings stakeholders together in a Implementation Consensus pediatric overweight and obesity.
collaborative effort to address Recommendation 3: The Although research has progressed in
population health. Integrators are subcommittee recommends that these areas, significant gaps remain
essential to addressing social EHR vendors, health systems, and and are described in detail in the
determinants of health and complex practices implement CDS systems accompanying technical reports. The
problems that no single stakeholder broadly in EHRs to provide gaps and limitations that are most
can address. prompts and facilitate best relevant to pediatricians and other
practices for managing children PHCPs treating children with obesity
Implementation Consensus and adolescents with obesity. include duration and heterogeneity
Recommendation 2: The of treatment effects and limits in our
subcommittee recommends that At the same time, EHRs can only do so understanding of how specific
public health agencies, community much and are ineffective in the treatment components interact.
organizations, health care absence of a clinical workforce that is
systems, health care providers, knowledgeable about evidence-based Duration of treatment effects.
and community members partner obesity treatment and skilled in Limited research with long-term
with each other to expand access delivering high-quality, patient-centered follow-up exists to determine:

by guest
(1) whether treatment leads to techniques, and approaches to comorbidity reevaluation. Consistent
sustained weight improvements, improve retention and family thresholds of laboratory values across
and (2) how comorbidities de- motivation. Further, the limited studies are also needed.
velop throughout childhood. Lon- research on potential synergies
ger-term data are needed to among lifestyle intervention com- Although many treatment studies
establish sufficient weight loss or ponents as well as pharmaceuti- examined change in biomedical
cardiovascular improvements cal and outcomes as markers of secondary
influencing health into adulthood. surgical interventions prevents prevention of comorbidities, few
Heterogeneity of treatment the development of individual- studies in primary care evaluated
effects and special populations. ized treatment plans tailored to a outcomes other than BMI.
Current research does not pro- child’s weight and health status, Additionally, studies that assess if
vide sufficient information about motivation, and readiness. comorbidity assessment and/or
the heterogeneity of treatment diagnosis influences patient and
effects for obesity interventions, Despite these limitations, half of the family engagement in weight
limiting our ability to identify lifestyle randomized-control trials management treatment are lacking.
which treatment is most likely to reviewed were effective in reducing The role of SDoHs and culture in the
be effective for a specific child. adiposity. Reports of future studies treatment of obesity comorbidities
Many factors may increase obe- detailing specific treatment is also limited. Studies examining
sity risk and impact treatment components, implementation of motivation for behavior change
course but are poorly isolated in behavioral approaches, provider related to health outcomes and
studies to date. These factors involvement in clinical practice, and inclusion of SDOH factors in
may include geographical region, the socioeconomic and cultural treatment outcomes are needed.
context of the family and community Finally, most studies provided no or
food insecurity, poverty, ACEs,
are needed to better understand very limited assessment of harms or
and other social drivers. Perhaps
which interventions work, for unintended consequences. In
most importantly, severity of
whom, and in what situations. general, behavioral interventions
obesity has not been clearly con-
carry low-risk of harms; this is not
sidered in most interventions,
In addition to these critical areas for well-documented in the existing
and treatment is likely to have
future research, there are other literature, however, as few studies
different effectiveness in children
limitations that should be considered report adverse events.
with greater severity of disease.
in the context of the guidelines.
Similar to obesity research, most The scope of the evidence review
research on treatment and co- For comorbidity assessment, studies for this CPG did not include primary
morbidities use relatively restric- were mostly cross-sectional, limiting prevention of obesity or assessment
tive inclusion criteria, excluding the ability to assess within-individual and treatment of children 0 to
children with comorbidities changes in comorbidity prevalence 2 years of age. Early prevention of
(including mental health condi- across age and obesity class and, obesity is important, as 1 in 7
tions), children with physical therefore, guidance on the appropriate preschool-aged children already
activity limitations, children with age to begin laboratory evaluation for have obesity, and disparities in
disabilities, or those using medi- cardiometabolic comorbidities. obesity are evident in the first years
cations. In clinical practice, these Epidemiologic studies intended for of life.3 Identification and guidance
children often have the greatest specific age ranges and that examine on treatment strategies in this
need for support in addressing comorbidity prevalence across population are needed. Resources
obesity. different levels of overweight and for primary prevention in children
Limited understanding of obesity would help identify specific of all ages and treatment of children
specific components, dose, and ages and BMI classes with increased younger than 2 years can be found
duration. Published intervention prevalence of cardiometabolic on the AAP Institute for Healthy
studies often provided limited comorbidities to focus further Childhood Weight’s Web site (www.
information about the dose, research. Longitudinal studies would ihcw.aap.org) and are also provided
duration, and specifics of the also help identify the optimal age and in the implementation materials.
intervention components.80 This BMI ranges to begin evaluation and Future CPGs should incorporate the
limitation makes it difficult to are needed to monitor progression of voices of caregivers, children or ado-
provide detailed information comorbidity related to age and BMI lescents, and organizations that rep-
about specific intervention level and provide guidance on the resent families to lend important
content, behavior change recommended frequency of context.

by guest
TABLE 21 List of Gaps
Type of Gap Example of Gap
Epidemiology Key drivers of reducing obesity prevalence
Predictors of severe obesity
Factors associated with obesity among racial and ethnic groups, including impact of
SDoHs on disparities
Identification of medical costs associated with obesity and comorbidities
Definition or measurement Alternative, accurate measurements of adiposity in primary care;
BMI trajectories in clinical practice and response to treatment over time;
BMI trajectories and development of comorbid conditions;
BMI status and trajectories among race/ethnic groups and the impact of social drivers on
BMI status and trajectories
Risk factors Mechanism by which maternal obesity predisposes to adverse outcomes in the offspring
Impact of sedentary behavior alone on BMI and comorbidities
Improved understanding of associations between obesity and food insecurity
Comorbidities Age to begin evaluation for cardiometabolic comorbidities
Frequency of evaluation to monitor progression of comorbidity
Comorbidity identification as motivation for behavior change
Role of social determinants of health in obesity comorbidities, especially among minority
populations
Role of social determinants of health in obesity comorbidities
Treatment Tailored age-based treatment approaches
Evidence-based treatment options for 0–5 5 year-olds
Optimal level of parent involvement among adolescents in weight management
Optimizing MI use with respect to training, fidelity to the MI process, and potential patient
characteristics
Evidence for specific components of intensive lifestyle intervention on BMI trajectory in
clinical practice
Approaches to intensive lifestyle intervention that are most effective, including clustering
of behavioral recommendations, messaging, delivery, and implementation, especially in
primary care
Optimal duration of treatment, including strategies to address attrition and sustainability
Adverse events of treatment
Treatment outcomes by age, degree of obesity, and social determinants of health
Studies reporting long term outcomes are limited
Paucity of published studies reporting negative outcomes
Evaluation of intervention on quality of life and mental health
Studies of EHR tools, including clinical decision support, to improve attention to weight,
counseling, and referral
Telemedicine and electronic and mobile health approaches
Robust community programs with clinical linkages
Cultural considerations in wt management
Systems of care Feasibility of application and benefits of recommended systems of care for CYSHCN in
obesity, including care transition strategies on the adolescents’ and young adult’s
improvements in the treatment of obesity and health outcomes
Barriers to and facilitators of CPG implementation Evidence informing best practices for rapid, cost-effective, and sustainable scale up of
effective treatment program for childhood obesity that balance fidelity with adaptability to
unique contexts
Research addressing the inconclusive evidence around technology-based interventions for
obesity prevention777
CPG, clinical practice guideline; CYSHCN, children and youth with special health care needs; EHR, electronic health record; MI, motivational interviewing.
In addition to the above, a list of ever before that support obesity treatment to each patient as soon as
other gaps and considerations for treatment that is effective, provides they receive the diagnosis of obesity.
further research are provided in ongoing health benefits, supports
Table 21. children and families longitudinally, and As highlighted in the previous
reduces potential harms for disordered sections, there are Key Action
XV. CONCLUSION—PUTTING IT ALL eating. In contrast to previous Statements (KASs) that, collectively,
TOGETHER recommendations, these clinical comprise a holistic patient-centered
Pediatricians and other PHCPs now guidelines highlight the urgency of approach to COT that should be
have more evidence-based tools than providing immediate, intensive obesity coordinated within the context of

by guest
the medical home. These strategies abnormalities in children and Providing or referring to intensive
form the basis for applying adolescents with overweight (BMI IHBLT, as described in KAS 11, is a
evidence-based approaches that take 85th to <95th percentile). foundational aspect of COT.
the child’s health status, family Pediatricians and other PHCPs
system, community context, and For younger children or children should provide or refer children
who are overweight, the 6 years and older and may provide
resources for treatment into
recommendations are more or refer children 2 through 5 years
consideration to create the best
conservative. In KAS 3.1, for with overweight and obesity to
evidence-based treatment plan for IHBLT. IHBLT is more effective with
children 10 years and older with
each individual child. Obesity is a greater contact hours; the most
overweight (BMI 85th to <95th
complex chronic disease but societal effective programs include 26 or
percentile), pediatricians and other
stigma around obesity results in more hours of face-to-face, family-
PHCPs may evaluate for abnormal
pervasive weight bias. This makes based, multicomponent treatment
glucose metabolism and liver
compassionate and sensitive over a 2- to 12-month period. IHBLT
function in the presence of risk
communication with patients and provides ongoing behavioral and
factors for T2DM or NAFLD. In lifestyle support to the child and
families even more imperative
children 2 through 9 years of age family and treatment of obesity-
(see the Communication of BMI and
with obesity (BMI $ 95th related comorbidities.
Weight Status to Children and percentile), pediatricians and other
Parents section). PHCPs may evaluate for lipid Delivering IHBLT requires being
abnormalities. In addition to able to address nutrition and
It is important to recognize that
laboratory evaluation, pediatricians activity in a holistic manner, using a
treatment of obesity is integral to
and other PHCPs should evaluate for family-centered and nonstigmatizing
the treatment of its comorbidities approach that acknowledges
hypertension by measuring blood
and overweight or obesity and structural and contextual drivers of
pressure at every visit starting at
comorbidities should be treated obesity and follows the principles of
3 years of age in children and
concurrently (KAS 4). It is also the chronic care model and medical
adolescents with overweight and
important to consider that a child home, in the same manner as other
with overweight and obesity and obesity (KAS 8). More specific
special health care needs (KAS 9).
their family require longitudinal and guidance for further evaluation for
IHBLT should be delivered by
coordinated care in a medical home each comorbidity is included in the primary care providers and their
(KAS 9) (see algorithm in Appendix 1). Appendices, along with discussion of teams, in collaboration with
other obesity-related comorbidities. pediatric obesity specialists, allied
Measuring BMI and assessing weight health providers, and community
classification (KAS 1) is a screening The purpose of the evaluation is to partners. If IHBLT is not available,
step that is applied to a practice determine the child’s individual the pediatrician or other PHCP
population of children, which allows health status, including the presence should deliver the highest-intensity
and extent of obesity related HBLT possible. In addition, the
the pediatrician and other PHCP’s
comorbidities, obesity risk factors pediatrician or other PHCP serves as
to initiate obesity evaluation.
present in the child’s history and a medical home for the patient,
This evaluation is guided by a
environment, and the resources coordinating care, advocating for the
comprehensive history, physical
available to the family to conduct patient and family, and supporting
examination, and diagnostic studies,
obesity treatment. Most importantly, transition to adult care.
including those for SDoHs,
comorbidities must be addressed
disordered eating, and mental and
concurrently with treatment of Concurrent treatment of obesity and
behavioral health (KAS 2). Overall
obesity (KAS 4). obesity-related comorbidities is
guidance for evaluation of crucial as is the provision of weight
comorbidities is that in children MI is a collaborative approach to loss pharmacologic treatment and
10 years and older, pediatricians conversation about change that is a metabolic and bariatric surgery to
and other PHCPs should evaluate for core component of delivering of COT, patients according to indications,
lipid abnormalities, abnormal including engaging patients and risks, and benefits of these
glucose metabolism, and abnormal families in addressing overweight modalities. Weight loss
liver function in children and and obesity (KAS 10), setting goals, pharmacotherapy and metabolic
adolescents with obesity (BMI $ and promoting participation in bariatric surgery are evidence-based
95th percentile) and for lipid available resources and programs. obesity treatment modalities that

by guest
should be available and offered to
Promptly engage and refer children to intensive HBL T treatment, if available. If intensive HBL T treatment is not available in your area, deliver highest intensity
patients when indicated and should
Use MI to engage patient and families in addressing overweight and obesity, set goals and promote participation or utilization of local resources or programs
For eligible patients with severe obesity, offer referral to a local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery center
always occur along with IHBLT.
Pediatricians and other PHCPs
should offer adolescents 12 years
and older with obesity weight loss
pharmacotherapy, according to
medication indications, risks, and
Offer weight loss pharmacotherapy, to eligible patients, according to medication indications, risks, and benefits, as an adjunct to HBL T.
benefits, as an adjunct to IHBLT
(KAS 12). Pediatricians and other
PHCPs should offer referral for
adolescents 13 and older with
severe obesity for evaluation for
metabolic and bariatric surgery to
local or regional comprehensive
multidisciplinary pediatric metabolic
Manage children with overweight & obesity following principles of chronic care model and medical home
and bariatric surgery centers
Serve as medical home, coordinate care, advocate for family, and support transition to adult care.
(KAS 13; see Table 22).
Role of the Pediatrician or PHCP
Pediatricians and other PHCPs play a

The Continuum of Obesity Care and the Role of PCP or PHCP
crucial role in providing COT as

primary treatment providers, in
coordinating care with subspecialists
and in the community, and in
This CPG uses “evaluation” to describe patient assessment, and “test” to describe specific tests conducted as part of the evaluation.
advocating for obesity treatment
resources and elimination of weight
bias and stigma. Because obesity is a
chronic disease with exacerbations and
Communicate BMI and weight status to patient and family
remissions, children and adolescents

Assess individual, structural, and contextual risk factors
with obesity need appropriate

Order relevant diagnostic studies and laboratories
reassessments of medical and

psychological risks and comorbidities
Treat obesity and comorbidities concurrently
with appropriate modifications to their

Calculate BMI and assess BMI Percentile
Perform comprehensive patient history
treatment plan. COT also requires

Foster self-management strategies
ongoing evaluation and capacity

Refer to subspecialists if needed
building of both practice and

Deliver nonstigmatizing care
HBL T treatment possible.

Assess readiness to change
Measure height and weight
Evaluate for comorbidities0
community resources that can aid the

for surgical evaluation.
family in addressing SDoHs as needed.

Conduct physical exam
Obesity in children and adolescents is

a complex, multifactorial, and treatable
disease. Evidence for successful
treatment, despite stated gaps and
TABLE 22 Role of the Pediatrician or PCHP
complexities, gives hope to patients

and families that pediatricians and
PHCPs can successfully assess and
address the disease of obesity with an
Diagnosis and measurement
individualized and compassionate

approach. In contrast to earlier
practices of watchful waiting or
Treat comorbidities
following a staged approach to

Treat obesity
intensifying treatment, this CPG

Risk factors
Evaluation
supports early treatment at the

Focus
highest level of intensity appropriate

for and available to the child. It is

by guest
hoped that pediatricians and other Sarah C. Armstrong, MD, FAAP Mona Sharifi, MD, MPH, FAAP
PHCPs, health systems, community Sarah E. Barlow, MD, MPH, FAAP Amanda E. Staiano, PhD, MPP
partners, payers, and policy Brook Belay, MD Ashley E. Weedn, MD, MPH, FAAP
makers will recognize the Christopher F. Bolling, MD, FAAP Susan K. Flinn, MA
significance and urgency outlined Kimberly C. Avila Edwards, MD, Jeanne Lindros, MPH
by this CPG to advance the FAAP Kymika Okechukwu, MPA
equitable and universal provision Ihuoma Eneli, MD, MS, FAAP
of treatment of the chronic disease Alyson B. Goodman, MD, MPH, FAAP ACKNOWLEDGMENTS
of obesity in children and Robin Hamre, MPH We thank Pia Daniels, MPH, PMP,
adolescents. Madeline M. Joseph, MD, FAAP Program Manager, Evidence-Based
Doug Lunsford, MEd Medicine Initiatives and Jeremiah
SUBCOMMITTEE ON OBESITY Eneida Mendonca, MD, PhD, FAAP Salmon, MPH, Manager, Clinical Ini-
Sarah E. Hampl, MD, FAAP Marc P. Michalsky, MD, MBA, FAAP tiatives, Institute for Healthy Child-
Sandra G. Hassink, MD, FAAP Nazrat Mirza, MD, ScD, FAAP hood Weight.
Asheley C. Skinner, PhD Eduardo R. Ochoa, Jr, MD, FAAP
filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of
Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this
publication.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances,
may be appropriate.
All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that
time.
DOI: https://doi.org/10.1542/peds.2022-060640
Address correspondence to Sarah Hampl, MD. E-mail: shampl@cmh.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2023 by the American Academy of Pediatrics
FUNDING: No external funding.
FINANCIAL/CONFLICT OF INTEREST DISCLOSURES: An Independent review for bias was completed by the American Academy of Pediatrics. Dr Barlow has disclosed a financial
relationship with the Eunice Kennedy Shriver National Institute of Child Health and Human Development as a co-investigator.
REFERENCES 2007-2008 to 2015-2016. JAMA. evolving policies and their implications.

1. Centers for Disease Control and 2018;319(16):1723–1725 Endocrinol Metab Clin North Am. 2016;
Prevention. Prevalence of childhood 4. Ogden CL, Fryar CD, Martin CB, et al. 45(3):511–520
obesity in the United States. 2021. Trends in obesity prevalence by race 8. Centers for Disease Control and Pre-
Available at: https://www.cdc.gov/ and Hispanic origin-1999-2000 to vention. About social determinants of
obesity/data/childhood.html. Accessed 2017-2018. JAMA. 2020;324(12): health (SDOH). Available at: https://
October 5, 2022 1208–1210 www.cdc.gov/socialdeterminants/
2. Fryar CD, Carroll MD, Afful J. Preva- 5. Centers for Disease Control and about.html. Accessed October 5, 2022
lence of overweight, obesity, and Prevention. Prevalence of childhood 9. Medvedyuk S, Ahmednur A, Raphael D.
severe obesity among children and obesity in the United States. 2021. Ideology, obesity and the social deter-
adolescents aged 2–19 years: United Available at: https://www.cdc.gov/ minants of health: a critical analysis of
States, 1963– 1965 through 2017–2018. obesity/data/childhood.html. Accessed the obesity and health relationship.
NCHS E-Health Stats. 2020. Available at: October 5, 2022 Crit Public Health. 2018;28(5):573–585
https://www.cdc.gov/nchs/data/hestat/ 6. National Institutes of Health. Obesity 10. Kaiser Permanente Research Affiliates,
obesity-child-17-18/obesity-child.htm. Research Task Force. Strategic Plan Evidence-based Practice Center. Multi-
Accessed October 5, 2022 for NIH Obesity Research. Bethesda, component Behavioral Interventions
MD: US Department of Health and for Weight Management in Children
3. Hales CM, Fryar CD, Carroll MD, Human Services, National Institutes of
Freedman DS, Ogden CL. Trends in and Adolescents Who Are Overweight
Health; 2011 or With Obesity: A Systematic Evidence
obesity and severe obesity prevalence in
7. Kyle TK, Dhurandhar EJ, Allison DB. Review for the American Psychological
US youth and adults by sex and age,
Regarding obesity as a disease: Association; Portland, OR: Kaiser

by guest
Permanente Research Affiliates Evi- 21. Pratt CA, Loria CM, Arteaga SS, et al. 32. Vargas CM, Stines EM, Granado HS.
dence-based Practice Center; 2016 A systematic review of obesity Health-equity issues related to child-
11. O’Connor EA, Evans CV, Burda BU, et al. disparities research. Am J Prev Med. hood obesity: a scoping review. J Public
Screening for Obesity and Interven- 2017;53(1):113–122 Health Dent. 2017;77(Suppl 1):S32–S42
tions for Weight Management in Chil- 22. Trust for America’s Health. State of 33. Byrd AS, Toth AT, Stanford FC. Racial
dren and Adolescents: A Systematic obesity 2018: better policies for a disparities in obesity treatment. Curr
Evidence Review for the U.S. Preventive healthier America. Available at: https:// Obes Rep. 2018;7(2):130–138
Services Task Force. Rockville, MD: www.tfah.org/report-details/the-state- 34. Rossen LM, Talih M. Social determi-
Agency for Healthcare Research and of-obesity-2018/. Accessed October 5, nants of disparities in weight among
Quality; 2017 2022 US children and adolescents. Ann
12. Barlow SE, Dietz WH. Obesity evaluation 23. Alvarado SE. Neighborhood Epidemiol. 2014;24(10):705–713.e2
and treatment: expert committee disadvantage and obesity across 35. Raphael JL, Cooley WC, Vega A, et al.
recommendations. Pediatrics. 1998; childhood and adolescence: evidence Outcomes for children with chronic
102(3):E29 from the NLSY children and young conditions associated with parent- and
13. Davis MM, Gance-Cleveland B, Hassink adults cohort (1986-2010). Soc Sci Res. provider-reported measures of the
S, Johnson R, Paradis G, Resnicow K. 2016;57:80–98 medical home. J Health Care Poor
Recommendations for prevention of Underserved. 2015;26(2):358–376
24. Linton JM, Green A; Council on Commu-
childhood obesity. Pediatrics. 2007; 36. Ward ZJ, Long MW, Resch SC, Giles CM,
nity Pediatrics. Providing care for chil-
120(Suppl 4):S229–S253 Cradock AL, Gortmaker SL. Simulation
dren in immigrant families. Pediatrics.
14. Krebs NF, Himes JH, Jacobson D, 2019;144(3):e20192077 of growth trajectories of childhood
Nicklas TA, Guilday P, Styne D. Assess- obesity into adulthood. N Engl J Med.
ment of child and adolescent over- 25. Ogden CL, Carroll MD, Fakhouri TH, 2017;377(22):2145–2153
weight and obesity. Pediatrics. et al. Prevalence of obesity among
37. Australian Institute of Health and
2007;120(Suppl 4):S193–S228 youths by household income and edu-
Welfare. Chronic diseases 2016.
cation level of head of household— Available at: www.aihw.gov.au/chronic-
15. Spear BA, Barlow SE, Ervin C, et al.
Recommendations for treatment of United States, 2011-2014. MMWR Morb diseases/. Accessed September 16,
child and adolescent overweight and Mortal Wkly Rep. 2018;67(6):186–189 2020
obesity. Pediatrics. 2007;120 26. Eales L, Reynolds AJ, Ou S-R. Childhood 38. Simmonds M, Llewellyn A, Owen CG,
(Suppl 4):S254–S288 predictors of adult obesity in the Woolacott N. Predicting adult obesity
16. American Academy of Pediatrics, Chicago Longitudinal Study. Prev Med. from childhood obesity: a systematic
Institute for Healthy Childhood Weight. 2020;132:105993 review and meta-analysis. Obes Rev.
Algorithm for the assessment and 27. Ortega Hinojosa AM, MacLeod KE, 2016;17(2):95–107
management of childhood obesity in Balmes J, Jerrett M. Influence of 39. Jung RT. Obesity as a disease. Br Med
patients 2 years and older. Available school environments on childhood Bull. 1997;53(2):307–321
at: https://downloads.aap.org/AAP/ obesity in California. Environ Res. 2018; 40. Jastreboff AM, Kotz CM, Kahan S, Kelly
PDF/algorithm_brightfutures_032819. 166:100–107 AS, Heymsfield SB. Obesity as a dis-
pdf?_ga=2.59652141.1052480977. 28. Pont SJ, Puhl R, Cook SR, Slusser W; ease: The Obesity Society 2018 position
1664918331-1880284146.1663164182. Section on Obesity; Obesity Society. statement. Obesity (Silver Spring).
Accessed October 5, 2022 Obesity Society. Stigma experienced by 2019;27(1):7–9
17. Timper K, Br€uning JC. Hypothalamic children and adolescents with obesity. 41. Dixon B, Pe~na M-M, Taveras EM. Life-
circuits regulating appetite and Pediatrics. 2017;140(6):e20173034 course approach to racial/ethnic dis-
energy homeostasis: pathways to 29. Kivim€aki M, Vahtera J, Tabak AG, parities in childhood obesity. Adv Nutr.
obesity. Dis Model Mech. 2017; et al. Neighbourhood socioeconomic 2012;3(1):73–82
10(6):679–689 disadvantage, risk factors, and diabetes 42. Council on Community Pediatrics and
18. Baumer Y, Powell-Wiley TM. Interdisci- from childhood to middle age in the Committee on Native American Child
plinary approaches are fundamental Young Finns Study: a cohort study. Lan- Health. Policy statement–health equity
to decode the biology of adversity. Cell. cet Public Health. 2018;3(8): and children’s rights. Pediatrics. 2010;
2021;184(11):2797–2801 e365–e373 125(4):838–849
19. Gao W, Liu J-L, Lu X, Yang Q. Epigenetic 30. Williams DR. Race, socioeconomic 43. Puhl R, Suh Y. Health consequences of
regulation of energy metabolism in status, and health. The added effects weight stigma: implications for obesity
obesity. J Mol Cell Biol. 2021; of racism and discrimination. Ann N Y prevention and treatment. Curr Obes
13(7):480–499 Acad Sci. 1999;896:173–188 Rep. 2015;4(2):182–190
20. Browne NT, Hodges EA, Small L, et al. 31. Marmot M. Social determinants of 44. Kirk SFL, Ramos Salas X, Alberga AS,
Childhood obesity within the lens of health inequalities. Lancet. 2005; Russell-Mayhew S. Canadian Adult Obe-
racism. Pediatr Obes. 2022;17(5):e12878 365(9464):1099–1104 sity Clinical Practice Guidelines:

by guest
Reducing Weight Bias in Obesity Man- racism, classism, and sexism: shared differential effect of adverse childhood
agement, Practice and Policy. forms of harassment in adolescents. J experiences in US children. Acad Pe-
Edmonton, Alberta: Canadian Associa- Adolesc Health. 2013;53(1): diatr. 2017;17(7S):S70–S78
tion of Bariatric Physicians and 47–53 66. Elsenburg LK, van Wijk KJE, Liefbroer
Surgeons, Obesity Canada; 56. Hunte HER. Association between per- AC, Smidt N. Accumulation of adverse
2020 ceived interpersonal everyday discrimi- childhood events and overweight in
45. Keating DP, Hertzman C, eds. Develop- nation and waist circumference over a children: a systematic review and
mental Health and the Wealth of Na- 9-year period in the Midlife Develop- meta-analysis. Obesity (Silver Spring).
tions: Social, Biological, and ment in the United States cohort study. 2017;25(5):820–832
Educational Dynamics. New York, NY: Am J Epidemiol. 2011;173(11):
67. Suglia SF, Koenen KC, Boynton-Jarrett
Guilford Press; 1999 1232–1239
R, et al; American Heart Association
46. Krieger N. A glossary for social epide- 57. Hunte HER. Association between per- Council on Epidemiology and Preven-
miology. J Epidemiol Community ceived interpersonal everyday discrimi- tion; Council on Cardiovascular
Health. 2001;55(10):693–700 nation and waist circumference over a Disease in the Young; Council on Func-
9-year period in the Midlife Develop- tional Genomics and Translational Biol-
47. Serdula MK, Ivery D, Coates RJ,
ment in the United States cohort study. ogy; Council on Cardiovascular and
Freedman DS, Williamson DF, Byers T.
Am J Epidemiol. 2011;173(11): Stroke Nursing; and Council on Quality
Do obese children become obese
1232–1239 of Care and Outcomes Research. Child-
adults? A review of the literature. Prev
Med. 1993;22(2):167–177 58. Lewis TT, Kravitz HM, Janssen I, Powell hood and adolescent adversity and
LH. Self-reported experiences of dis- cardiometabolic outcomes: a scientific
48. Whitehead M, Dahlgren G. What can be statement from the American Heart
crimination and visceral fat in middle-
done about inequalities in health? aged African-American and Caucasian Association. Circulation.
Lancet. 1991;338(8774):1059–1063 women. Am J Epidemiol. 2011;173(11): 2018;137(5):e15–e28
49. American Academy of Pediatrics, 1223–1231 68. Felitti VJ, Anda RF, Nordenberg D, et al.
Committee on Community Pediatrics, 59. Molina KM, Estrella ML, Rivera-Olmedo Relationship of childhood abuse and
Committee on Native American Child N, Frisard C, Lemon S, Rosal MC. It household dysfunction to many of the
Health. Policy statemen–health equity weigh(t)s on you: everyday discrimina- leading causes of death in adults. The
and children’s rights. Pediatrics. 2010; tion and adiposity among Latinos. Adverse Childhood Experiences (ACE)
125(4):838–849 Obesity (Silver Spring). 2018;26(9): Study. Am J Prev Med. 1998;14(4):
50. Jones CP, Truman BI, Elam-Evans LD, 1474–1480 245–258
et al. Using “socially assigned race” to 60. Gmeiner MS, Warschburger P. Intraper- 69. Anda RF, Croft JB, Felitti VJ, et al.
probe white advantages in health sta- sonal predictors of weight bias inter- Adverse childhood experiences and
tus. Ethn Dis. 2008;18(4):496–504 nalization among elementary school smoking during adolescence and adult-
51. Paradies Y, Ben J, Denson N, et al. children: a prospective analysis. BMC hood. JAMA. 1999;282(17):1652–1658
Racism as a determinant of health: a Pediatr. 2020;20(1):408
70. Schuler BR, Vazquez C, Kobulsky JM,
systematic review and meta-analysis. 61. Palad CJ, Yarlagadda S, Stanford FC. Schroeder K, Tripicchio GL, Wildfeuer
PLoS One. 2015;10(9):e0138511 Weight stigma and its impact on paedi- R. The early effects of cumulative and
52. Trent M, Dooley DG, Douge J; Section atric care. Curr Opin Endocrinol Diabe- individual adverse childhood experien-
on Adolescent Health; Council on Com- tes Obes. 2019;26(1):19–24 ces on child diet: examining the role
munity Pediatrics; Committee on 62. Rubino F, Puhl RM, Cummings DE, et al. of socioeconomic status. Prev Med.
Adolescence. The impact of racism on Joint international consensus state- 2021;145:106447
child and adolescent health. Pediatrics. ment for ending stigma of obesity. Nat 71. Wiss DA, Brewerton TD. Adverse child-
2019;144(2):e20191765 Med. 2020;26(4):485–497 hood experiences and adult obesity: a
53. Bell CN, Kerr J, Young JL. Associations 63. Gundersen C, Mahatmya D, Garasky S, systematic review of plausible mecha-
between obesity, obesogenic environ- Lohman B. Linking psychosocial stres- nisms and meta-analysis of cross-sec-
ments, and structural racism vary by sors and childhood obesity. Obes Rev. tional studies. Physiol Behav. 2020;223:
county-level racial composition. Int J 2011;12(5):e54–e63 112964
Environ Res Public Health. 2019; 72. Centers for Disease Control and
64. Slopen N, Goodman E, Koenen KC,
16(5):861 Prevention. Body mass index (BMI).
Kubzansky LD. Socioeconomic and
54. Cozier YCYJ, Yu J, Coogan PF, Bethea other social stressors and biomarkers Available at: https://www.cdc.gov/
TN, Rosenberg L, Palmer JR. Racism, of cardiometabolic risk in youth: healthyweight/assessing/bmi/index.
segregation, and risk of obesity in the a systematic review of less studied html. Accessed October 5, 2022
Black Women’s Health Study. Am J Epi- risk factors. PLoS One. 2013;8(5): 73. Health Resources and Services Admin-
demiol. 2014;179(7):875–883 e64418 istration. National organizations of
55. Bucchianeri MMEM, Eisenberg ME, 65. Halfon N, Larson K, Son J, Lu M, Bethell state and local officials: public health
Neumark-Sztainer D. Weightism, C. Income inequality and the capacity. Available at: https://www.

by guest
hrsa.gov/grants/find-funding/hrsa- withpeople.html. Accessed October 5, Weight-for-Height and Body Mass
20-084. Accessed October 5, 2022 2022 Index-for-Age: Methods and Develop-
74. McPherson M, Arango P, Fox H, et al. A 83. Skinner AC, Skelton JA. Prevalence and ment. Geneva, Switzerland: World
new definition of children with special trends in obesity and severe obesity Health Organization; 2006
health care needs. Pediatrics. 1998; among children in the United States, 92. Barlow SE; Expert Committee. Expert
102(1 Pt 1):137–140 1999-2012. JAMA Pediatr. 2014;168(6): committee recommendations regard-
561–566 ing the prevention, assessment, and
75. Health Resources and Services Admin-
istration. Chronic care model. Available 84. Sokol R, Austin A, Chandler C, et al. treatment of child and adolescent
at: https://www.hrsa.gov/behavioral- Screening children for social determi- overweight and obesity: summary
health/chronic-care-model. Accessed nants of health: a systematic review. report. Pediatrics. 2007;120(Suppl
October 5, 2022 Pediatrics. 2019;144(4):e20191622 4):S164–S192
76. National Center for Chronic Disease 85. US Department of Health and Human 93. American Academy of Pediatrics.
Prevention and Health Promotion. Services, Office of Disease Prevention Evidence-Based Clinical Practice Guide-
About chronic diseases. Available at: and Health Promotion. Healthy people lines Development and Implementation
https://www.cdc.gov/chronicdisease/ 2030. Available at: https://health.gov/ Manual. Itasca, IL: American Academy
about/index.htm. Accessed October 5, healthypeople/objectives-and-data/ of Pediatrics; 2019
2022 social-determinants-health. Accessed 94. Centers for Disease Control and Pre-
October 5, 2022 vention. Childhood obesity causes and
77. American Academy of Pediatrics.
COVID-19 interim guidance. Obesity 86. Expert Panel on Integrated Guidelines consequences. Available at: https://
management and treatment during for Cardiovascular Health and Risk Re- www.cdc.gov/obesity/childhood/causes.
COVID-19. Available at: https://services. duction in Children and Adolescents; html. Accessed October 5, 2022
aap.org/en/pages/2019-novel- National Heart, Lung, and Blood Insti- 95. Centers for Disease Control and
coronavirus-covid-19-infections/ tute. Expert panel on integrated guide- Prevention. Defining childhood obesity.
lines for cardiovascular health and
clinicalguidance/obesity-management- Available at: https://www.cdc.gov/
risk reduction in children and adoles-
and-treatment-during-covid-19/. obesity/childhood/defining.html.
cents: summary report. Pediatrics.
Accessed October 5, 2022 Accessed October 5, 2022
2011;128(Suppl 5):S213–S256
78. Cuda S, Censani M, O’Hara V, Browne 96. Skinner AC, Ravanbakht SN, Skelton JA,
87. Flynn JT, Kaelber DC, Baker-Smith CM,
N, Paisley J. Pediatric Obesity Perrin EM, Armstrong SC. Prevalence
et al. Clinical practice guideline for
Algorithm. Centennial, CO: Obesity of obesity and severe obesity in US
screening and management of high
Medicine Association; 2020–2022 children, 1999-2016. Pediatrics.
blood pressure in children and adoles-
79. Grossman DC, Bibbins-Domingo K, 2018;141(3):e20173459
cents. Pediatrics. 2017;140(6):
Curry SJ, et al; US Preventive Services e20173035 97. Lange SJ, Kompaniyets L, Freedman
Task Force. Screening for obesity in DS, et al; DNP3. Longitudinal trends in
88. Vos MB, Abrams SH, Barlow SE, et al.
children and adolescents: US Preven- NASPGHAN clinical practice guideline body mass index before and during
tive Services Task Force recommenda- for the diagnosis and treatment of the COVID-19 pandemic among persons
tion statement. JAMA. 2017;317(23): nonalcoholic fatty liver disease in chil- aged 2-19 years—United States, 2018-
2417–2426 dren: recommendations from the Ex- 2020. MMWR Morb Mortal Wkly Rep.
80. Skinner AC. Appraisal of clinical care pert Committee on NAFLD (ECON) and 2021;70(37):1278–1283
practices for child obesity prevention the North American Society of Pediat- 98. Lobstein T, Neveux M, Brown T, et al;
and treatment to inform quality ric Gastroenterology, Hepatology and STOP project consortium. Social dis-
improvement. Part I: interventions. Nutrition (NASPGHAN). J Pediatr Gas- parities in obesity treatment for chil-
Pediatrics. 2023;151(2):e2022060642 troenterol Nutr. 2017;64(2):319–334 dren age 3-10 years: a systematic
81. American Academy of Pediatrics, 89. Marcus CL, Brooks LJ, Draper KA, et al; review. Obes Rev. 2021;22(2):e13153
National Resource Center for Patient/ American Academy of Pediatrics. Diag- 99. Vazquez CE, Cubbin C. Socioeconomic
Family-Centered Medical Home. What is nosis and management of childhood status and childhood obesity: a review
a medical home? Available at: https:// obstructive sleep apnea syndrome. of literature from the past decade to
medicalhomeinfo.aap.org/overview/ Pediatrics. 2012;130(3):e714–e755 inform intervention research. Curr
Pages/Whatisthemedicalhome.aspx. 90. American Diabetes Association. 2. Obes Rep. 2020;9(4):562–570
Accessed October 5, 2022 Classification and diagnosis of diabe- 100. Buoncristiano M, Williams J, Simmonds
82. National Center on Birth Defects and tes: standards of medical care in P, et al. Socioeconomic inequalities in
Developmental Disabilities. Communi- diabetes-2021. Diabetes Care. 2021; overweight and obesity among 6- to
cating with and about people with dis- 44(Suppl 1):S15–S33 9-year-old children in 24 countries from
abilities. Available at: https://www.cdc. 91. World Health Organization. WHO Child the World Health Organization European
gov/ncbddd/disabilityandhealth/ Growth Standards: Length/Height-for- region. Obes Rev. 2021;22(Suppl 6):
materials/factsheets/fs-communicating- Age, Weight-for-Age, Weight-for-Length, e13213

by guest
101. Rogers R, Eagle TF, Sheetz A, et al. The 111. Li X, Keown-Stoneman CDG, Lebovic G, adolescents with obesity: report on
relationship between childhood obe- et al; TARGet Kids! Collaboration. The 1300 patients (the Madrid Cohort).
sity, low socioeconomic status, and association between body mass index Pediatr Obes. 2019;14(12):e12565
race/ethnicity: lessons from Massa- trajectories and cardiometabolic risk 120. Messiah SE, Arheart KL, Luke B,
chusetts. Child Obes. 2015;11(6): in young children. Pediatr Obes. 2020; Lipshultz SE, Miller TL. Relationship
691–695 15(8):e12633 between body mass index and meta-
102. Maïano C, Hue O, Morin AJ, Moullec G. 112. Kelly B, West J, Yang TC, Mason D, bolic syndrome risk factors among
Prevalence of overweight and obesity Hasan T, Wright J. The association US 8- to 14-year-olds, 1999 to 2002.
among children and adolescents with between body mass index, primary J Pediatr. 2008;153(2):215–221
intellectual disabilities: a systematic healthcare use and morbidity in early
121. Kompaniyets L, Lundeen EA, Belay B,
review and meta-analysis. Obes Rev. childhood: findings from the Born In
Goodman AB, Tangka F, Blanck HM.
2016;17(7):599–611 Bradford cohort study. Public Health.
Hospital length of stay, charges, and
2019;167:21–27
103. Lynch BA, Agunwamba A, Wilson PM, costs associated with a diagnosis of
et al. Adverse family experiences and 113. Umer A, Kelley GA, Cottrell LE, Giacobbi obesity in US children and youth,
obesity in children and adolescents in P Jr, Innes KE, Lilly CL. Childhood obe- 2006-2016. Med Care. 2020;58(8):
the United States. Prev Med. 2016;90: sity and adult cardiovascular disease 722–726
148–154 risk factors: a systematic review with
122. Finkelstein EA, Graham WC, Malhotra
meta-analysis. BMC Public Health.
104. Bullock A, Sheff K, Moore K, Manson S. R. Lifetime direct medical costs of
2017;17(1):683
Obesity and overweight in American childhood obesity. Pediatrics. 2014;
Indian and Alaska Native children, 114. Andes LJ, Cheng YJ, Rolka DB, Gregg 133(5):854–862
2006–2015. Am J Public Health. EW, Imperatore G. Prevalence of pre-di-
123. Sherwood NE, Levy RL, Seburg EM,
2017;107(9):1502–1507 abetes among adolescents and young
et al. The Healthy Homes/Healthy Kids
adults in the United States, 2005-2016.
105. Centers for Disease Control and Pre- JAMA Pediatr. 2020;174(2):e194498 5-10 Obesity Prevention Trial: 12 and
vention. Obesity among young children 24-month outcomes. Pediatr Obes.
enrolled in WIC. Available at: https:// 115. Moradi M, Mozaffari H, Askari M, 2019;14(8):e12523
www.cdc.gov/obesity/data/obesity- Azadbakht L. Association between
overweight/obesity with depression, 124. Sepulveda AR, Solano S, Blanco M,
among-WIC-enrolled-young-children. Lacruz T, Veiga O. Feasibility, accept-
html. Accessed October 5, 2022 anxiety, low self-esteem, and body
dissatisfaction in children and ability, and effectiveness of a multidis-
106. Ghandour RM, Grason HA, Schempf AH, adolescents: a systematic review and ciplinary intervention in childhood
et al. Healthy people 2010 leading meta-analysis of observational studies. obesity from primary care: Nutrition,
health indicators: how children with Crit Rev Food Sci Nutr. 2022;62(2): physical activity, emotional regulation,
special health care needs fared. Am J 555–570 and family. Eur Eat Disord Rev. 2020;
Public Health. 2013;103(6):e99–e106 28(2):184–198
116. Schwartz BS, Glass TA, Pollak J, et al.
107. Rimmer JH, Yamaki K, Lowry BM, Depression, its comorbidities and 125. Kozioł-Kozakowska A, Wojcik M, Furtak
Wang E, Vogel LC. Obesity and obesity- treatment, and childhood body mass A, Janus D, Starzyk JB. A comparison
related secondary conditions in ado- index trajectories. Obesity (Silver of the impact of two methods of nutri-
lescents with intellectual/developmen- Spring). 2016;24(12):2585–2592 tion-behavioral intervention on se-
tal disabilities. J Intellect Disabil Res. lected auxological and biochemical
117. Akhabue E, Perak AM, Chan C,
2010;54(9):787–794 parameters in obese prepubertal chil-
Greenland P, Allen NB. Racial
108. Must A, Curtin C, Hubbard K, Sikich L, dren-crossover preliminary study. Int J
differences in rates of change of
Bedford J, Bandini L. Obesity preven- Environ Res Public Health.
childhood body mass index and blood
tion for children with developmental 2019;16(16):2841
pressure percentiles. J Pediatr.
disabilities. Curr Obes Rep. 2014;3(2): 2018;202:98–105.e6 126. Inge TH, Coley RY, Bazzano LA, et al;
156–170 PCORnet Bariatric Study Collaborative.
118. de Ferranti SD, Gauvreau K, Ludwig
109. Singh AS, Mulder C, Twisk JW, van Me- Comparative effectiveness of bariatric
DS, Neufeld EJ, Newburger JW, Rifai N.
chelen W, Chinapaw MJ. Tracking of procedures among adolescents: the
Prevalence of the metabolic syndrome
childhood overweight into adulthood: PCORnet bariatric study. Surg Obes Re-
in American adolescents: findings
a systematic review of the literature. lat Dis. 2018;14(9):1374–1386
from the Third National Health and
Obes Rev. 2008;9(5):474–488 Nutrition Examination Survey. 127. Gulati AK, Kaplan DW, Daniels SR. Clini-
110. Freedman DSLH, Lawman HG, Galuska Circulation. 2004;110(16):2494–2497 cal tracking of severely obese chil-
DA, Goodman AB, Berenson GS. Track- 119. Martos-Moreno GA, Martınez-Villanueva dren: a new growth chart. Pediatrics.
ing and variability in childhood levels J, Gonzalez-Leal R, Chowen JA, Argente 2012;130(6):1136–1140
of BMI: The Bogalusa Heart Study. J. Sex, puberty, and ethnicity have a 128. Racette SB, Yu L, DuPont NC, Clark BR.
Obesity (Silver Spring). 2018;26(7): strong influence on growth and meta- BMI-for-age graphs with severe obesity
1197–1202 bolic comorbidities in children and percentile curves: tools for plotting

by guest
cross-sectional and longitudinal youth model of body composition in children: child visits with family nutrition and
BMI data. BMC Pediatr. 2017;17(1):130 density and hydration of fat-free mass physical activity risk assessment on
129. Chambers M, Tanamas SK, Clark EJ, and comparison with simpler models. body mass index. Obes Sci Pract.
et al. Growth tracking in severely Am J Clin Nutr. 1999;69(5):904–912 2019;5(3):220–230
obese or underweight children. 140. Weber DR, Moore RH, Leonard MB, 150. Fedele DA, Janicke DM, McQuaid EL,
Pediatrics. 2017;140(6):e20172248 Zemel BS. Fat and lean BMI reference et al. A behavioral family intervention
curves in children and adolescents for children with overweight and
130. Tucker JM, DeFrang R, Orth J,
and their utility in identifying excess asthma. Clin Pract Pediatr Psychol.
Wakefield S, Howard K. Evaluation of a
adiposity compared with BMI and 2018;6(3):259–269
primary care weight management pro-
percentage body fat. Am J Clin Nutr.
gram in children aged 2-5 years: 151. Forsell C, Gronowitz E, Larsson Y, Kjell-
2013;98(1):49–56
changes in feeding practices, health berg B-M, Friberg P, Mårild S. Four-
behaviors, and body mass index. 141. WHO Expert Consultation. Appropriate year outcome of randomly assigned
Nutrients. 2019;11(3):498 body-mass index for Asian populations lifestyle treatments in primary care of
and its implications for policy and children with obesity. Acta Paediatr.
131. Freedman DS, Sherry B. The validity of
intervention strategies. Lancet. 2004; 2019;108(4):718–724
BMI as an indicator of body fatness
363(9403):157–163
and risk among children. Pediatrics. 152. Inge TH, Laffel LM, Jenkins TM, et al;
2009;124(Suppl 1):S23–S34 142. Freedman DS, Wang J, Maynard LM, Teen–Longitudinal Assessment of Bar-
et al. Relation of BMI to fat and fat-
132. Javed A, Jumean M, Murad MH, et al. iatric Surgery (Teen-LABS) and Treat-
free mass among children and adoles-
Diagnostic performance of body mass ment Options of Type 2 Diabetes in
cents. Int J Obes. 2005;29(1):1–8
index to identify obesity as defined by Adolescents and Youth (TODAY) Con-
body adiposity in children and adoles- 143. Centers for Disease Control and sortia. Comparison of surgical and
cents: a systematic review and meta- Prevention, National Center for Health medical therapy for type 2 diabetes in
analysis. Pediatr Obes. 2015;10(3): Statistics. Clinical growth charts. severely obese adolescents. JAMA
234–244 Available at: https://www.cdc.gov/ Pediatr. 2018;172(5):452–460
growthcharts/clinical_charts.htm.
133. Lohman TG. Advances in Body Compo- Accessed October 5, 2022 153. Hagan JF, Shaw JS, Duncan PM, eds.
sition Assessment. Champaign, IL: Bright Futures: Guidelines for Health
Human Kinetics Publishers; 1992 144. Kuczmarski RJ, Ogden CL, Guo SS, Supervision of Infants, Children, and
et al. 2000 CDC growth charts for the Adolescents, 4th ed. Elk Grove Village,
134. Lazarus R, Baur L, Webb K, Blyth F. United States: methods and develop-
Body mass index in screening for adi- IL: American Academy of Pediatrics;
ment. Vital Health Stat 11. 2002;(246): 2017
posity in children and adolescents: 1–190
systematic evaluation using receiver 154. O’Connor SG, Maher JP, Belcher BR,
operating characteristic curves. Am J 145. Freedman DS, Butte NF, Taveras EM,
et al. Associations of maternal stress
Clin Nutr. 1996;63(4):500–506 Goodman AB, Ogden CL, Blanck HM.
with children’s weight-related behav-
The limitations of transforming very
135. Ryder JR, Kaizer AM, Rudser KD, Dan- iours: a systematic literature review.
high body mass indexes into z-scores
iels SR, Kelly AS. Utility of body mass Obes Rev. 2017;18(5):514–525
among 8.7 million 2- to 4-year-old chil-
index in identifying excess adiposity in dren. J Pediatr. 2017;188:50–56.e1 155. McPherson AC, Hamilton J, Kingsnorth
youth across the obesity spectrum. S, et al. Communicating with children
146. Grummer-Strawn LM, Reinold C, Krebs
J Pediatr. 2016;177:255–261.e2 and families about obesity and weight-
NF; Centers for Disease Control and
136. Wilkes M, Thornton J, Horlick M, et al. Prevention (CDC). Use of World Health related topics: a scoping review of
Relationship of BMI z score to fat Organization and CDC growth charts best practices. Obes Rev.
percent and fat mass in multiethnic for children aged 0-59 months in the 2017;18(2):164–182
prepubertal children. Pediatr Obes. United States. MMWR Recomm Rep. 156. Knierim SD, Rahm AK, Haemer M,
2019;14(1):10.1111/ijpo12463 2010;59(RR-9):1–15 et al. Latino parents’ perceptions of
137. Horlick M, Hediger ML. Measurement 147. World Health Organization. Weight-for- weight terminology used in pediatric
matters. J Pediatr. 2010;156(2): length/height charts. Available at: weight counseling. Acad Pediatr.
178–179 https://www.who.int/tools/child- 2015;15(2):210–217
138. Dioum A, Gartner A, Maire B, Delpeuch growth-standards/standards/weight- 157. McPherson AC, Knibbe TJ, Oake M,
F, Wade S. Body composition predicted for-length-height. Accessed October 5, et al. “Fat is really a four-letter word”:
from skinfolds in African women: 2022 Exploring weight-related communica-
a cross-validation study using 148. Zemel BS, Pipan M, Stallings VA, et al. tion best practices in children with
air-displacement plethysmography and Growth charts for children with Down and without disabilities and their care-
a black-specific equation. Br J Nutr. syndrome in the United States. givers. Child Care Health Dev.
2005;93(6):973–979 Pediatrics. 2015;136(5):e1204–e1211 2018;44(4):636–643
139. Wells JCK, Fuller NJ, Dewit O, Fewtrell 149. Bailey-Davis L, Kling SMR, Wood GC, 158. American Medical Association. Person-
MS, Elia M, Cole TJ. Four-component et al. Feasibility of enhancing well- first Language For Obesity. Policy H-

by guest
440.821. Chicago, IL: American Medical Johnston BC. Influence of unhealthy box of childhood. Soc Sci Res. 2018;
Association; 2017 food and beverage marketing on 76:92–104
159. Ames H, Mosdøl A, Blaasvær N, children’s dietary intake and 180. Isong IA, Rao SR, Bind M-A, Avenda~no
Nøkleby H, Berg RC, Langøien LJ. Com- preference: a systematic review and M, Kawachi I, Richmond TK. Racial and
munication of children’s weight status: meta-analysis of randomized trials. ethnic disparities in early childhood
what is effective and what are the Obes Rev. 2016;17(10):945–959 obesity. Pediatrics. 2018;141(1):
children’s and parents’ experiences 169. Strasburger VC; Committee on e20170865
and preferences? A mixed methods Communications, American Academy 181. Drewnowski A, Specter SE. Poverty
systematic review. BMC Public Health. of Pediatrics. Children, adolescents, and obesity: the role of energy density
2020;20(1):574 and advertising. Pediatrics. 2006; and energy costs. Am J Clin Nutr.
160. Karnik S, Kanekar A. Childhood obesity: 118(6):2563–2569 2004;79(1):6–16
a global public health crisis. Int J Prev 170. Council on Communications and 182. Harvard University, Center on the
Med. 2012;3(1):1–7 Media. Media and young minds. Developing Child. Key concepts.
161. McFarland MR, Wehbe-Alamah HB. Pediatrics. 2016;138(5):e20162591 Toxic stress. Available at: https://
Leininger’s theory of culture care 171. Poulsen MN, Glass TA, Pollak J, et al. developingchild.harvard.edu/science/
diversity and universality: an overview Associations of multidimensional key-concepts/toxic-stress/. Accessed
with a historical retrospective and a socioeconomic and built environment October 5, 2022
view toward the future. J Transcult factors with body mass index trajecto- 183. Baker EH, Rendall MS, Weden MM.
Nurs. 2019;30(6):540–557 ries among youth in geographically Epidemiological paradox or immigrant
162. Swinburn B, Egger G, Raza F. Dissect- heterogeneous communities. Prev Med vulnerability? Obesity among young
ing obesogenic environments: the de- Rep. 2019;15:100939 children of immigrants. Demography.
velopment and application of a 172. Jia P, Dai S, Rohli KE, et al. Natural en- 2015;52(4):1295–1320
framework for identifying and priori- vironment and childhood obesity: a
tizing environmental interventions for 184. Gilbert PA, Khokhar S. Changing die-
systematic review. Obes Rev. 2021; tary habits of ethnic groups in Europe
obesity. Prev Med. 1999;29(6 Pt 22(Suppl 1):e13097
1):563–570 and implications for health. Nutr Rev.
173. Ogden CL, Carroll MD, Curtin LR, Lamb 2008;66(4):203–215
163. Boyland EJ, Halford JC. Television ad- MM, Flegal KM. Prevalence of high
vertising and branding. Effects on eat- 185. Gualdi-Russo E, Zaccagni L, Manzon VS,
body mass index in US children and Masotti S, Rinaldo N, Khyatti M. Obesity
ing behaviour and food preferences in adolescents, 2007-2008. JAMA. 2010;
children. Appetite. 2013;62:236–241 and physical activity in children of im-
303(3):242–249 migrants. Eur J Public Health. 2014;
164. Boyland EJ, Nolan S, Kelly B, et al. Ad- 174. Ogden CL, Carroll MD, Kit BK, Flegal 24(Suppl 1):40–46
vertising as a cue to consume: a sys- KM. Prevalence of obesity in the United
tematic review and meta-analysis of 186. Buttenheim AM, Pebley AR, Hsih K,
States, 2009-2010. NCHS Data Brief. Chung CY, Goldman N. The shape of
the effects of acute exposure to un- 2012;82:1–8
healthy food and nonalcoholic bever- things to come? Obesity prevalence
age advertising on intake in children 175. Ogden CL, Lamb MM, Carroll MD, Fle- among foreign-born vs. US-born Mexi-
and adults. Am J Clin Nutr. 2016; gal KM. Obesity and socioeconomic can youth in California. Soc Sci Med.
103(2):519–533 status in children and adolescents: 2013;78:1–8
United States, 2005-2008. NCHS Data 187. Gualdi-Russo E, Manzon VS, Masotti S,
165. Jenkin G, Madhvani N, Signal L,
Brief. 2010;51(51):1–8 et al. Weight status and perception of
Bowers S. A systematic review of per-
suasive marketing techniques to pro- 176. Babey SH, Hastert TA, Wolstein J, Dia- body image in children: the effect of
mote food to children on television. mant AL. Income disparities in obesity maternal immigrant status. Nutr J.
Obes Rev. 2014;15(4):281–293 trends among California adolescents. 2012;11:85
Am J Public Health. 2010;100(11): 188. Flores G, Fuentes-Afflick E, Barbot O,
166. Smith R, Kelly B, Yeatman H, Boyland E.
2149–2155 et al. The health of Latino children: ur-
Food marketing influences children’s
attitudes, preferences and consump- 177. Children’s Defense Fund. The State of gent priorities, unanswered questions,
tion: a systematic critical review. Nu- America’s Children. Washington, DC: and a research agenda. JAMA. 2002;
trients. 2019;11(4):875 Children’s Defense Fund; 2020 288(1):82–90
167. Villegas-Navas V, Montero-Simo MJ, 178. Lee H, Andrew M, Gebremariam A, 189. Dubois L, Francis D, Burnier D, et al.
Araque-Padilla RA. The effects of foods Lumeng JC, Lee JM. Longitudinal asso- Household food insecurity and child-
embedded in entertainment media on ciations between poverty and obesity hood overweight in Jamaica and
children’s food choices and food in- from birth through adolescence. Am J Quebec: a gender-based analysis. BMC
take: a systematic review and meta- Public Health. 2014;104(5):e70–e76 Public Health. 2011;11:199
analyses. Nutrients. 2020;12(4):964 179. Li M, Mustillo S, Anderson J. Childhood 190. Burke MP, Martini LH, Çayõr E,
168. Sadeghirad B, Duhaney T, poverty dynamics and adulthood over- Hartline-Grafton HL, Meade RL. Severity
Motaghipisheh S, Campbell NR, weight/obesity: unpacking the black of household food insecurity is

by guest
positively associated with mental around schools on obesity-related out- 212. Lovasi GS, Schwartz-Soicher O, Quinn
disorders among children and adoles- comes. Obes Rev. 2014;15(5):359–374 JW, et al. Neighborhood safety and
cents in the United States. J Nutr. 201. Fiechtner L, Kleinman K, Melly SJ, green space as predictors of obesity
2016;146(10):2019–2026 et al. Effects of proximity to supermar- among preschool children from low-in-
191. Gross RS, Mendelsohn AL, Fierman AH, kets on a randomized trial studying income families in New York City. Prev
Racine AD, Messito MJ. Food insecurity terventions for obesity. Am J Public Med. 2013;57(3):189–193
and obesogenic maternal infant feed- Health. 2016;106(3):557–562 213. Ghassabian A, Vandenberg L, Kannan
ing styles and practices in low-income 202. Griffiths C, Frearson A, Taylor A, Radley K, Trasande L. Endocrine-disrupting
families. Pediatrics. 2012;130(2): chemicals and child health. Annu Rev
D, Cooke C. A cross sectional study in-
254–261 Pharmacol Toxicol. 2022;62:573–594
vestigating the association between
192. Coleman-Jensen A, Rabbitt MP, Gregory exposure to food outlets and child- 214. Kassotis CD, Vandenberg LN, Demeneix
CA, Singh A. Household Food Security hood obesity in Leeds, UK. Int J Behav BA, Porta M, Slama R, Trasande L.
in the United States in 2018. Nutr Phys Act. 2014;11:138 Endocrine-disrupting chemicals:
Washington, DC: US Department
203. Zhou Q, Zhao L, Zhang L, et al. Neigh- economic, regulatory, and policy
of Agriculture, Economic Research
borhood supermarket access and implications. Lancet Diabetes
Service; 2019
childhood obesity: a systematic review. Endocrinol. 2020;8(8):719–730
193. Powell LM, Chaloupka FJ. Food prices Obes Rev. 2021;22(Suppl 1):e12937 215. Kahn LG, Philippat C, Nakayama SF,
and obesity: evidence and policy impli-
204. Kim Y, Cubbin C, Oh S. A systematic re- Slama R, Trasande L. Endocrine-dis-
cations for taxes and subsidies.
view of neighbourhood economic con- rupting chemicals: implications for hu-
Milbank Q. 2009;87(1):229–257
text on child obesity and obesity- man health. Lancet Diabetes
194. Sturm R, Datar A. Body mass index in related behaviours. Obes Rev. Endocrinol. 2020;8(8):703–718
elementary school children, metropoli- 2019;20(3):420–431
tan area food prices and food outlet 216. Ebbeling CB, Pawlak DB, Ludwig DS.
205. Yang S, Zhang X, Feng P, et al. Access Childhood obesity: public-health crisis,
density. Public Health. 2005;119(12):
to fruit and vegetable markets and common sense cure. Lancet.
1059–1068
childhood obesity: a systematic review. 2002;360(9331):473–482
195. Sturm R, Datar A. Food prices and Obes Rev. 2021;22(Suppl 1):e12980
weight gain during elementary school: 217. Kral TVE, Moore RH, Chittams J, Jones
206. Demory-Luce D. Fast food and children E, O’Malley L, Fisher JO. Identifying be-
5-year update. Public Health. 2008;
and adolescents: implications for prac- havioral phenotypes for childhood obe-
122(11):1140–1143
titioners. Clin Pediatr (Phila). sity. Appetite. 2018;127:87–96
196. Lee J, Kubik MY, Fulkerson JA. Diet 2005;44(4):279–288
quality and fruit, vegetable, and sugar- 218. Baumrind D. Effects of authoritative
207. Rosenheck R. Fast food consumption parental control on child behavior.
sweetened beverage consumption by
and increased caloric intake: a sys- Child Dev. 1966;37(4) 887–907
household food insecurity among 8- to
12-year-old children during summer tematic review of a trajectory towards
weight gain and obesity risk. Obes 219. Maccoby EE, Martin JA. Socialization in
months. J Acad Nutr Diet. 2019; the Context of the Family: Parent–Child
119(10):1695–1702 Rev. 2008;9(6):535–547
Interaction. New York, NY: Wiley; 1983
197. Adams EL, Caccavale LJ, Smith D, Bean 208. Cobb LK, Appel LJ, Franco M, Jones-
Smith JC, Nur A, Anderson CA. The rela- 220. Sleddens EF, Gerards SM, Thijs C, de
MK. Food insecurity, the home food en-
tionship of the local food environment Vries NK, Kremers SP. General parent-
vironment, and parent feeding practi-
with obesity: a systematic review of ing, childhood overweight and obesity-
ces in the era of COVID-19. Obesity
methods, study quality, and results. Obe- inducing behaviors: a review. Int J
(Silver Spring). 2020;28(11):2056–2063
sity (Silver Spring). 2015;23(7):1331–1344 Pediatr Obes. 2011;6(2-2):e12–e27
198. Kakarala M, Keast DR, Hoerr S. School-
209. Jia P, Luo M, Li Y, Zheng JS, Xiao Q, Luo 221. Sokol RL, Qin B, Poti JM. Parenting styles
children’s consumption of competitive
foods and beverages, excluding a la J. Fast-food restaurant, unhealthy eat- and body mass index: a systematic re-
carte. J Sch Health. 2010;80(9): ing, and childhood obesity: a system- view of prospective studies among chil-
429–435, quiz 461–463 atic review and meta-analysis. Obes dren. Obes Rev. 2017;18(3):281–292
Rev. 2021;22(Suppl 1):e12944 222. Frankel LA, Hughes SO, O’Connor TM,
199. Matsuzaki M, Sanchez BN, Acosta ME,
Botkin J, Sanchez-Vaznaugh EV. Food 210. Islam MZ, Johnston J, Sly PD. Green Power TG, Fisher JO, Hazen NL. Paren-
environment near schools and body space and early childhood develop- tal influences on children’s self-regula-
weight-A systematic review of associa- ment: a systematic review. Rev Environ tion of energy intake: insights from
tions by race/ethnicity, gender, grade, Health. 2020;35(2):189–200 developmental literature on emotion
and socio-economic factors. Obes Rev. regulation. J Obes. 2012;2012:327259
211. Malacarne D, Handakas E, Robinson O,
2020;21(4):e12997 et al. The built environment as deter- 223. Patrick H, Hennessy E, McSpadden K,
200. Williams J, Scarborough P, Matthews minant of childhood obesity: a system- Oh A. Parenting styles and practices in
A, et al. A systematic review of the in- atic literature review. Obes Rev. children’s obesogenic behaviors: scien-
fluence of the retail food environment 2022;23(Suppl 1):e13385 tific gaps and future research

by guest
directions. Child Obes. 2013;9(Suppl): nutritional health in children: a meta- 244. Ruan H, Xun P, Cai W, He K, Tang Q. Ha-
S73–S86 analysis. Obes Rev. 2018;19(5):638–653 bitual sleep duration and risk of child-
224. Kakinami L, Barnett TA, Seguin L, Para- 234. Poitras VJ, Gray CE, Janssen X, et al. hood obesity: systematic review and
Systematic review of the relationships dose-response meta-analysis of pro-
dis G. Parenting style and obesity risk
between sedentary behaviour and spective cohort studies. Sci Rep.
in children. Prev Med. 2015;75:18–22
health indicators in the early years 2015;5:16160
225. Bates CR, Buscemi J, Nicholson LM,
(0–4 years). BMC Public Health. 2017; 245. Nedeltcheva AV, Kilkus JM, Imperial J,
Cory M, Jagpal A, Bohnert AM. Links
17(Suppl 5):868 Kasza K, Schoeller DA, Penev PD. Sleep
between the organization of the family
235. Stiglic N, Viner RM. Effects of screen- curtailment is accompanied by in-
home environment and child obesity:
time on the health and well-being of creased intake of calories from
a systematic review. Obes Rev.
children and adolescents: a systematic snacks. Am J Clin Nutr. 2009;89(1):
2018;19(5):716–727 126–133
review of reviews. BMJ Open. 2019;
226. Luger M, Lafontan M, Bes-Rastrollo M, 9(1):e023191 246. Weiss A, Xu F, Storfer-Isser A, Thomas
Winzer E, Yumuk V, Farpour-Lambert N. A, Ievers-Landis CE, Redline S. The as-
Sugar-sweetened beverages and 236. Tripathi M, Mishra SK. Screen time
and adiposity among children and sociation of sleep duration with ado-
weight gain in children and adults: a lescents’ fat and carbohydrate
adolescents: a systematic review.
systematic review from 2013 to 2015 consumption. Sleep. 2010;33(9):
J Public Health (Germany). 2019;
and a comparison with previous stud- 1201–1209
28:227–244
ies. Obes Facts. 2017;10(6):674–693
237. Viner RM, Cole TJ. Television viewing in 247. Larque E, Labayen I, Flodmark CE,
227. Muth ND, Dietz WH, Magge SN, Johnson et al. From conception to infancy -
early childhood predicts adult body
RK; American Academy of Pediatrics; mass index. J Pediatr. 2005;147(4): early risk factors for childhood
Section on Obesity; Committee on Nu- 429–435 obesity. Nat Rev Endocrinol. 2019;15(8):
trition; American Heart Association. 456–478
Public policies to reduce sugary drink 238. Poorolajal J, Sahraei F, Mohamdadi Y,
Doosti-Irani A, Moradi L. Behavioral 248. Nadhiroh SR, Djokosujono K, Utari DM.
consumption in children and adoles- The association between secondhand
factors influencing childhood obesity:
cents. Pediatrics. 2019;143(4): smoke exposure and growth outcomes
a systematic review and meta-analy-
e20190282 of children: a systematic literature
sis. Obes Res Clin Pract.
228. Birch LL, Savage JS, Fisher JO. Right 2020;14(2):109–118 review. Tob Induc Dis. 2020;18:12
sizing prevention. Food portion size 249. Tate EB, Wood W, Liao Y, Dunton GF. Do
239. Coombs NA, Stamatakis E. Associations
effects on children’s eating and stressed mothers have heavier chil-
between objectively assessed and
weight. Appetite. 2015;88:11–16 questionnaire-based sedentary behav- dren? A meta-analysis on the relation-
229. Costa CS, Del-Ponte B, Assunç~ao MCF, iour with BMI-defined obesity among ship between maternal stress and
Santos IS. Consumption of ultra-proc- general population children and ado- child body mass index. Obes Rev.
essed foods and body fat during child- lescents living in England. BMJ Open. 2015;16(5):351–361
hood and adolescence: a systematic 2015;5(6):e007172 250. Kumar S, Kelly AS. Review of childhood
review. Public Health Nutr. 2018; 240. Strasburger VC; Council on Communi- obesity: from epidemiology, etiology,
21(1):148–159 cations and Media. Children, adoles- and comorbidities to clinical assess-
230. Lachat C, Nago E, Verstraeten R, cents, obesity, and the media. ment and treatment. Mayo Clin Proc.
Roberfroid D, Van Camp J, Kolsteren P. Pediatrics. 2011;128(1):201–208 2017;92(2):251–265
Eating out of home and its association 241. Biddle SJ, Garcıa Bengoechea E, 251. Solmi M, K€ohler CA, Stubbs B, et al.
with dietary intake: a systematic Wiesner G. Sedentary behaviour and Environmental risk factors and non-
review of the evidence. Obes Rev. adiposity in youth: a systematic review pharmacological and nonsurgical
2012;13(4):329–346 of reviews and analysis of causality. interventions for obesity: an umbrella
Int J Behav Nutr Phys Act. 2017; review of meta-analyses of cohort
231. Nago ES, Lachat CK, Dossa RA, Kolste-
14(1):43 studies and randomized controlled
ren PW. Association of out-of-home eat-
trials. Eur J Clin Invest. 2018;48(12):
ing with anthropometric changes: a 242. Magee L, Hale L. Longitudinal associa-
e12982
systematic review of prospective stud- tions between sleep duration and sub-
sequent weight gain: a systematic 252. Jackson DB, Chilton M, Johnson KR,
ies. Crit Rev Food Sci Nutr. 2014;54(9):
review. Sleep Med Rev. 2012;16(3): Vaughn MG. Adverse childhood experi-
1103–1116
231–241 ences and household food insecurity:
232. Hammons AJ, Fiese BH. Is frequency of findings from the 2016 National Survey
243. Reilly JJ, Armstrong J, Dorosty AR,
shared family meals related to the nutri- of Children’s Health. Am J Prev Med.
et al; Avon Longitudinal Study of
tional health of children and adolescents? 2019;57(5):667–674
Parents and Children Study Team.
Pediatrics. 2011;127(6):e1565–e1574 Early life risk factors for obesity in 253. Harvard University, Center on the
233. Dallacker M, Hertwig R, Mata J. The childhood: cohort study. BMJ. 2005; Developing Child. Key concepts.
frequency of family meals and 330(7504):1357 Toxic stress. Available at: https://

by guest
developingchild.harvard.edu/science/ meta-regression. Front Endocrinol after extremely preterm birth. Pediatr
key-concepts/toxic-stress/. Accessed (Lausanne). 2012;3:29 Res. 2005;57(2):211–215
October 5, 2022 264. Speliotes EK, Willer CJ, Berndt SI, et al; 275. Ou-Yang MC, Sun Y, Liebowitz M, et al.
254. Chapman DP, Whitfield CL, Felitti VJ, MAGIC; Procardis Consortium. Associa- Accelerated weight gain, prematurity,
Dube SR, Edwards VJ, Anda RF. Ad- tion analyses of 249,796 individuals re- and the risk of childhood obesity: a
verse childhood experiences and the veal 18 new loci associated with body meta-analysis and systematic review.
risk of depressive disorders in adult- mass index. Nat Genet. PLoS One. 2020;15(5):e0232238
hood. J Affect Disord. 2004;82(2): 2010;42(11):937–948 276. Whitaker RC, Wright JA, Pepe MS,
217–225 Seidel KD, Dietz WH. Predicting obesity
265. Vaisse C, Clement K, Durand E,
255. Dube SR, Anda RF, Felitti VJ, Chapman Hercberg S, Guy-Grand B, Froguel P. in young adulthood from childhood
DP, Williamson DF, Giles WH. Childhood Melanocortin-4 receptor mutations and parental obesity. N Engl J Med.
abuse, household dysfunction, and the are a frequent and heterogeneous 1997;337(13):869–873
risk of attempted suicide throughout cause of morbid obesity. J Clin Invest. 277. Lima NMS, Leal VS, Oliveira JS, et al.
the life span: findings from the Ad- 2000;106(2):253–262 Overweight among adolescents and
verse Childhood Experiences Study. nutritional status of their parents: a
266. Farooqi S, O’Rahilly S. Genetics of obe-
JAMA. 2001;286(24):3089–3096 systematic review. Cien Saude Colet.
sity in humans. Endocr Rev. 2006;27(7):
256. Isohookana R, Marttunen M, Hakko H, 710–718 2017;22(2):627–636
Riipinen P, Riala K. The impact of ad- 278. Isganaitis E, Suehiro H, Cardona C.
267. Heymsfield SB, Avena NM, Baier L,
verse childhood experiences on obe- Who’s your daddy?: paternal inheri-
et al. Hyperphagia: current concepts
sity and unhealthy weight control tance of metabolic disease risk. Curr
and future directions proceedings of
behaviors among adolescents. Compr Opin Endocrinol Diabetes Obes. 2017;
the 2nd international conference on
Psychiatry. 2016;71:17–24 24(1):47–55
hyperphagia. Obesity (Silver Spring).
257. Schilling EA, Aseltine RH Jr, Gore S. Ad- 2014;22(Suppl 1):S1–S17 279. Rasmussen KM, Yaktine AL, eds.
verse childhood experiences and men- Weight Gain During Pregnancy: Reex-
tal health in young adults: a 268. Styne DM, Arslanian SA, Connor EL,
amining the Guidelines. Washington,
longitudinal survey. BMC Public Health. et al. pediatric obesity-assessment,
DC: National Academies Press; 2009
2007;7:30 treatment, and prevention: an Endo-
crine Society clinical practice guide- 280. Lau EY, Liu J, Archer E, McDonald SM,
258. Burke NJ, Hellman JL, Scott BG, Weems line. J Clin Endocrinol Metab. 2017; Liu J. Maternal weight gain in preg-
CF, Carrion VG. The impact of adverse 102(3):709–757 nancy and risk of obesity among off-
childhood experiences on an urban spring: a systematic review. J Obes.
pediatric population. Child Abuse Negl. 269. Cordero P, Li J, Oben JA. Epigenetics of
2014;2014:524939
2011;35(6):408–413 obesity: beyond the genome sequence.
Curr Opin Clin Nutr Metab Care. 2015; 281. Matusiak K, Barrett HL, Callaway LK,
259. Benyshek DC. The “early life” origins Nitert MD. Periconception weight loss:
18(4):361–366
of obesity-related health disorders: common sense for mothers, but what
new discoveries regarding the inter- 270. van Dijk SJ, Molloy PL, Varinli H, about for babies? J Obes. 2014;2014:
generational transmission of develop- Morrison JL, Muhlhausler BS; Mem- 204295
mentally programmed traits in the bers of EpiSCOPE. Epigenetics and
human obesity. Int J Obes. 2015;39(1): 282. Buckley AJ, Jaquiery AL, Harding JE.
global cardiometabolic health crisis.
85–97 Nutritional programming of adult dis-
Am J Phys Anthropol. 2013;152(Suppl
ease. Cell Tissue Res. 2005;322(1):73–79
57):79–93 271. Bell CG, Walley AJ, Froguel P. The
genetics of human obesity. Nat Rev 283. Logan KM, Gale C, Hyde MJ,
260. McEwen CA, McEwen BS. Social struc-
Santhakumaran S, Modi N. Diabetes in
ture, adversity, toxic stress, and inter- Genet. 2005;6(3):221–234
pregnancy and infant adiposity:
generational poverty: an early 272. Bouret S, Levin BE, Ozanne SE. Gene- systematic review and meta-analysis.
childhood model. Annu Rev Sociol. environment interactions control- Arch Dis Child Fetal Neonatal Ed.
2017;43:445–472 ling energy and glucose homeosta- 2017;102(1):F65–F72
261. Maes HH, Neale MC, Eaves LJ. Genetic sis and the developmental origins
284. Kim SY, Sharma AJ, Callaghan WM.
and environmental factors in relative of obesity. Physiol Rev.
Gestational diabetes and childhood
body weight and human adiposity. 2015;95(1):47–82
obesity: what is the link? Curr Opin
Behav Genet. 1997;27(4):325–351 273. Gnawali A. Prematurity and the risk of Obstet Gynecol. 2012;24(6):376–381
262. Stunkard AJ, Foch TT, Hrubec Z. A twin development of childhood obesity:
285. Nehring I, Chmitorz A, Reulen H,
study of human obesity. JAMA. piecing together the pathophysiologi-
von Kries R, Ensenauer R. Gestational
1986;256(1):51–54 cal puzzle. A literature review. Cureus. diabetes predicts the risk of childhood
263. Elks CE, den Hoed M, Zhao JH, et al. 2021;13(12):e20518 overweight and abdominal circumfer-
Variability in the heritability of body 274. Uthaya S, Thomas EL, Hamilton G, Dore ence independent of maternal obesity.
mass index: a systematic review and CJ, Bell J, Modi N. Altered adiposity Diabet Med. 2013;30(12):1449–1456

by guest
286. Lawlor DA, Lichtenstein P, Långstr€om pregnancy and childhood obesity. Am 308. Pearce J, Taylor MA, Langley-Evans SC.
N. Association of maternal diabetes J Epidemiol. 2002;156(10):954–961 Timing of the introduction of comple-
mellitus in pregnancy with offspring 297. Trandafir LM, Temneanu OR. Pre and mentary feeding and risk of childhood
adiposity into early adulthood: sibling post-natal risk and determination of obesity: a systematic review. Int J
study in a prospective cohort of Obes. 2013;37(10):1295–1306
factors for child obesity. J Med Life.
280 866 men from 248 293 families. 2016;9(4):386–391 309. Cox LM, Blaser MJ. Antibiotics in early
Circulation. 2011;123(3):258–265 life and obesity. Nat Rev Endocrinol.
298. Symonds ME, Garnder DS. The Devel-
287. Catalano PM, Hauguel-De Mouzon S. Is 2015;11(3):182–190
opmental Environment and the Devel-
it time to revisit the Pedersen hypothe- 310. Miller SA, Wu RKS, Oremus M. The
opment of Obesity. Cambridge, United
sis in the face of the obesity epidemic? association between antibiotic use in
Kingdom: Cambridge University Press;
Am J Obstet Gynecol. 2011;204(6): infancy and childhood overweight or
2006
479–487 obesity: a systematic review and
299. Oken E, Gillman MW. Fetal origins of
288. Gibson KS, Waters TP, Catalano PM. meta-analysis. Obes Rev. 2018;19(11):
obesity. Obes Res. 2003;11(4):496–506
Maternal weight gain in women who 1463–1475
develop gestational diabetes mellitus. 300. Dean SV, Lassi ZS, Imam AM, Bhutta
311. Poulsen MN, Pollak J, Bailey-Davis L,
Obstet Gynecol. 2012;119(3):560–565 ZA. Preconception care: nutritional
Hirsch AG, Glass TA, Schwartz BS.
risks and interventions. Reprod Health. Associations of prenatal and childhood
289. Heerwagen MJ, Miller MR, Barbour LA,
2014;11(Suppl 3):S3 antibiotic use with child body mass
Friedman JE. Maternal obesity and
fetal metabolic programming: a fertile 301. Taveras EM, Scanlon KS, Birch L, index at age 3 years. Obesity (Silver
epigenetic soil. Am J Physiol Regul Rifas-Shiman SL, Rich-Edwards JW, Spring). 2017;25(2):438–444
Integr Comp Physiol. 2010;299(3): Gillman MW. Association of breast- 312. Aghaali M, Hashemi-Nazari SS. Associa-
R711–R722 feeding with maternal control of tion between early antibiotic exposure
infant feeding at age 1 year. and risk of childhood weight gain and
290. Dabelea D, Mayer-Davis EJ, Saydah S,
et al; SEARCH for Diabetes in Youth Pediatrics. 2004;114(5):e577–e583 obesity: a systematic review and meta-
Study. Prevalence of type 1 and type 2 302. Azad MB, Vehling L, Chan D, et al; analysis. J Pediatr Endocrinol Metab.
diabetes among children and adoles- CHILD Study Investigators. Infant feed- 2019;32(5):439–445
cents from 2001 to 2009. JAMA. ing and weight gain: separating breast 313. Li DK, Chen H, Ferber J, Odouli R. Infec-
2014;311(17):1778–1786 milk from breastfeeding and formula tion and antibiotic use in infancy and
291. Ge ZJ, Zhang CL, Schatten H, Sun QY. from food. Pediatrics. 2018;142(4): risk of childhood obesity: a longitudi-
Maternal diabetes mellitus and the e20181092 nal birth cohort study. Lancet Diabetes
origin of non-communicable diseases 303. Appleton J, Russell CG, Laws R, Fowler Endocrinol. 2017;5(1):18–25
in offspring: the role of epigenetics. C, Campbell K, Denney-Wilson E. Infant 314. Rasmussen SH, Shrestha S, Bjerregaard
Biol Reprod. 2014;90(6):139 formula feeding practices associated LG, et al. Antibiotic exposure in early
292. Rayfield S, Plugge E. Systematic review with rapid weight gain: a systematic life and childhood overweight and
and meta-analysis of the association review. Matern Child Nutr. 2018;14(3): obesity: a systematic review and
between maternal smoking in preg- e12602–e12602 meta-analysis. Diabetes Obes Metab.
nancy and childhood overweight and 304. Pearce J, Langley-Evans SC. The types 2018;20(6):1508–1514
obesity. J Epidemiol Community Health. of food introduced during complemen- 315. Karam JG, McFarlane SI. Secondary
2017;71(2):162–173 tary feeding and risk of childhood obe- causes of obesity. Therapy. 2007;4(5):
293. Ino T. Maternal smoking during preg- sity: a systematic review. Int J Obes. 641–650
nancy and offspring obesity: meta- 2013;37(4):477–485 316. Bandini L, Danielson M, Esposito LE,
analysis. Pediatr Int. 2010;52(1):94–99 305. Stettler N, Iotova V. Early growth pat- et al. Obesity in children with develop-
294. Oken E, Levitan EB, Gillman MW. Mater- terns and long-term obesity risk. Curr mental and/or physical disabilities.
nal smoking during pregnancy and Opin Clin Nutr Metab Care. 2010;13(3): Disabil Health J. 2015;8(3):309–316
child overweight: systematic review 294–299 317. Institute of Medicine, Committee on
and meta-analysis. Int J Obes. 2008; 306. Zheng M, Lamb KE, Grimes C, et al. Prevention of Obesity in Children and
32(2):201–210 Rapid weight gain during infancy and Youth. In: Koplan JP, Liverman CT, Kraak
295. Qureshi R, Jadotte Y, Zha P, et al. The subsequent adiposity: a systematic VA, eds. Preventing Childhood Obesity:
association between prenatal expo- review and meta-analysis of evidence. Health in the Balance. Washington, DC:
sure to environmental tobacco smoke Obes Rev. 2018;19(3):321–332 National Academies Press; 2005
and childhood obesity: a systematic 307. Woo Baidal JA, Locks LM, Cheng ER, 318. Cassidy SB, Driscoll DJ. Prader-Willi
review. JBI Database Syst Rev Imple- Blake-Lamb TL, Perkins ME, Taveras EM. syndrome. Eur J Hum Genet. 2009;
ment Reports. 2018;16(8):1643–1662 Risk factors for childhood obesity in the 17(1):3–13
296. von Kries R, Toschke AM, Koletzko B, first 1,000 days: a systematic review. 319. McPheeters ML, Warren Z, Sathe N,
Slikker W Jr. Maternal smoking during Am J Prev Med. 2016;50(6):761–779 et al. A systematic review of medical

by guest
treatments for children with autism population smoking metrics as moder- patients. Childs Nerv Syst. 2020;36(7):
spectrum disorders. Pediatrics. 2011; ators. Sci Rep. 2017;7(1):4315 1515–1520
127(5):e1312–e1321 331. Raz R, Levine H, Pinto O, Broday DM, 341. Littlewood RA, Trocki O, Shepherd RW,
320. Tardieu S, Micallef J, Gentile S, Blin O. Yuval Weisskopf MG. Traffic-related air Shepherd K, Davies PSW. Resting
Weight gain profiles of new anti-psy- pollution and autism spectrum disor- energy expenditure and body composi-
chotics: public health consequences. der: a population-based nested case- tion in children with myelomeningo-
Obes Rev. 2003;4(3):129–138 control study in Israel. Am J Epidemiol. cele. Pediatr Rehabil. 2003;6(1):31–37
2018;187(4):717–725
321. Cermak SA, Curtin C, Bandini LG. Food 342. Caminiti C, Saure C, Weglinski J, de
selectivity and sensory sensitivity in chil- 332. Wan H, Zhang C, Li H, Luan S, Liu C. Castro F, Campmany L. Body composi-
dren with autism spectrum disorders. Association of maternal diabetes with tion and energy expenditure in a pop-
J Am Diet Assoc. 2010;110(2):238–246 autism spectrum disorders in ulation of children and adolescents
offspring: a systemic review and with myelomeningocele. Arch Argent
322. Puder JJ, Munsch S. Psychological cor- meta-analysis. Medicine (Baltimore). Pediatr. 2018;116(1):e8–e13
relates of childhood obesity. Int J Obes 2018;97(2):e9438
(Lond). 2010;34(Suppl 2):S37–S43 343. Mueske NM, Ryan DD, Van Speybroeck
333. Sanchez CE, Barry C, Sabhlok A, et al. AL, Chan LS, Wren TAL. Fat distribution
323. Eichstaedt CB, Lavay BW. Physical Activ- Maternal pre-pregnancy obesity and in children and adolescents with mye-
ity for Individuals with Mental Retar- child neurodevelopmental outcomes: a lomeningocele. Dev Med Child Neurol.
dation: Infancy through Adulthood. meta-analysis. Obes Rev. 2015;57(3):273–278
Champaign, IL: Human Kinetics Books; 2018;19(4):464–484
1992 344. van den Berg-Emons HJG, Bussmann
334. Hack M, Taylor HG, Schluchter M, JBJ, Meyerink HJ, Roebroeck ME, Stam
324. Rimmer JA, Rowland JL. Physical activ- Andreias L, Drotar D, Klein N. Behav- HJ. Body fat, fitness and level of every-
ity for youth with disabilities: a critical ioral outcomes of extremely low birth day physical activity in adolescents
need in an underserved population. weight children at age 8 years. J Dev and young adults with meningomyelo-
Dev Neurorehabil. 2008;11(2):141–148 Behav Pediatr. 2009;30(2):122–130
cele. J Rehabil Med. 2003;35(6):
325. Kahathuduwa CN, West BD, Blume J, 335. Lindberg J, Norman M, Westrup B, 271–275
Dharavath N, Moustaid-Moussa N, €Ohrman T, Domell€of M, Berglund SK.
345. Cortese S, Moreira-Maia CR, St Fleur
Mastergeorge A. The risk of over- Overweight, obesity, and body compo-
D, Morcillo-Pe~nalver C, Rohde LA,
weight and obesity in children with sition in 3.5- and 7-year-old Swedish
Faraone SV. Association between ADHD
autism spectrum disorders: a system- children born with marginally low
and obesity: a systematic review and
atic review and meta-analysis. Obes birth weight. J Pediatr. 2015;167(6):
meta-analysis. Am J Psychiatry. 2016;
Rev. 2019;20(12):1667–1679 1246–52.e3
173(1):34–43
326. Maillard AM, Ruef A, Pizzagalli F, et al; 336. Dominick KC, Davis NO, Lainhart J,
346. Cortese S, Ramos Olazagasti MA, Klein
16p11.2 European Consortium. The Tager-Flusberg H, Folstein S. Atypical
RG, Castellanos FX, Proal E, Mannuzza
16p11.2 locus modulates brain struc- behaviors in children with autism and
children with a history of language S. Obesity in men with childhood
tures common to autism, schizophrenia ADHD: a 33-year controlled, prospec-
impairment. Res Dev Disabil.
and obesity. Mol Psychiatry. 2015;20(1): tive, follow-up study. Pediatrics. 2013;
2007;28(2):145–162
140–147 131(6):e1731–e1738
337. Sharp WG, Berry RC, McCracken C,
327. Shinawi M, Sahoo T, Maranda B, et al. 347. Khalife N, Kantomaa M, Glover V, et al.
et al. Feeding problems and nutrient
11p14.1 microdeletions associated Childhood attention-deficit/hyperactiv-
intake in children with autism spec-
with ADHD, autism, developmental de- ity disorder symptoms are risk factors
trum disorders: a meta-analysis and
lay, and obesity. Am J Med Genet A. for obesity and physical inactivity in
comprehensive review of the litera-
2011;155A(6):1272–1280 ture. J Autism Dev Disord. 2013;43(9): adolescence. J Am Acad Child Adolesc
328. Atladottir HO, Henriksen TB, Schendel 2159–2173 Psychiatry. 2014;53(4):425–436
DE, Parner ET. Autism after infection, 338. Fournier KA, Hass CJ, Naik SK, Lodha 348. Kooij JJS. ADHD and obesity. Am J Psy-
febrile episodes, and antibiotic use N, Cauraugh JH. Motor coordination in chiatry. 2016;173(1):1–2
during pregnancy: an exploratory autism spectrum disorders: a synthe- 349. Ohkuma T, Hirakawa Y, Nakamura U,
study. Pediatrics. 2012;130(6): sis and meta-analysis. J Autism Dev Kiyohara Y, Kitazono T, Ninomiya T. As-
e1447–e1454 Disord. 2010;40(10):1227–1240 sociation between eating rate and
329. Mueller NT, Whyatt R, Hoepner L, et al. 339. Shetreat-Klein M, Shinnar S, Rapin I. obesity: a systematic review and meta-
Prenatal exposure to antibiotics, ce- Abnormalities of joint mobility and analysis. Int J Obes. 2015;39(11):
sarean section and risk of childhood gait in children with autism spectrum 1589–1596
obesity. Int J Obes. 2015;39(4):665–670 disorders. Brain Dev. 2014;36(2):91–96 350. Berkowitz RI, Moore RH, Faith MS,
330. Jung Y, Lee AM, McKee SA, Picciotto 340. Rendeli C, Kuczynska E, Giuliano AC, Stallings VA, Kral TV, Stunkard AJ. Iden-
MR. Maternal smoking and autism Chiaretti A, Ausili E. Dietary approach tification of an obese eating style in
spectrum disorder: meta-analysis with to prevent obesity risk in Spina Bifida 4-year-old children born at high and

by guest
low risk for obesity. Obesity (Silver 360. Quek YH, Tam WWS, Zhang MWB, Ho 371. Neumark-Sztainer D, Story M, Hannan
Spring). 2010;18(3):505–512 RCM. Exploring the association be- PJ, Perry CL, Irving LM. Weight-related
351. Llewellyn CH, van Jaarsveld CH, Boni- tween childhood and adolescent obe- concerns and behaviors among over-
face D, Carnell S, Wardle J. Eating rate sity and depression: a meta-analysis. weight and nonoverweight adoles-
Obes Rev. 2017;18(7):742–754 cents: implications for preventing
is a heritable phenotype related to
weight-related disorders. Arch Pediatr
weight in children. Am J Clin Nutr. 361. Esposito M, Gallai B, Roccella M, et al.
Adolesc Med. 2002;156(2):171–178
2008;88(6):1560–1566 Anxiety and depression levels in pre-
pubertal obese children: a case-con- 372. Puhl RM, Peterson JL, Luedicke J. Pa-
352. Wood AC, Blissett JM, Brunstrom JM,
trol study. Neuropsychiatr Dis Treat. rental perceptions of weight terminol-
et al; American Heart Association
2014;10:1897–1902 ogy that providers use with youth.
Council on Lifestyle and Cardiometa-
Pediatrics. 2011;128(4):e786–e793
bolic Health; Council on Epidemiology 362. Lindberg L, Hagman E, Danielsson P,
and Prevention; Council on Lifelong Marcus C, Persson M. Anxiety and de- 373. Knierim SD, Newcomer S, Castillo A,
Congenital Heart Disease and Heart pression in children and adolescents et al. Latino parents’ perceptions of
Health in the Young; Council on Cardio- with obesity: a nationwide study in pediatric weight counseling terms.
vascular and Stroke Nursing; and Sweden. BMC Med. 2020;18(1):30 Acad Pediatr. 2018;18(3):342–353
Stroke Council. Caregiver influences 363. Berk M, Williams LJ, Jacka FN, et al. 374. Valente TW, Fujimoto K, Chou C-P,
on eating behaviors in young children: So depression is an inflammatory dis- Spruijt-Metz D. Adolescent affiliations
a scientific statement from the Ameri- ease, but where does the inflamma- and adiposity: a social network analy-
can Heart Association. J Am Heart tion come from? BMC Med. 2013; sis of friendships and obesity. J Ado-
Assoc. 2020;9(10):e014520 11:200 lesc Health. 2009;45(2):202–204
353. Karam JG, McFarlane SI. Prevention 364. Reeves GM, Postolache TT, Snitker S. 375. Eismann EA, Theuerling J, Maguire S,
of type 2 diabetes: evidence and Childhood depression: connection be- Hente EA, Shapiro RA. Integration of
strategies. J Clin Outcomes Manag. tween these growing problems in the Safe Environment for Every Kid
2017;24(4) growing children. Int J Child Health (SEEK) model across primary care set-
Hum Dev. 2008;1(2):103–114 tings. Clin Pediatr (Phila). 2019;58(2):
354. Eneli IU, Wang W, Kelleher K. Identifica-
166–176
tion and counseling for obesity among 365. Armstrong S, Lazorick S, Hampl S,
children on psychotropic medications et al. Physical examination findings 376. Center for Medicare and Medicaid In-
in ambulatory settings. Obesity (Silver among children and adolescents novation. The accountable health com-
Spring). 2013;21(8):1656–1661 with obesity: an evidence-based re- munities health-related social needs
view. Pediatrics. 2016;137(2): screening tool. Available at: https://
355. Bak M, Fransen A, Janssen J, van Os J,
e20151766 innovation.cms.gov/files/worksheets/
Drukker M. Almost all antipsychotics
ahcm-screeningtool.pdf. Accessed
result in weight gain: a meta-analysis. 366. Visscher TLS, Lakerveld J, Olsen N, October 5, 2022
PLoS One. 2014;9(4):e94112 et al. Perceived health status: is obe-
sity perceived as a risk factor and dis- 377. Goddard A. Adverse childhood experi-
356. Tarricone I, Ferrari Gozzi B, Serretti A, ences and trauma-informed care.
Grieco D, Berardi D. Weight gain in ease? Obes Facts. 2017;10(1):52–60
J Pediatr Health Care. 2021;35(2):
antipsychotic-naive patients: a review 367. Spurrier NJ, Magarey A, Wong C. Rec- 145–155
and meta-analysis. Psychol Med. ognition and management of child-
2010;40(2):187–200 378. Forkey H, Szilagyi M, Kelly ET, Duffee J;
hood overweight and obesity by
Council on Foster Care, Adoption, and
357. Pillay J, Boylan K, Carrey N, et al. First- clinicians. J Paediatr Child Health.
Kinship Care; Council on Community
and Second-Generation Antipsychotics 2006;42(7-8):411–418
Pediatrics; Council on Child Abuse and
in Children and Young Adults: System- 368. Robinson E, Sutin AR. Parental percep- Neglect; Committee on Psychosocial
atic Review Update. Comparative Effec- tion of weight status and weight gain Aspects of Child and Family Health.
tiveness Reviews, No. 184. Rockville, across childhood. Pediatrics. 2016; Trauma-informed care. Pediatrics.
MD: Agency for Healthcare Research 137(5):e20153957 2021;148(2):e2021052580
and Quality; 2017 369. He M, Evans A. Are parents aware that 379. Lobelo F, Muth ND, Hanson S, Nemeth
358. Galling B, Roldan A, Nielsen RE, et al. their children are overweight or BA; Council on Sports Medicine and
Type 2 diabetes mellitus in youth ex- obese? Do they care? Can Fam Fitness; Section on Obesity. Physical
posed to antipsychotics: a systematic Physician. 2007;53(9):1493–1499 activity assessment and counseling in
review and meta-analysis. JAMA 370. Uy MJA, Pereira MA, Berge JM, Loth pediatric clinical settings. Pediatrics.
Psychiatry. 2016;73(3):247–259 KA. How should we approach and dis- 2020;145(3):e20193992
359. Sweeney B, Kelly AS, San Giovanni CB, cuss children’s weight with parents? A 380. Rankin J, Matthews L, Cobley S, et al.
Kelsey MM, Skelton JA. Clinical ap- qualitative analysis of recommenda- Psychological consequences of child-
proaches to minimize iatrogenic tions from parents of preschool-aged hood obesity: psychiatric comorbidity
weight gain in children and adoles- children to physicians. Clin Pediatr and prevention. Adolesc Health Med
cents. Clin Obes. 2021;11(1):e12417 (Phila). 2019;58(2):226–237 Ther. 2016;7:125–146

by guest
381. Jellinek M, Murphy M. Pediatric Symp- 390. Fernandez CJ, Chacko EC, Pappachan selected counties and Indian reserva-
tom Checklist. Boston, MA: Massachu- JM. Male obesity-related secondary tions, United States, 2002-2015. MMWR
setts General Hospital; 1988 hypogonadism—pathophysiology, Morb Mortal Wkly Rep. 2020;69(6):
clinical implications and management. 161–165
382. Johnson JG, Harris ES, Spitzer RL,
Eur Endocrinol. 2019;15(2):83–90
Williams JB. The patient health ques- 400. Copeland KC, Zeitler P, Geffner M, et al;
tionnaire for adolescents: validation of 391. O’Malley GC, Shultz SP, Thivel D, Tsiros TODAY Study Group. Characteristics of
an instrument for the assessment of MD. Neuromusculoskeletal health in adolescents and youth with recent-on-
mental disorders among adolescent pediatric obesity: incorporating evi- set type 2 diabetes: the TODAY cohort
primary care patients. J Adolesc dence into clinical examination. Curr at baseline. J Clin Endocrinol Metab.
Health. 2002;30(3):196–204 Obes Rep. 2021;10(4):467–477 2011;96(1):159–167
383. Albert Perez E, Mateu Olivares V, 392. Miller WR, Rollnick S. Motivational 401. McCarthy MI. Genomics, type 2 diabe-
Martınez-Espinosa RM, Molina Vila MD, Interviewing: Helping People Change, tes, and obesity. N Engl J Med. 2010;
Reig Garcıa-Galbis M. New insights 3rd ed. New York, NY: Guilford Press; 363(24):2339–2350
about how to make an intervention in 2013
402. Commodore-Mensah Y, Matthie N,
children and adolescents with meta- 393. Baker JL, Olsen LW, Sørensen TI. Child- Wells J, et al. African Americans,
bolic syndrome: diet, exercise vs. hood body-mass index and the risk of African immigrants, and Afro-Carib-
changes in body composition. A sys- coronary heart disease in adulthood. beans differ in social determinants of
tematic review of RCT. Nutrients. N Engl J Med. 2007;357(23):2329–2337 hypertension and diabetes: evidence
2018;10(7):878 394. Kelly AS, Barlow SE, Rao G, et al; from the National Health Interview
384. Spitzer RL, Kroenke K, Williams JBW, American Heart Association Athero- Survey. J Racial Ethn Health
L€owe B. A brief measure for assessing sclerosis; Hypertension, and Obesity in Disparities. 2018;5(5):995–1002
generalized anxiety disorder: the the Young Committee of the Council 403. Rughani A, Friedman JE, Tryggestad
GAD-7. Arch Intern Med. 2006;166(10): on Cardiovascular Disease in the JB. Type 2 diabetes in youth: the role
1092–1097 Young; Council on Nutrition, Physical
of early life exposures. Curr Diab Rep.
Activity and Metabolism; and Council
385. Wolraich ML, Lambert W, Doffing MA, 2020;20(9):45
on Clinical Cardiology. Severe obesity
Bickman L, Simmons T, Worley K. Psy- in children and adolescents: identifica- 404. Duncan DT, Sharifi M, Melly SJ, et al.
chometric properties of the Vanderbilt tion, associated health risks, and Characteristics of walkable built envi-
ADHD diagnostic parent rating scale in treatment approaches: a scientific ronments and BMI z-scores in chil-
a referred population. J Pediatr Psy- statement from the American Heart dren: evidence from a large electronic
chol. 2003;28(8):559–567 Association. Circulation. health record database. Environ
386. Wolraich ML, Hagan JFJ Jr, Allan C, 2013;128(15):1689–1712 Health Perspect. 2014;122(12):
et al; Subcommittee on Children and 1359–1365
395. Skinner AC, Perrin EM, Moss LA,
Adolescents With Attention-Deficit/Hy- Skelton JA. Cardiometabolic risks and 405. Sharifi M, Sequist TD, Rifas-Shiman SL,
peractive Disorder. Clinical practice severity of obesity in children and et al. The role of neighborhood char-
guideline for the diagnosis, evaluation, young adults. N Engl J Med. acteristics and the built environment
and treatment of attention-deficit/hy- 2015;373(14):1307–1317 in understanding racial/ethnic dispar-
peractivity disorder in children and ities in childhood obesity. Prev Med.
396. Skinner AC. Appraisal of clinical care
adolescents. Pediatrics. 2019;144(4): 2016;91:103–109
practices for child obesity prevention
e20192528 and treatment to inform quality 406. Gaston SA, Atere-Roberts J, Ward J,
387. Golden NH, Schneider M, Wood C; Com- improvement. Part II: comorbidities. et al. Experiences with everyday and
mittee on Nutrition; Committee on Ado- Pediatrics. 2023;151(2):e2022060643 major forms of racial/ethnic discrimi-
lescence; Section on Obesity. 397. Schwimmer JB, Deutsch R, Kahen T, nation and type 2 diabetes risk among
Preventing obesity and eating disor- Lavine JE, Stanley C, Behling C. Preva- White, Black, and Hispanic/Latina
ders in adolescents. Pediatrics. lence of fatty liver in children and women: findings from the Sister Study.
2016;138(3):e20161649 adolescents. Pediatrics. 2006;118(4): Am J Epidemiol. 2021;190(12):
388. Hornberger LL, Lane MA; Committee 1388–1393 2552–2562
on Adolescence. Identification and 398. Rehm JL, Connor EL, Wolfgram PM, 407. Jaffiol C, Thomas F, Spira A, Pannier B,
management of eating disorders in Eickhoff JC, Reeder SB, Allen DB. Pre- Danchin N. Prediabetes and depriva-
children and adolescents. Pediatrics. dicting hepatic steatosis in a racially tion: a couple at high risk of diabetes.
2021;147(1):e2020040279 and ethnically diverse cohort of ado- Rev Epidemiol Sante Publique. 2021;
389. Butler MG, Miller JL, Forster JL. lescent girls. J Pediatr. 2014;165(2): 69(6):361–365
Prader-Willi syndrome—clinical genet- 319–325.e1 408. Butler AM. Social determinants of
ics, diagnosis and treatment 399. Divers J, Mayer-Davis EJ, Lawrence JM, health and racial/ethnic disparities in
approaches: an update. Curr Pediatr et al. Trends in incidence of type 1 type 2 diabetes in youth. Curr Diab
Rev. 2019;15(4):207–244 and type 2 diabetes among youths - Rep. 2017;17(8):60

by guest
409. Kelsey MM, Zeitler PS. Insulin resis- 419. Panagiotopoulos C, Hadjiyannakis S, 428. Welsh JA, Karpen S, Vos MB. Increas-
tance of puberty. Curr Diab Rep. Henderson M; Diabetes Canada Clinical ing prevalence of nonalcoholic fatty
2016;16(7):64 Practice Guidelines Expert Committee. liver disease among United States
410. Rajjo T, Almasri J, Al Nofal A, et al. The Type 2 diabetes in children and adolescents, 1988-1994 to 2007-2010.
association of weight loss and cardio- adolescents. Can J Diabetes. 2018; J Pediatr. 2013;162(3):496–500.e1
metabolic outcomes in obese children: 42(Suppl 1):S247–S254 429. Anderson EL, Howe LD, Jones HE,
systematic review and meta-regres- 420. Pe~na AS, Curran JA, Fuery M, et al. Higgins JP, Lawlor DA, Fraser A. The
sion. J Clin Endocrinol Metab. Screening, assessment and manage- prevalence of non-alcoholic fatty liver
2017;102(3):758–762 ment of type 2 diabetes mellitus in disease in children and adolescents: a
children and adolescents: Australasian systematic review and meta-analysis.
411. Grundy SM, Stone NJ, Bailey AL, et al.
Paediatric Endocrine Group guidelines. PLoS One. 2015;10(10):e0140908
2018 AHA/ACC/AACVPR/AAPA/ABC/
Med J Aust. 2020;213(1):30–43
ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA 430. Drobac S, Brickman W, Smith T, Binns
guideline on the management of blood 421. Harlow KE, Africa JA, Wells A, et al; HJ. Evaluation of a type 2 diabetes
cholesterol: executive summary: a re- Nonalcoholic Steatohepatitis Clinical screening protocol in an urban pediat-
port of the American College of Cardi- Research Network (NASH CRN). Clini- ric clinic. Pediatrics. 2004;114(1):
ology/American Heart Association Task cally actionable hypercholesterolemia 141–148
Force on Clinical Practice Guidelines. and hypertriglyceridemia in children
431. Cook S, Weitzman M, Auinger P, Barlow
J Am Coll Cardiol. 2019;73(24): with nonalcoholic fatty liver disease.
SE. Screening and counseling associ-
3168–3209 J Pediatr. 2018;198:76–83.e2
ated with obesity diagnosis in a na-
412. National Institutes of Health, National 422. Newton KP, Hou J, Crimmins NA, et al; tional survey of ambulatory pediatric
Heart Lung and Blood Institute. Expert Nonalcoholic Steatohepatitis Clinical visits. Pediatrics. 2005;116(1):112–116
Panel on Integrated Guidelines for Research Network. Prevalence of pre-
432. Eneli IU, Keast DR, Rappley MD,
Cardiovascular Health and Risk Reduc- diabetes and type 2 diabetes in chil-
dren with nonalcoholic fatty liver Camargo CA Jr. Adequacy of two am-
tion in Children and Adolescents: Sum- bulatory care surveillance systems for
mary Report. NIH Publication 12-7486A. disease. JAMA Pediatr. 2016;170(10):
e161971 tracking childhood obesity practice
Washington, DC: National Heart Lung patterns. Public Health. 2008;122(7):
and Blood Institute; 2012 423. Andes LJ, Cheng YJ, Rolka DB, Gregg 700–707
413. Juonala M, Magnussen CG, Berenson EW, Imperatore G. Prevalence of predi-
abetes among adolescents and young 433. Xanthakos SA, Lavine JE, Yates KP,
GS, et al. Childhood adiposity, adult et al; NASH Clinical Research Network.
adiposity, and cardiovascular risk adults in the United States, 2005-2016.
JAMA Pediatr. 2020;174(2):e194498 Progression of fatty liver disease in
factors. N Engl J Med. 2011;365(20): children receiving standard of care
1876–1885 424. Holterman AX, Guzman G, Fantuzzi G, lifestyle advice. Gastroenterology.
414. Arslanian S, Bacha F, Grey M, Marcus et al. Nonalcoholic fatty liver disease 2020;159(5):1731–1751.e10
in severely obese adolescent and adult
MD, White NH, Zeitler P. Evaluation and 434. Vajravelu ME, Lee JM, Shah R, Shults
patients. Obesity (Silver Spring).
management of youth-onset type 2 dia- J, Amaral S, Kelly A. Association be-
2013;21(3):591–597
betes: a position statement by the tween prediabetes diagnosis and body
American Diabetes Association. Diabe- 425. Bacha F, Gungor N, Lee S, Arslanian
mass index trajectory of overweight
tes Care. 2018;41(12):2648–2668 SA. Progressive deterioration of b-cell
and obese adolescents. Pediatr
function in obese youth with type 2
415. American Diabetes Association. 13. Diabetes. 2020;21(5):743–746
diabetes. Pediatr Diabetes. 2013;14(2):
Children and adolescents: standards 435. Bolling CF, Armstrong SC, Reichard KW,
106–111
of medical care in diabetes-2019. Michalsky MP; Section on Obesity; Sec-
Diabetes Care. 2019;42(Suppl 1): 426. Kahn SE, Lachin JM, Zinman B, et al;
tion on Surgery. Metabolic and bariat-
S148–S164 ADOPT Study Group. Effects of rosiglita-
ric surgery for pediatric patients with
zone, glyburide, and metformin on
416. American Diabetes Association. 2.0 severe obesity. Pediatrics. 2019;144(6):
b-cell function and insulin sensitivity
Classification and diagnosis of diabe- e20193224
in ADOPT. Diabetes. 2011;60(5):
tes. Diabetes Care. 2017;40(suppl 1): 436. Derderian SC, Patten L, Kaizer AM,
1552–1560
S11–S24 et al. Influence of weight loss on
427. Sam S, Edelstein SL, Arslanian SA,
417. Nguyen D, Kit B, Carroll M. Abnormal obesity-associated complications after
et al; RISE Consortium; RISE Consor-
cholesterol among children and ado- metabolic and bariatric surgery in
tium Investigators. Baseline predictors
lescents in the United States, 2011- of glycemic worsening in youth and adolescents. Obesity (Silver Spring).
2014. NCHS Data Brief. 2015;(228):1–8 adults with impaired glucose toler- 2020;28(12):2397–2404
418. Astudillo M, Tosur M, Castillo B, et al. ance or recently diagnosed type 2 dia- 437. de Ferranti SD, Steinberger J, Ameduri
Type 2 diabetes in prepubertal chil- betes in the Restoring Insulin R, et al. Cardiovascular risk reduction
dren. Pediatr Diabetes. 2021;22(7): Secretion (RISE) Study. Diabetes Care. in high-risk pediatric patients: a scien-
946–950 2021;44(9):1938–1947 tific statement from the American

by guest
Heart Association. Circulation. risk-reducing behaviors. Am J Prev children and adolescents recom-
2019;139(13):e603–e634 Med. 2015;49(4):512–519 mended for a statin? Circulation.
438. Ryder JR, Xu P, Inge TH, et al. Thirty- 448. Murillo R, Katic BJ, Gonzalez T, Vasquez 2013;128(19):2162–2165
year risk of cardiovascular disease E, Echeverria S. The association of pre- 458. Mayer-Davis EJ, Lawrence JM, Dabelea
events in adolescents with severe obe- diabetes and diabetes risk perception D, et al; SEARCH for Diabetes in Youth
sity. Obesity (Silver Spring). 2020;28(3): with leisure-time physical activity and Study. Incidence trends of type 1 and
616–623 weight loss. Am J Health Promot. type 2 diabetes among youths, 2002-
2019;33(4):534–540 2012. N Engl J Med. 2017;376(15):
439. Savoye M, Shaw M, Dziura J, et al. Ef-
449. Owei I, Umekwe N, Ceesay F, Dagogo- 1419–1429
fects of a weight management pro-
gram on body composition and Jack S. Awareness of prediabetes sta- 459. Klingensmith GJ, Connor CG, Ruedy KJ,
metabolic parameters in overweight tus and subsequent health behavior, et al; Pediatric Diabetes Consortium.
children: a randomized controlled trial. body weight, and blood glucose levels. Presentation of youth with type 2 dia-
JAMA. 2007;297(24):2697–2704 J Am Board Fam Med. 2019;32(1): betes in the Pediatric Diabetes Consor-
20–27 tium. Pediatr Diabetes. 2016;17(4):
440. Akinbami LJRL, Rossen LM, Fakhouri
450. Doshi N, Perrin EM, Lazorick S, Esser- 266–273
THI, Simon AE, Kit BK. Contribution of
weight status to asthma prevalence man D, Steiner MJ. Short-term change 460. Hutchins J, Barajas RA, Hale D,
racial disparities, 2-19 year olds, 1988- in body mass index in overweight ado- Escaname E, Lynch J. Type 2 diabetes
2014. Ann Epidemiol. 2017;27(8): lescents following cholesterol screen- in a 5-year-old and single center
472–478.e3 ing. Arch Pediatr Adolesc Med. 2009; experience of type 2 diabetes in youth
163(9):812–817 under 10. Pediatr Diabetes. 2017;18(7):
441. Andersen IG, Holm J-C, Homøe P. 674–677
Obstructive sleep apnea in children 451. Silva DFO, Sena-Evangelista KCM, Lyra
and adolescents with and without obe- CO, Pedrosa LFC, Arrais RF, Lima SCVC. 461. Love-Osborne KA, Sheeder JL, Nadeau
Motivations for weight loss in adoles- KJ, Zeitler P. Longitudinal follow up of
sity. Eur Arch Otorhinolaryngol. 2019;
cents with overweight and obesity: a dysglycemia in overweight and obese
276(3):871–878
systematic review. BMC Pediatr. pediatric patients. Pediatr Diabetes.
442. Hadjiyannakis S, Ibrahim Q, Li J, et al. 2018;18(1):364 2018;19(2):199–204
Obesity class versus the Edmonton
452. Ayer J, Charakida M, Deanfield JE, 462. Hubbard RA, Xu J, Siegel R, Chen Y,
Obesity Staging System for Pediatrics
Celermajer DS. Lifetime risk: childhood Eneli I. Studying pediatric health out-
to define health risk in childhood obe-
obesity and cardiovascular risk. Eur comes with electronic health records
sity: results from the CANPWR cross-
Heart J. 2015;36(22):1371–1376 using Bayesian clustering and trajec-
sectional study. Lancet Child Adolesc
453. Friedemann C, Heneghan C, Mahtani K, tory analysis. J Biomed Inform. 2021;
Health. 2019;3(6):398–407
Thompson M, Perera R, Ward AM. Car- 113:103654
443. Kim SJ, Lee J, Nam CM, Lee SY. Impact
diovascular disease risk in healthy 463. Piccolo RS, Pearce N, Araujo AB,
of obesity on metabolic syndrome
children and its association with body McKinlay JB. The contribution of
among adolescents as compared with mass index: systematic review and biogeographical ancestry and socio-
adults in Korea. Yonsei Med J. 2011; meta-analysis. BMJ. 2012;345:e4759 economic status to racial/ethnic dis-
52(5):746–752 parities in type 2 diabetes mellitus:
454. Li L, Perez A, Wu LT, Ranjit N, Brown
444. Reinehr T, Kleber M, Toschke AM. Life- HS, Kelder SH. Cardiometabolic risk results from the Boston Area Commu-
style intervention in obese children is factors among severely obese children nity Health Survey. Ann Epidemiol.
associated with a decrease of the met- and adolescents in the United States, 2014;24(9):648–654, 654.e1
abolic syndrome prevalence. Athero- 1999-2012. Child Obes. 2016;12(1): 464. Magge SN, Silverstein J, Elder D,
sclerosis. 2009;207(1):174–180 12–19 Nadeau K, Hannon TS. Evaluation and
445. Ciemins EL, Joshi V, Cuddeback JK, 455. Kreatsoulas C, Fleegler EW, Kubzansky treatment of prediabetes in youth.
Kushner RF, Horn DB, Garvey WT. Diag- LD, McGorrian CM, Subramanian SV. J Pediatr. 2020;219:11–22
nosing obesity as a first step to Young adults and adverse childhood 465. Zeitler P, Arslanian S, Fu J, et al. ISPAD
weight loss: an observational study. events: a potent measure of cardiovas- Clinical Practice Consensus Guidelines
Obesity (Silver Spring). 2020;28(12): cular risk. Am J Med. 2019;132(5): 2018: type 2 diabetes mellitus in youth.
2305–2309 605–613 Pediatr Diabetes. 2018;19(Suppl
446. Banerjee ES, Gambler A, Fogleman C. 456. Berglund L, Brunzell JD, Goldberg AC, 27):28–46
Adding obesity to the problem list et al; Endocrine society. Evaluation and 466. Libman IM, Barinas-Mitchell E, Bartucci
increases the rate of providers treatment of hypertriglyceridemia: an A, Robertson R, Arslanian S. Reproduc-
addressing obesity. Fam Med. 2013; Endocrine Society clinical practice ibility of the oral glucose tolerance
45(9):629–633 guideline. J Clin Endocrinol Metab. test in overweight children. J Clin En-
447. Gopalan A, Lorincz IS, Wirtalla C, 2012;97(9):2969–2989 docrinol Metab. 2008;93(11):4231–4237
Marcus SC, Long JA. Awareness of pre- 457. McCrindle BW, Tyrrell PN, Kavey R-EW. 467. Cowie CC, Rust KF, Byrd-Holt DD, et al.
diabetes and engagement in diabetes Will obesity increase the proportion of Prevalence of diabetes and high risk

by guest
for diabetes using A1C criteria in the 477. Levy-Marchal C, Arslanian S, Cutfield W, 486. K€ochli S, Endes K, Steiner R, et al. Obe-
U.S. population in 1988-2006. Diabetes et al; ESPE-LWPES-ISPAD-APPES-APEG- sity, high blood pressure, and physical
Care. 2010;33(3):562–568 SLEP-JSPE; Insulin Resistance in Chil- activity determine vascular phenotype
468. Peters A, Laffel L; American Diabetes dren Consensus Conference Group. in young children. Hypertension. 2019;
Association Transitions Working Group. Insulin resistance in children: consen- 73(1):153–161
Diabetes care for emerging adults: sus, perspective, and future directions. 487. Zhang T, Li S, Bazzano L, He J, Whelton
recommendations for transition from J Clin Endocrinol Metab. 2010;95(12): P, Chen W. Trajectories of childhood
pediatric to adult diabetes care sys- 5189–5198 blood pressure and adult left ventricu-
tems: a position statement of the 478. International Expert Committee. Inter- lar hypertrophy: the Bogalusa Heart
American Diabetes Association. Diabe- national Expert Committee report on Study. Hypertension. 2018;72(1):93–101
tes Care. 2011;34(11):2477–2485 the role of the A1C assay in the diag- 488. Hagman E, Danielsson P, Elimam A,
469. Wu EL, Kazzi NG, Lee JM. Cost-effective- nosis of diabetes. Diabetes Care. Marcus C. The effect of weight loss
ness of screening strategies for identi- 2009;32(7):1327–1334 and weight gain on blood pressure in
fying pediatric diabetes mellitus and 479. Feldstein AE, Charatcharoenwitthaya P, children and adolescents with obesity.
dysglycemia. JAMA Pediatr. 2013; Treeprasertsuk S, Benson JT, Enders Int J Obes. 2019;43(10):1988–1994
167(1):32–39 FB, Angulo P. The natural history of 489. Falkner B, Gidding SS, Portman R,
470. Peter A, Fritsche A, Stefan N, Heni M, non-alcoholic fatty liver disease in chil- Rosner B. Blood pressure variability
H€aring HU, Schleicher E. Diagnostic dren: a follow-up study for up to 20 and classification of prehypertension
value of hemoglobin A1c for type 2 years. Gut. 2009;58(11):1538–1544 and hypertension in adolescence.
diabetes mellitus in a population at 480. Lazo M, Bilal U, Perez-Escamilla R. Epi- Pediatrics. 2008;122(2):238–242
risk. Exp Clin Endocrinol Diabetes. demiology of NAFLD and type 2 diabe- 490. Jackson SL, Zhang Z, Wiltz JL, et al. Hy-
2011;119(4):234–237 tes: health disparities among persons pertension among youths—United
471. Love-Osborne KA, Sheeder J, Svircev A, of Hispanic origin. Curr Diab Rep. States, 2001-2016. MMWR Morb Mortal
Chan C, Zeitler P, Nadeau KJ. Use of 2015;15(12):116 Wkly Rep. 2018;67(27):758–762
glycosylated hemoglobin increases di- 481. Schwimmer JB, Newton KP, Awai HI, 491. Ruiz LD, Zuelch ML, Dimitratos SM,
abetes screening for at-risk adoles- et al. Paediatric gastroenterology eval- Scherr RE. Adolescent obesity: diet
cents in primary care settings. Pediatr uation of overweight and obese chil- quality, psychosocial health, and cardi-
Diabetes. 2013;14(7):512–518 dren referred from primary care for ometabolic risk factors. Nutrients.
472. Vijayakumar P, Nelson RG, Hanson RL, suspected non-alcoholic fatty liver 2019;12(1):43
Knowler WC, Sinha M. HbA1c and the disease. Aliment Pharmacol Ther.
2013;38(10):1267–1277 492. Au CT, Ho CK, Wing YK, Lam HS, Li AM.
prediction of type 2 diabetes in chil-
Acute and chronic effects of sleep du-
dren and adults. Diabetes Care. 482. Macumber IR, Weiss NS, Halbach SM, ration on blood pressure. Pediatrics.
2017;40(1):16–21 Hanevold CD, Flynn JT. The association 2014;133(1):e64–e72
473. Wallace AS, Wang D, Shin JI, Selvin E. of pediatric obesity with nocturnal
non-dipping on 24-hour ambulatory 493. Jiang W, Hu C, Li F, Hua X, Zhang X. As-
Screening and diagnosis of prediabe-
blood pressure monitoring. Am J sociation between sleep duration and
tes and diabetes in US children and
Hypertens. 2016;29(5):647–652 high blood pressure in adolescents: a
adolescents. Pediatrics. 2020;146(3):
systematic review and meta-analysis.
e20200265 483. Chen X, Wang Y. Tracking of blood Ann Hum Biol. 2018;45(6-8):457–462
474. Lee JM, Wu EL, Tarini B, Herman WH, pressure from childhood to adulthood:
a systematic review and meta-regres- 494. American Academy of Pediatrics. Sec-
Yoon E. Diagnosis of diabetes using he-
sion analysis. Circulation. 2008; tion on Obesity. 5210 Pediatric Obesity
moglobin A1c: should recommenda-
117(25):3171–3180 Clinical Decision Support Chart, 3rd
tions in adults be extrapolated to
ed. Itasca, IL: American Academy of
adolescents? J Pediatr. 2011;158(6): 484. Hao G, Wang X, Treiber FA, Harshfield Pediatrics; 2019
947–952.e1-3 G, Kapuku G, Su S. Blood pressure tra-
jectories from childhood to young 495. Hansen ML, Gunn PW, Kaelber DC. Un-
475. Herman WH, Ma Y, Uwaifo G, et al; Dia-
adulthood associated with cardiovas- derdiagnosis of hypertension in chil-
betes Prevention Program Research
Group. Differences in A1C by race and cular risk: results from the 23-year dren and adolescents. JAMA. 2007;
ethnicity among patients with im- Longitudinal Georgia Stress and Heart 298(8):874–879
paired glucose tolerance in the Diabe- Study. Hypertension. 2017;69(3): 496. American Academy of Sleep Medicine.
tes Prevention Program. Diabetes 435–442 International Classification of Sleep
Care. 2007;30(10):2453–2457 485. Theodore RF, Broadbent J, Nagin D, Disorders, 3rd ed. Darien, IL: American
476. Rao LV, Pratt GW, Bi C, Kroll MH. Large- et al. Childhood to early-midlife sys- Academy of Sleep Medicine; 2014
scale retrospective analyses of the ef- tolic blood pressure trajectories: 497. El Hayek S, Bitar L, Hamdar LH, Mirza
fect of iron deficiency anemia on he- early-life predictors, effect modifiers, FG, Daoud G. Poly cystic ovarian syn-
moglobin A1c concentrations. Clin and adult cardiovascular outcomes. drome: an updated overview. Front
Chim Acta. 2022;529:21–24 Hypertension. 2015;66(6):1108–1115 Physiol. 2016;7:124

by guest
498. Bremer AA. Polycystic ovary syndrome 508. Novais EN, Millis MB. Slipped capital intracranial hypertension with and
in the pediatric population. Metab femoral epiphysis: prevalence, patho- without concurrent polycystic ovary
Syndr Relat Disord. 2010;8(5):375–394 genesis, and natural history. Clin syndrome or hyperinsulinemia.
499. Iba~nez L, Oberfield SE, Witchel S, et al. Orthop Relat Res. 2012;470(12): Transl Res. 2006;148(5):215–222
An international consortium update: 3432–3438 520. Kilic K, Korsbæk JJ, Jensen RH, Cvet-
pathophysiology, diagnosis, and treat- 509. Castillo C, Mendez M. Slipped capital kovic VV. Diagnosis of idiopathic intra-
ment of polycystic ovarian syndrome femoral epiphysis: a review for pedia- cranial hypertension - the importance
in adolescence. Horm Res Paediatr. tricians. Pediatr Ann. 2018;47(9): of excluding secondary causes: a
2017;88(6):371–395 e377–e380 systematic review. Cephalalgia. 2022;
500. Witchel SF, Oberfield S, Rosenfield RL, 510. Janoyer M. Blount disease. Orthop 42(6):524–541
et al. The diagnosis of polycystic Traumatol Surg Res. 2019;105(1S): 521. Dietz WH, Belay B, Bradley D, et al. A
ovary syndrome during adolescence. S111–S121 Model Framework That Integrates
Horm Res Paediatr. 2015;83(6):376–389. 511. Sabharwal S. Blount disease: an up- Community and Clinical Systems for
DOI: 10.1159/000375530 date. Orthop Clin North Am. the Prevention and Management of
501. Naz MSG, Tehrani FR, Majd HA, et al. 2015;46(1):37–47 Obesity and Other Chronic Diseases.
The prevalence of polycystic ovary syn- Washington, DC: National Academy of
512. Banwarie RR, Hollman F, Meijs N, et al.
drome in adolescents: a systematic re- Medicine; 2017
Insight into the possible aetiologies of
view and meta-analysis. Int J Reprod Blount’s disease: a systematic review 522. Medical Home Initiatives for Children
Biomed (Yazd). 2019;17(8):533–542 of the literature. J Pediatr Orthop B. With Special Needs Project Advisory
502. Legro RS, Arslanian SA, Ehrmann DA, 2020;29(4):323–336 Committee; American Academy of Pedi-
et al; Endocrine Society. Diagnosis and atrics. The medical home. Pediatrics.
513. Jansen N, Hollman F, Bovendeert F,
treatment of polycystic ovary syn- 2002;110(1 Pt 1):184–186
Moh P, Stegmann A, Staal HM.
drome: an Endocrine Society clinical Blount disease and familial 523. Cardel MI, Newsome FA, Pearl RL,
practice guideline. J Clin Endocrinol inheritance in Ghana, area cross- et al. Patient-centered care for obesity:
Metab. 2013;98(12):4565–4592 sectional study. BMJ Paediatr Open. how health care providers can treat
503. Estrada E, Eneli I, Hampl S, et al; Child- 2021;5(1):e001052 obesity while actively addressing
ren’s Hospital Association. Children’s 514. Markey KA, Mollan SP, Jensen RH, weight stigma and eating disorder
Hospital Association consensus state- Sinclair AJ. Understanding idiopathic risk. J Acad Nutr Diet. 2022;122(6):
ments for comorbidities of childhood intracranial hypertension: mecha- 1089–1098
obesity. Child Obes. 2014;10(4):304–317 nisms, management, and future direc- 524. Resnicow K, Davis R, Rollnick S. Moti-
504. Sutaria S, Devakumar D, Yasuda SS, tions. Lancet Neurol. 2016;15(1):78–91 vational interviewing for pediatric obe-
Das S, Saxena S. Is obesity associated 515. Wall M. Update on idiopathic intracra- sity: conceptual issues and evidence
with depression in children? System- nial hypertension. Neurol Clin. 2017; review. J Am Diet Assoc. 2006;106(12):
atic review and meta-analysis. Arch 35(1):45–57 2024–2033
Dis Child. 2019;104(1):64–74 516. Ko MW, Chang SC, Ridha MA, et al. 525. Resnicow K, McMaster F, Bocian A,
505. Jebeile H, Gow ML, Baur LA, Garnett Weight gain and recurrence in idio- et al. Motivational interviewing and
SP, Paxton SJ, Lister NB. Association pathic intracranial hypertension: a dietary counseling for obesity in
of pediatric obesity treatment, in- case-control study. Neurology. 2011; primary care: an RCT. Pediatrics. 2015;
cluding a dietary component, with 76(18):1564–1567 135(4):649–657
change in depression and anxiety: a 517. Kilgore KP, Lee MS, Leavitt JA, et al. 526. Taylor RW, Cox A, Knight L, et al. A
systematic review and meta-analy- Re-evaluating the incidence of idiopathic tailored family-based obesity interven-
sis. JAMA Pediatr. intracranial hypertension in an era of tion: a randomized trial. Pediatrics.
2019;173(11):e192841–e192841 increasing obesity. Ophthalmology. 2015;136(2):281–289
506. Zuckerbrot RA, Cheung A, Jensen PS, 2017;124(5):697–700 527. Broccoli S, Davoli AM, Bonvicini L,
Stein REK, Laraque D; GLAD-PC Steering 518. Daniels AB, Liu GT, Volpe NJ, et al. Pro- et al. Motivational interviewing to treat
Group. Guidelines for Adolescent De- files of obesity, weight gain, and qual- overweight children: 24-month follow-
pression in Primary Care (GLAD-PC): ity of life in idiopathic intracranial up of a randomized controlled trial.
part I. Practice preparation, identifica- hypertension (pseudotumor cerebri). Pediatrics. 2016;137(1)
tion, assessment, and initial manage- Am J Ophthalmol. 2007;143(4):635–641 528. Gourlan M, Sarrazin P, Trouilloud D.
ment. Pediatrics. 2018;141(3): 519. Glueck CJ, Golnik KC, Aregawi D, Motivational interviewing as a way to
e20174081 Goldenberg N, Sieve L, Wang P. promote physical activity in obese
507. Lehmann CL, Arons RR, Loder RT, Vitale Changes in weight, papilledema, adolescents: a randomised-controlled
MG. The epidemiology of slipped capi- headache, visual field, and life sta- trial using self-determination theory
tal femoral epiphysis: an update. J tus in response to diet and metfor- as an explanatory framework. Psychol
Pediatr Orthop. 2006;26(3):286–290 min in women with idiopathic Health. 2013;28(11):1265–1286

by guest
529. Taveras EM, Marshall R, Kleinman KP, overweight prevention: outcomes of randomized, controlled trial with DASH
et al. Comparative effectiveness of the ‘be active, eat right’ study. PLoS eating plan plus physical activity im-
childhood obesity interventions in pe- One. 2013;8(5):e65376 proves fruit and vegetable intake and
diatric primary care: a cluster-ran- 539. Small L, Bonds-McClain D, Melnyk B, diastolic blood pressure in children.
domized clinical trial. JAMA Pediatr. Vaughan L, Gannon AM. The prelimi- Child Obes. 2015;11(2):177–186
2015;169(6):535–542 nary effects of a primary care-based 548. Parra-Medina D, Mojica C, Liang Y,
530. Chen JL, Guedes CM, Cooper BA, Lung randomized treatment trial with over- Ouyang Y, Ramos AI, Gomez I. Promot-
AE. Short-term efficacy of an innova- weight and obese young children and ing weight maintenance among over-
tive mobile phone technology-based their parents. J Pediatr Health Care. weight and obese Hispanic children in
intervention for weight management 2014;28(3):198–207 a rural practice. Child Obes. 2015;
for overweight and obese adolescents: 540. Stovitz SD, Berge JM, Wetzsteon RJ, 11(4):355–363
pilot study. Interact J Med Res. 2017; Sherwood NE, Hannan PJ, Himes JH. 549. Wake M, Baur LA, Gerner B, et al. Out-
6(2):e12 Stage 1 treatment of pediatric over- comes and costs of primary care sur-
531. Love-Osborne K, Fortune R, Sheeder J, weight and obesity: a pilot and feasi- veillance and intervention for
Federico S, Haemer MA. School-based bility randomized controlled trial. Child overweight or obese children: the
health center-based treatment for Obes. 2014;10(1):50–57 LEAP 2 randomised controlled trial.
obese adolescents: feasibility and 541. Looney SM, Raynor HA. Examining the BMJ. 2009;339:b3308
body mass index effects. Child Obes. effect of three low-intensity pediatric
2014;10(5):424–431 550. Armstrong S, Mendelsohn A, Bennett
obesity interventions: a pilot random- G, Taveras EM, Kimberg A, Kemper AR.
532. McCallum Z, Wake M, Gerner B, et al. ized controlled trial. Clin Pediatr Texting motivational interviewing: a
Outcome data from the LEAP (Live, Eat (Phila). 2014;53(14):1367–1374 randomized controlled trial of motiva-
and Play) trial: a randomized con- 542. Macdonell K, Brogan K, Naar-King S, tional interviewing text messages de-
trolled trial of a primary care inter- Ellis D, Marshall S. A pilot study of signed to augment childhood obesity
vention for childhood overweight/mild motivational interviewing targeting treatment. Child Obes. 2018;14(1):4–10
obesity. Int J Obes. 2007;31(4):630–636 weight-related behaviors in overweight
551. Bean MK, Ingersoll KS, Powell P, et al.
533. Sherwood NE, JaKa MM, Crain AL, or obese African American
Impact of motivational interviewing on
Martinson BC, Hayes MG, Anderson JD. adolescents. J Adolesc Health.
outcomes of an adolescent obesity
Pediatric primary care-based obesity 2012;50(2):201–203
treatment: results from the MI Values
prevention for parents of preschool 543. Walpole B, Dettmer E, Morrongiello BA, randomized controlled pilot trial. Clin
children: a pilot study. Child Obes. McCrindle BW, Hamilton J. Motivational Obes. 2018;8(5):323–326
2015;11(6):674–682 interviewing to enhance self-efficacy
552. Akgul Gundogdu N, Sevig EU, Guler N.
534. Taveras EM, Gortmaker SL, Hohman and promote weight loss in over-
The effect of the solution-focused ap-
KH, et al. Randomized controlled trial weight and obese adolescents: a ran-
to improve primary care to prevent domized controlled trial. J Pediatr proach on nutrition-exercise attitudes
and manage childhood obesity: the Psychol. 2013;38(9):944–953 and behaviours of overweight and
High Five for Kids study. Arch Pediatr obese adolescents: randomised con-
544. Crespo NC, Talavera GA, Campbell NR, trolled trial. J Clin Nurs. 2018;27(7-
Adolesc Med. 2011;165(8):714–722 et al. A randomized controlled trial to 8):e1660–e1672
535. Rifas-Shiman SL, Taveras EM, Gort- prevent obesity among Latino paediat-
maker SL, et al. Two-year follow-up of ric patients. Pediatr Obes. 2018;13(11): 553. Berkowitz RI, Wadden TA, Gehrman CA,
a primary care-based intervention to 697–704 et al. Meal replacements in the treat-
prevent and manage childhood obe- ment of adolescent obesity: a random-
545. Moschonis G, Michalopoulou M, Tsout-
sity: the High Five for Kids study. ized controlled trial. Obesity (Silver
soulopoulou K, et al. Assessment of
Pediatr Obes. 2017;12(3):e24–e27 Spring). 2011;19(6):1193–1199
the effectiveness of a computerised
536. Fonseca H, Prioste A, Sousa P, Gaspar decision-support tool for health pro- 554. Crabtree VM, Moore JB, Jacks DE,
P, Machado MC. Effectiveness analysis fessionals for the prevention and Cerrito P, Topp RV. A transtheoretical,
of an internet-based intervention for treatment of childhood obesity. Results case management approach to the
overweight adolescents: next steps for from a randomised controlled trial. treatment of pediatric obesity. J Prim
researchers and clinicians. BMC Obes. Nutrients. 2019;11(3):706 Care Community Health. 2010;1(1):4–7
2016;3:15 546. Davis AM, James RL, Boles RE, Goetz 555. DeBar LL, Stevens VJ, Perrin N, et al. A
537. Davoli AM, Broccoli S, Bonvicini L, JR, Belmont J, Malone B. The use of primary care-based, multicomponent
et al. Pediatrician-led motivational in- TeleMedicine in the treatment of pae- lifestyle intervention for overweight
terviewing to treat overweight chil- diatric obesity: feasibility and accept- adolescent females. Pediatrics.
dren: an RCT. Pediatrics. 2013; ability. Matern Child Nutr. 2011;7(1): 2012;129(3):e611–e620
132(5):e1236–e1246 71–79 556. Ek A, Lewis Chamberlain K, Sorjonen K,
538. van Grieken A, Veldhuis L, Renders CM, 547. Novotny R, Nigg CR, Li F, Wilkens LR. et al. A parent treatment program for
et al. Population-based childhood Pacific kids DASH for health (PacDASH) preschoolers with obesity: a

by guest
randomized controlled trial. Pediatrics. 566. Quattrin T, Cao Y, Paluch RA, Roemmich childhood obesity: a randomized
2019;144(2):e20183457 JN, Ecker MA, Epstein LH. Cost-effec- controlled trial. Am J Prev Med.
557. Fleischman A, Hourigan SE, Lyon HN, tiveness of family-based obesity treat- 2013;44(3 Suppl 3):S247–S257
et al. Creating an integrated care ment. Pediatrics. 2017;140(3): 576. Flodmark CE, Ohlsson T, Ryden O,
model for childhood obesity: a ran- e20162755
Sveger T. Prevention of progression to
domized pilot study utilizing telehealth 567. Saelens BE, Sallis JF, Wilfley DE, Patrick severe obesity in a group of obese
in a community primary care setting. K, Cella JA, Buchta R. Behavioral schoolchildren treated with family
Clin Obes. 2016;6(6):380–388 weight control for overweight adoles- therapy. Pediatrics. 1993;91(5):880–884
558. Garipagaoglu M, Sahip Y, Darendeliler cents initiated in primary care. Obes
577. Martınez-Andrade GO, Cespedes EM,
F, Akdikmen O, Kopuz S, Sut N. Family- Res. 2002;10(1):22–32
Rifas-Shiman SL, et al. Feasibility and
based group treatment versus individ- 568. Shelton D, Le Gros K, Norton L, Stan- impact of Creciendo Sanos, a clinic-
ual treatment in the management of ton-Cook S, Morgan J, Masterman P. based pilot intervention to prevent
childhood obesity: randomized, pro- Randomised controlled trial: a parent- obesity among preschool children in
spective clinical trial. Eur J Pediatr. based group education programme Mexico City. BMC Pediatr. 2014;14:77
2009;168(9):1091–1099 for overweight children. J Paediatr
Child Health. 2007;43(12):799–805 578. Boutelle KN, Norman GJ, Rock CL, Rhee
559. Hofsteenge GH, Chinapaw MJ, Dele- KE, Crow SJ. Guided self-help for the
marre-van de Waal HA, Weijs PJ. Long- 569. Stark LJ, Clifford LM, Towner EK, et al. treatment of pediatric obesity. Pediat-
term effect of the Go4it group treat- A pilot randomized controlled trial of rics. 2013;131(5):e1435–e1442
ment for obese adolescents: a rando- a behavioral family-based intervention
mised controlled trial. Clin Nutr. with and without home visits to de- 579. Croker H, Viner RM, Nicholls D, et al.
2014;33(3):385–391 crease obesity in preschoolers. J Pe- Family-based behavioural treatment of
diatr Psychol. 2014;39(9):1001–1012 childhood obesity in a UK National
560. Kalavainen MP, Korppi MO, Nuutinen Health Service setting: randomized
OM. Clinical efficacy of group-based 570. Stark LJ, Spear Filigno S, Bolling C, controlled trial. Int J Obes. 2012;36(1):
treatment for childhood obesity com- et al. Clinic and home-based behav-
16–26
pared with routinely given individual ioral intervention for obesity in
counseling. Int J Obes. 2007;31(10): preschoolers: a randomized trial. 580. Deforche B, De Bourdeaudhuij I,
1500–1508 J Pediatr. 2018;192:115–121.e1 Tanghe A, Debode P, Hills AP, Bouckaert
J. Post-treatment phone contact: a
561. Njardvik U, Gunnarsdottir T, Olafsdottir 571. Stettler N, Wrotniak BH, Hill DL, et al.
weight maintenance strategy in obese
AS, Craighead LW, Boles RE, Bjarnason Prevention of excess weight gain in
youngsters. Int J Obes. 2005;29(5):
R. Incorporating appetite awareness paediatric primary care: beverages
543–546
training within family-based behavioral only or multiple lifestyle factors. The
treatment of pediatric obesity: a ran- Smart Step Study, a cluster-random- 581. Kalavainen M, Korppi M, Nuutinen O.
domized controlled pilot study. J Pe- ized clinical trial. Pediatr Obes. 2015; Long-term efficacy of group-based
diatr Psychol. 2018;43(9):1017–1027 10(4):267–274 treatment for childhood obesity com-
562. Norman G, Huang J, Davila EP, et al. 572. Truby H, Baxter K, Ware RS, et al. A pared with routinely given individual
Outcomes of a 1-year randomized con- randomized controlled trial of two dif- counselling. Int J Obes. 2011;35(4):
trolled trial to evaluate a behavioral ferent macronutrient profiles on 530–533
‘stepped-down’ weight loss interven- weight, body composition and meta- 582. Wright JA, Phillips BD, Watson BL,
tion for adolescent patients with obe- bolic parameters in obese adolescents Newby PK, Norman GJ, Adams WG.
sity. Pediatr Obes. 2016;11(1):18–25 seeking weight loss. PLoS One. Randomized trial of a family-based, au-
563. Nova A, Russo A, Sala E. Long-term 2016;11(3):e0151787 tomated, conversational obesity treat-
management of obesity in paediatric 573. Verbeken S, Braet C, Goossens L, van ment program for underserved
office practice: experimental evalua- der Oord S. Executive function training populations. Obesity (Silver Spring).
tion of two different types of interven- with game elements for obese chil- 2013;21(9):E369–E378
tion. Ambul Child Health. 2001;7(3-4): dren: a novel treatment to enhance 583. Yackobovitch-Gavan M, Wolf Linhard D,
239–247 self-regulatory abilities for weight- Nagelberg N, et al. Intervention for
564. Parillo M, Licenziati MR, Vacca M, De control. Behav Res Ther. 2013;51(6): childhood obesity based on parents
Marco D, Iannuzzi A. Metabolic 290–299 only or parents and child compared
changes after a hypocaloric, low-glyce- 574. Ebbeling CB, Leidig MM, Sinclair KB, with follow-up alone. Pediatr Obes.
mic-index diet in obese children. J En- Hangen JP, Ludwig DS. A reduced-gly- 2018;13(11):647–655
docrinol Invest. 2012;35(7):629–633 cemic load diet in the treatment of ad- 584. Bohlin A, Hagman E, Klaesson S,
565. Quattrin T, Roemmich JN, Paluch R, Yu olescent obesity. Arch Pediatr Adolesc Danielsson P. Childhood obesity
J, Epstein LH, Ecker MA. Treatment out- Med. 2003;157(8):773–779 treatment: telephone coaching is as
comes of overweight children and pa- 575. Arauz Boudreau AD, Kurowski DS, good as usual care in maintaining
rents in the medical home. Pediatrics. Gonzalez WI, Dimond MA, Oreskovic weight loss - a randomized controlled
2014;134(2):290–297 NM. Latino families, primary care, and trial. Clin Obes. 2017;7(4):199–205

by guest
585. Ford AL, Bergh C, S€odersten P, et al. randomized controlled trial. Pediatr controlled trial. J Telemed Telecare.
Treatment of childhood obesity by re- Obes. 2012;7(3):205–219 2016;22(2):86–95
training eating behaviour: randomised 595. Demol S, Yackobovitch-Gavan M, 604. O’Connor TM, Hilmers A, Watson K,
controlled trial. BMJ. 2009;340:b5388 Shalitin S, Nagelberg N, Gillon-Keren Baranowski T, Giardino AP. Feasibility
586. Hills AP, Parker AW. Obesity manage- M, Phillip M. Low-carbohydrate (low & of an obesity intervention for paediat-
ment via diet and exercise interven- high-fat) versus high-carbohydrate ric primary care targeting parenting
tion. Child Care Health Dev. 1988;14(6): low-fat diets in the treatment of and children: helping HAND. Child Care
409–416 obesity in adolescents. Acta Paediatr. Health Dev. 2013;39(1):141–149
2009;98(2):346–351 605. Wilfley DE, Stein RI, Saelens BE, et al.
587. Hughes AR, Stewart L, Chapple J, et al.
Randomized, controlled trial of a best- 596. Yackobovitch-Gavan M, Nagelberg N, Efficacy of maintenance treatment ap-
practice individualized behavioral pro- Demol S, Phillip M, Shalitin S. Influence proaches for childhood overweight: a
gram for treatment of childhood over- of weight-loss diets with different mac- randomized controlled trial. JAMA.
weight: Scottish Childhood Overweight ronutrient compositions on health-re- 2007;298(14):1661–1673
Treatment Trial (SCOTT). Pediatrics. lated quality of life in obese youth. 606. Wake M, Lycett K, Clifford SA, et al.
2008;121(3):e539–e546 Appetite. 2008;51(3):697–703 Shared care obesity management in
588. Pedrosa C, Oliveira BM, Albuquerque I, 597. Larsen LM, Hertel NT, Mølgaard C, 3-10 year old children: 12 month out-
Sim~oes-Pereira C, Vaz-de-Almeida MD, Christensen RD, Husby S, Jarbøl DE. comes of HopSCOTCH randomised trial.
Early intervention for childhood over- BMJ. 2013;346:f3092
Correia F. Markers of metabolic syn-
drome in obese children before and weight: a randomized trial in general 607. Krebs NF, Gao D, Gralla J, Collins JS,
after 1-year lifestyle intervention pro- practice. Scand J Prim Health Care. Johnson SL. Efficacy and safety of a
gram. Eur J Nutr. 2011;50(6):391–400 2015;33(3):184–190 high protein, low carbohydrate diet
598. Mirza NM, Palmer MG, Sinclair KB, for weight loss in severely obese ado-
589. Banks J, Sharp DJ, Hunt LP, Shield JP.
et al. Effects of a low glycemic load or lescents. J Pediatr. 2010;157(2):
Evaluating the transferability of a hos-
a low-fat dietary intervention on body 252–258
pital-based childhood obesity clinic to
weight in obese Hispanic American 608. Williams CL, Strobino BA, Brotanek J.
primary care: a randomised controlled
children and adolescents: a random- Weight control among obese adoles-
trial. Br J Gen Pract. 2012;62(594):
ized controlled trial. Am J Clin Nutr. cents: a pilot study. Int J Food Sci
e6–e12
2013;97(2):276–285 Nutr. 2007;58(3):217–230
590. Bathrellou E, Yannakoulia M, Papaniko-
599. Partsalaki I, Karvela A, Spiliotis BE. 609. Kumar S, Croghan IT, Biggs BK, et al.
laou K, et al. Parental involvement
Metabolic impact of a ketogenic diet Family-based mindful eating interven-
does not augment the effectiveness of
compared to a hypocaloric diet in tion in adolescents with obesity: a pi-
an intense behavioral program for the
obese children and adolescents. lot randomized clinical trial. Children
treatment of childhood obesity. Hor-
J Pediatr Endocrinol Metab. 2012; (Basel). 2018;5(7):93
mones (Athens). 2010;9(2):171–175 25(7-8):697–704
610. Kokkvoll A, Grimsgaard S, Ødegaard R,
591. Berkowitz RI, Rukstalis MR, Bishop- 600. Ba~nos RM, Oliver E, Navarro J, et al. Flægstad T, Njølstad I. Single versus
Gilyard CT, et al. Treatment of adolescent Efficacy of a cognitive and behavioral multiple-family intervention in child-
obesity comparing self-guided and treatment for childhood obesity sup- hood overweight–Finnmark Activity
group lifestyle modification programs: a ported by the ETIOBE web platform. School: a randomised trial. Arch Dis
potential model for primary care. Psychol Health Med. 2019;24(6): Child. 2014;99(3):225–231
J Pediatr Psychol. 2013;38(9):978–986 703–713
611. Tjønna AE, Stølen TO, Bye A, et al. Aero-
592. Casazza K, Cardel M, Dulin-Keita A, 601. Stark LJ, Filigno SS, Kichler JC, et al. bic interval training reduces cardio-
et al. Reduced carbohydrate diet to Maintenance following a randomized vascular risk factors more than a
improve metabolic outcomes and de- trial of a clinic and home-based multitreatment approach in over-
crease adiposity in obese peripubertal behavioral intervention of obesity in weight adolescents. Clin Sci (Lond).
African American girls. J Pediatr Gas- preschoolers. J Pediatr. 2019;213: 2009;116(4):317–326
troenterol Nutr. 2012;54(3):336–342 128–136.e3
612. Weigel C, Kokocinski K, Lederer P,
593. de Ferranti SD, Milliren CE, Denhoff ER, 602. Davis AM, Sampilo M, Gallagher KS, D€otsch J, Rascher W, Knerr I. Child-
et al. Providing food to treat adoles- Landrum Y, Malone B. Treating rural hood obesity: concept, feasibility, and
cents at risk for cardiovascular dis- pediatric obesity through telemedicine: interim results of a local group-based,
ease. Obesity (Silver Spring). outcomes from a small randomized long-term treatment program. J Nutr
2015;23(10):2109–2117 controlled trial. J Pediatr Psychol. Educ Behav. 2008;40(6):369–373
594. de Niet J, Timman R, Bauer S, et al. 2013;38(9):932–943 613. Savoye M, Nowicka P, Shaw M, et al.
The effect of a short message service 603. Davis AM, Sampilo M, Gallagher KS, Long-term results of an obesity pro-
maintenance treatment on body mass et al. Treating rural paediatric obesity gram in an ethnically diverse pediatric
index and psychological well-being in through telemedicine vs. telephone: population. Pediatrics. 2011;127(3):
overweight and obese children: a outcomes from a cluster randomized 402–410

by guest
614. Kokkvoll A, Grimsgaard S, Steinsbekk 623. Kirk S, Armstrong S, King E, et al. Es- with early success in obesity treatment.
S, Flægstad T, Njølstad I. Health in tablishment of the Pediatric Obesity Clin Pediatr (Phila). 2010;49(5):457–465
overweight children: 2-year follow-up Weight Evaluation Registry: a national 633. Berge JM, Everts JC. Family-based in-
of Finnmark Activity School–a research collaborative for identifying terventions targeting childhood obe-
randomised trial. Arch Dis Child. 2015; the optimal assessment and treatment sity: a meta-analysis. Child Obes. 2011;
100(5):441–448 of pediatric obesity. Child Obes. 2017; 7(2):110–121
13(1):9–17
615. Wilfley DE, Saelens BE, Stein RI, et al. 634. Bean MK, Caccavale LJ, Adams EL,
Dose, content, and mediators of fam- 624. Skelton JA, Irby MB, Beech BM, Rhodes et al. Parent involvement in adolescent
ily-based treatment for childhood SD. Attrition and family participation obesity treatment: a systematic review.
obesity: a multisite randomized clinical in obesity treatment programs: clini- Pediatrics. 2020;146(3):e20193315
trial. JAMA Pediatr. 2017;171(12): cians’ perceptions. Acad Pediatr.
2012;12(5):420–428 635. Piercy KL, Troiano RP. Physical activity
1151–1159 guidelines for Americans from the US
616. Lison JF, Real-Montes JM, Torro I, 625. O’Connor EA, Evans CV, Burda BU, Department of Health and Human
et al. Exercise intervention in child- Walsh ES, Eder M, Lozano P. Screening Services. Circ Cardiovasc Qual Out-
hood obesity: a randomized controlled for obesity and intervention for weight comes. 2018;11(11):e005263
trial comparing hospital-versus home- management in children and adoles-
cents: evidence report and systematic 636. van der Horst K, Ferrage A, Rytz A. In-
based groups. Acad Pediatr. 2012; volving children in meal preparation.
review for the US Preventive Services
12(4):319–325 Effects on food intake. Appetite. 2014;
Task Force. JAMA. 2017;317(23):
617. Vos RC, Huisman SD, Houdijk EC, Pijl H, 79:18–24
2427–2444
Wit JM. The effect of family-based mul- 637. Vos RC, Wit JM, Pijl H, Houdijk EC.
626. Jasik CB, King EC, Rhodes E, et al.
tidisciplinary cognitive behavioral Long-term effect of lifestyle interven-
Characteristics of youth presenting for
treatment on health-related quality of tion on adiposity, metabolic parame-
weight management: retrospective na-
life in childhood obesity. Qual Life Res. ters, inflammation and physical
tional data from the POWER Study
2012;21(9):1587–1594 fitness in obese children: a random-
Group. Child Obes. 2015;11(5):630–637
618. Bocca G, Corpeleijn E, Stolk RP, Sauer ized controlled trial. Nutr Diabetes.
627. Liu S, Weismiller J, Strange K, et al. 2011;1(10):e9
PJ. Results of a multidisciplinary treat- Evaluation of the scale-up and imple-
ment program in 3-year-old to 5-year- 638. Stark LJ, Spear S, Boles R, et al.
mentation of mind, exercise, nutrition
old overweight or obese children: a A pilot randomized controlled trial of
… do it! (MEND) in British Columbia:
randomized controlled clinical trial. a clinic and home-based behavioral
a hybrid trial type 3 evaluation. BMC
Arch Pediatr Adolesc Med. 2012; intervention to decrease obesity in
Pediatr. 2020;20(1):392
166(12):1109–1115 preschoolers. Obesity (Silver Spring).
628. Hoffman J, Frerichs L, Story M, et al. 2011;19(1):134–141
619. Bocca G, Ongering EC, Stolk RP, Sauer An integrated clinic-community part-
PJ. Insulin resistance and cardiovascu- 639. Makkes S, Renders CM, Bosmans JE,
nership for child obesity treatment: a
lar risk factors in 3- to 5-year-old over- van der Baan-Slootweg OH, Hoekstra T,
randomized pilot trial. Pediatrics.
weight or obese children. Horm Res Seidell JC. One-year effects of two in-
2018;141(1):e20171444
Paediatr. 2013;80(3):201–206 tensive inpatient treatments for se-
629. Andrews M, Sawyer C, Frerichs L, verely obese children and adolescents.
620. Nemet D, Oren S, Pantanowitz M, et al. Feasibility of a clinic-community BMC Pediatr. 2016;16:120
Eliakim A. Effects of a multidisciplinary partnership to treat childhood obesity.
640. Quattrin T, Roemmich JN, Paluch R,
childhood obesity treatment interven- Clin Pediatr (Phila). 2018;57(7):
Yu J, Epstein LH, Ecker MA. Efficacy of
tion on adipocytokines, inflammatory 783–791
family-based weight control program
and growth mediators. Horm Res 630. Kong AS, Sussman AL, Yahne C, for preschool children in primary
Paediatr. 2013;79(6):325–332 Skipper BJ, Burge MR, Davis SM. care. Pediatrics. 2012;130(4):660–666
621. Nemet D, Barkan S, Epstein Y, School-based health center interven-
641. Bocca G, Kuitert MW, Sauer PJ, Stolk
Friedland O, Kowen G, Eliakim A. Short- tion improves body mass index in
RP, Flapper BC, Corpeleijn E. A multi-
and long-term beneficial effects of a overweight and obese adolescents.
disciplinary intervention programme
combined dietary-behavioral-physical J Obes. 2013;2013:575016
has positive effects on quality of life in
activity intervention for the treatment 631. Bocca G, Corpeleijn E, van den Heuvel overweight and obese preschool chil-
of childhood obesity. Pediatrics. 2005; ER, Stolk RP, Sauer PJ. Three-year dren. Acta Paediatr. 2014;103(9):
115(4):e443–e449 follow-up of 3-year-old to 5-year-old 962–967
622. van der Baan-Slootweg O, Benninga children after participation in a multi- 642. Butte NF, Hoelscher DM, Barlow SE,
MA, Beelen A, et al. Inpatient treatment disciplinary or a usual-care obesity et al. Efficacy of a community- versus
of children and adolescents with se- treatment program. Clin Nutr. 2014; primary care-centered program for
vere obesity in the Netherlands: a ran- 33(6):1095–1100 childhood obesity: TX CORD RCT.
domized clinical trial. JAMA Pediatr. 632. Heinberg LJ, Kutchman EM, Berger NA, Obesity (Silver Spring). 2017;25(9):
2014;168(9):807–814 et al. Parent involvement is associated 1584–1593

by guest
643. Reinehr T, Schaefer A, Winkel K, Finne metabolic and bariatric surgery: evi- children and adolescents: are they
E, Toschke AM, Kolip P. An effective life- dence, barriers, and best practices. appropriate? Pediatrics. 2011;127(6):
style intervention in overweight chil- Pediatrics. 2019;144(6):e20193223 1182–1189
dren: findings from a randomized 655. Children’s Hospital Association. 2013 662. Heyman MB, Abrams SA; Section on
controlled trial on “Obeldicks light”. Survey Findings on Children’s Hospi- Gastroenterology, Hepatology, and Nu-
Clin Nutr. 2010;29(3):331–336 tals Obesity Services. Overland Park, trition; Committee on Nutrition. Fruit
644. Skelton JA, Beech BM. Attrition in pae- KS: Children’s Hospital Association; juice in infants, children, and adoles-
diatric weight management: a review 2014 cents: current recommendations.
of the literature and new directions. 656. Azevedo LB, Ling J, Soos I, Robalino S, Pediatrics. 2017;139(6):e20170967
Obes Rev. 2011;12(5):e273–e281 Ells L. The effectiveness of sedentary 663. Thivel D, Masurier J, Baquet G, et al.
645. Butte NF, Watson KB, Ridley K, et al. A behaviour interventions for reducing High-intensity interval training in over-
youth compendium of physical activi- body mass index in children and ado- weight and obese children and adoles-
ties: activity codes and metabolic in- lescents: systematic review and meta- cents: systematic review and meta-
tensities. Med Sci Sports Exerc. analysis. Obes Rev. 2016;17(7):623–635 analysis. J Sports Med Phys Fitness.
2018;50(2):246–256 657. Fanburg JT, Rogers VW, Dedekian MA; 2019;59(2):310–324
646. Anderson YC, Wynter LE, Grant CC, National Initiative for Children’s Health- 664. Garcıa-Hermoso A, Sanchez-Lopez M,
et al. A novel home-based intervention care Quality; The Barbara Bush Child- Martınez-Vizcaıno V. Effects of aerobic
for child and adolescent obesity: the ren’s Hospital; American Academy of plus resistance exercise on body
results of the Whanau Pakari random- Pediatrics Maine Chapter. Next Steps composition related variables in
ized controlled trial. Obesity (Silver Activity Book! Activity Book for pediatric obesity: a systematic review
Spring). 2017;25(11):1965–1973 Caregivers and Children Aged 5 to and meta-analysis of randomized
12 Years. Elk Grove Village, IL: controlled trials. Pediatr Exerc Sci.
647. Jebeile H, Lister NB, Baur LA, Garnett
American Academy of Pediatrics; 2016 2015;27(4):431–440
SP, Paxton SJ. Eating disorder risk in
adolescents with obesity. Obes Rev. 658. Fanburg JT, Rogers VW, Dedekian MA; 665. Kelley GA, Kelley KS. Effects of exercise
2021;22(5):e13173 National Initiative for Children’s Health- in the treatment of overweight and
care Quality; The Barbara Bush Child- obese children and adolescents: a
648. Rhodes ET, Boles RE, Chin K, et al. Ex- ren’s Hospital; American Academy of
pectations for treatment in pediatric systematic review of meta-analyses.
Pediatrics Maine Chapter. Pasos J Obes. 2013;2013:783103
weight management and relationship Proximos <Libro de Actividades! Libro
to attrition. Child Obes. 2017;13(2): de Actividades para Cuidadores y 666. Ruotsalainen H, Kyng€as H, Tammelin T,
120–127 Ni~nos de Entre 5 y 12 A~nos. Elk Grove K€a€ari€ainen M. Systematic review of
649. Kumar S, King EC, Christison AL, et al; Village, IL: American Academy of physical activity and exercise interven-
POWER Work Group. Health outcomes Pediatrics; 2016 tions on body mass indices, subse-
of youth in clinical pediatric weight quent physical activity and
659. Malik VS, Pan A, Willett WC, Hu FB. psychological symptoms in overweight
management programs in POWER. J Sugar-sweetened beverages
Pediatr. 2019;208:57–65.e4 and obese adolescents. J Adv Nurs.
and weight gain in children and
2015;71(11):2461–2477
650. Lycett K, Juonala M, Magnussen CG, adults: a systematic review and
et al. Body mass index from early to meta-analysis. Am J Clin Nutr. 667. Marson EC, Delevatti RS, Prado AKG,
late childhood and cardiometabolic 2013;98(4):1084–1102 Netto N, Kruel LFM. Effects of aerobic,
measurements at 11 to 12 years. Pedi- resistance, and combined exercise
660. Vos MB, Kaar JL, Welsh JA, et al;
atrics. 2020;146(2):e20193666 training on insulin resistance markers
American Heart Association Nutrition
in overweight or obese children and
651. Haemer M, Cluett S, Hassink SG, et al. Committee of the Council on Lifestyle
adolescents: a systematic review and
Building capacity for childhood obesity and Cardiometabolic Health; Council
meta-analysis. Prev Med.
prevention and treatment in the medi- on Clinical Cardiology; Council on
2016;93:211–218
cal community: call to action. Pediat- Cardiovascular Disease in the Young;
rics. 2011;128(Suppl 2):S71–S77 Council on Cardiovascular and Stroke 668. Monzani A, Ricotti R, Caputo M, et al. A
Nursing; Council on Epidemiology and systematic review of the association
652. Long KA, Weinert C. Rural nursing: de- of skipping breakfast with weight and
Prevention; Council on Functional
veloping the theory base. Sch Inq Nurs cardiometabolic risk factors in chil-
Genomics and Translational Biology;
Pract. 1989;3(2):113–127 dren and adolescents. What should we
and Council on Hypertension. Added
653. Tolbert J. The Coverage Provisions in sugars and cardiovascular disease better investigate in the future?
the Affordable Care Act: An Update. risk in children: a scientific statement Nutrients. 2019;11(2):387
San Francisco, CA: Kaiser Family Foun- from the American Heart Association. 669. Tucker SJ, Ytterberg KL, Lenoch LM,
dation; 2015 Circulation. 2017;135(19):e1017–e1034 et al. Reducing pediatric overweight:
654. Armstrong SC, Bolling CF, Michalsky 661. Committee on Nutrition and the Coun- nurse-delivered motivational interview-
MP, Reichard KW; Section on Obesity; cil on Sports Medicine and Fitness. ing in primary care. J Pediatr Nurs.
Section on Surgery. Pediatric Sports drinks and energy drinks for 2013;28(6):536–547

by guest
670. Gortmaker SL, Polacsek M, Letourneau overweight and obese adolescent 690. Ruggiero L, Glasgow R, Dryfoos JM,
L, et al. Evaluation of a primary care girls. Pediatr Obes. 2017;12(2):120–128 et al. Diabetes self-management. Self-
intervention on body mass index: the 681. Staiano AE, Beyl RA, Guan W, Hendrick reported recommendations and pat-
Maine Youth Overweight Collaborative. terns in a large population. Diabetes
CA, Hsia DS, Newton RL Jr. Home-based
Child Obes. 2015;11(2):187–193 Care. 1997;20(4):568–576
exergaming among children with over-
671. Khalsa AS, Kharofa R, Ollberding NJ, weight and obesity: a randomized clin- 691. Richard AA, Shea K. Delineation of self-
Bishop L, Copeland KA. Attainment of ical trial. Pediatr Obes. 2018;13(11): care and associated concepts. J Nurs
‘5-2-1-0’ obesity recommendations in 724–733 Scholarsh. 2011;43(3):255–264
preschool-aged children. Prev Med 682. Trost SG, Sundal D, Foster GD, Lent 692. Welch JL, Johnson M, Zimmerman L,
Rep. 2017;8:79–87 MR, Vojta D. Effects of a pediatric Russell CL, Perkins SM, Decker BS.
672. LeBlanc AG, Chaput JP, McFarlane A, weight management program with Self-management interventions in
et al. Active video games and health and without active video games a ran- stages 1 to 4 chronic kidney disease:
indicators in children and youth: a domized trial. JAMA Pediatr. 2014; an integrative review. West J Nurs
systematic review. PLoS One. 2013; 168(5):407–413 Res. 2015;37(5):652–678
8(6):e65351 693. Ory MG, Ahn S, Jiang L, et al. National
683. Staiano AE. Exergames, energy expen-
673. Madsen KA, Thompson HR, Wlasiuk diture, and obesity. In: van den Bulck study of chronic disease self-manage-
L, Queliza E, Schmidt C, Newman TB. J, ed. The International Encyclopedia ment: six-month outcome findings. J
After-school program to reduce Aging Health. 2013;25(7):1258–1274
of Media Psychology. Hoboken, NJ:
obesity in minority children: a pilot John Wiley and Sons; 2020 694. Havas K, Douglas C, Bonner A. Meeting
study. J Child Health Care. patients where they are: improving
684. American Psychological Association.
2009;13(4):333–346 outcomes in early chronic kidney dis-
Clinical Practice Guideline Panel. Clini-
674. Oliveira CB, Pinto RZ, Saraiva BTC, ease with tailored self-management
cal Practice Guideline for Multicompo-
et al. Effects of active video games on support (the CKD-SMS study). BMC
nent Behavioral Treatment of Obesity
Nephrol. 2018;19(1):279
children and adolescents: a systematic and Overweight in Children and Ado-
review with meta-analysis. Scand J lescents: Current State of the Evidence 695. Pugh P, Hemingway P, Christian M,
Med Sci Sports. 2020;30(1):4–12 and Research Needs. Washington, DC: Higginbottom G. Children’s, parents’,
American Psychological Association; and other stakeholders’ perspectives
675. Staiano AE, Abraham AA, Calvert SL.
2018 on the factors influencing the
Adolescent exergame play for weight
initiation of early dietary change in
loss and psychosocial improvement: a 685. Rosenkranz RR, Bauer A, Dzewaltowski the management of childhood chronic
controlled physical activity interven- DA. Mother-daughter resemblance in disease: a mixed studies systematic
tion. Obesity (Silver Spring). 2013; BMI and obesity-related behaviors. Int review using a narrative synthesis.
21(3):598–601 J Adolesc Med Health. 2010;22(4): Patient Educ Couns. 2021;104(4):844–857
676. Staiano AE, Webster EK, Allen AT, 477–489
696. Jabs J, Devine CM. Time scarcity and
Jarrell AR, Martin CK. Screen-time 686. van der Kruk JJ, Kortekaas F, Lucas C, food choices: an overview. Appetite.
policies and practices in early care Jager-Wittenaar H. Obesity: a system- 2006;47(2):196–204
and education centers in relationship atic review on parental involvement in
to child physical activity. Child Obes. 697. Curtin C, Hyman SL, Boas DD, et al.
long-term European childhood weight
2018;14(6):341–348 Weight management in primary care
control interventions with a nutritional
for children with autism: expert rec-
677. Trost SG, O’Neil M. Clinical use of ob- focus. Obes Rev. 2013;14(9):745–760 ommendations. Pediatrics.
jective measures of physical activity. 687. Van Ryzin MJ, Nowicka P. Direct and in- 2020;145(Suppl 1):S126–S139
Br J Sports Med. 2014;48(3):178–181 direct effects of a family-based inter- 698. Zablotsky B, Black LI, Maenner MJ,
678. Lu AS, Kharrazi H, Gharghabi F, vention in early adolescence on et al. Prevalence and trends of devel-
Thompson D. A systematic review of parent-youth relationship quality, late opmental disabilities among children
health videogames on childhood adolescent health, and early adult obe- in the United States: 2009-2017. Pediat-
obesity prevention and intervention. sity. J Fam Psychol. 2013;27(1):106–116 rics. 2019;144(4):e20190811
Games Health J. 2013;2(3):131–141 688. Enright G, Allman-Farinelli M, Redfern 699. Feehan K, O’Neil ME, Abdalla D, et al.
679. Maddison R, Foley L, Ni Mhurchu C, J. Effectiveness of family-based behav- Factors influencing physical activity in
et al. Effects of active video games on ior change interventions on obesity-re- children and youth with special health
body composition: a randomized con- lated behavior change in children: a care needs: a pilot study. Int J Pediatr.
trolled trial. Am J Clin Nutr. 2011; realist synthesis. Int J Environ Res 2012;2012:583249
94(1):156–163 Public Health. 2020;17(11):4099
700. Abeysekara P, Turchi R, O’Neil M.
680. Staiano AE, Marker AM, Beyl RA, Hsia 689. Modi AC, Pai AL, Hommel KA, et al. Obesity and children with special
DS, Katzmarzyk PT, Newton RL. A ran- Pediatric self-management: a frame- healthcare needs: special considera-
domized controlled trial of dance exer- work for research, practice, and policy. tions for a special population. Curr
gaming for exercise training in Pediatrics. 2012;129(2):e473–e485 Opin Pediatr. 2014;26(4):508–515

by guest
701. Ptomey LT, Washburn RA, Goetz JR, 712. Pu R, Shi D, Gan T, et al. Effects of met- 721. Freemark M, Bursey D. The effects of
et al. Weight loss interventions for formin in obesity treatment in differ- metformin on body mass index and
adolescents with intellectual disabil- ent populations: a meta-analysis. Ther glucose tolerance in obese adoles-
ities: an RCT. Pediatrics. 2021;148(3): Adv Endocrinol Metab. 2020;11: cents with fasting hyperinsulinemia
e2021050261 2042018820926000 and a family history of type 2 diabe-
713. Wilson DM, Abrams SH, Aye T, et al; tes. Pediatrics. 2001;107(4):E55
702. Ptomey LT, Wittenbrook W. Position of
the Academy of Nutrition and Dietetics: Glaser Pediatric Research Network 722. Kendall D, Vail A, Amin R, et al. Metfor-
nutrition services for individuals with Obesity Study Group. Metformin ex- min in obese children and adoles-
intellectual and developmental disabil- tended release treatment of adolescents: the MOCA trial. J Clin
ities and special health care needs. J cent obesity: a 48-week randomized, Endocrinol Metab. 2013;98(1):322–329
Acad Nutr Diet. 2015;115(4):593–608 double-blind, placebo-controlled trial 723. Rynders C, Weltman A, Delgiorno C,
with 48-week follow-up. Arch Pediatr et al. Lifestyle intervention improves
703. Haney K, Messiah SE, Arheart KL, et al.
Adolesc Med. 2010;164(2):116–123 fitness independent of metformin in
Park-based afterschool program to im-
prove cardiovascular health and physi- 714. Yanovski JA, Krakoff J, Salaita CG, et al. obese adolescents. Med Sci Sports Ex-
cal fitness in children with disabilities. Effects of metformin on body weight erc. 2012;44(5):786–792
Disabil Health J. 2014;7(3):335–342 and body composition in obese insulin- 724. Srinivasan S, Ambler GR, Baur LA,
resistant children: a randomized clinical et al. Randomized, controlled trial of
704. Carbone PS, Smith PJ, Lewis C, LeBlanc
trial. Diabetes. 2011;60(2):477–485 metformin for obesity and insulin re-
C. Promoting the participation of chil-
dren and adolescents with disabilities 715. van der Aa MP, Elst MA, van de Garde sistance in children and adolescents:
in sports, recreation, and physical ac- EM, van Mil EG, Knibbe CA, van der improvement in body composition and
tivity. Pediatrics. 2021;148(6): Vorst MM. Long-term treatment with fasting insulin. J Clin Endocrinol
e2021054664 metformin in obese, insulin-resistant Metab. 2006;91(6):2074–2080
adolescents: results of a randomized 725. Allen HF, Mazzoni C, Heptulla RA, et al.
705. CanChild. Research in practice: F
double-blinded placebo-controlled trial. Randomized controlled trial evaluating
words knowledge hub. Available at:
Nutr Diabetes. 2016;6(8):e228 response to metformin versus stan-
https://www.canchild.ca/en/research-
in-practice/f-words-in-childhood- 716. Akcam M, Boyaci A, Pirgon O, Kaya S, dard therapy in the treatment of
disability. Accessed October 5, 2022 Uysal S, Dundar BN. Therapeutic effect adolescents with polycystic ovary
of metformin and vitamin E versus syndrome. J Pediatr Endocrinol Metab.
706. Duis J, van Wattum PJ, Scheimann A, 2005;18(8):761–768
prescriptive diet in obese adolescents
et al. A multidisciplinary approach to
with fatty liver. Int J Vitam Nutr Res. 726. Evia-Viscarra ML, Rodea-Montero ER,
the clinical management of Prader-
Willi syndrome. Mol Genet Genomic
2011;81(6):398–406 Apolinar-Jimenez E, et al. The effects
Med. 2019;7(3):e514 717. Atabek ME, Pirgon O. Use of metformin of metformin on inflammatory media-
in obese adolescents with hyperinsuli- tors in obese adolescents with insulin
707. McCandless SE; Committee on Genet- resistance: controlled randomized clin-
nemia: a 6-month, randomized, double-
ics. Clinical report—health supervi- ical trial. J Pediatr Endocrinol Metab.
blind, placebo-controlled clinical trial.
sion for children with Prader-Willi 2012;25(1-2):41–49
J Pediatr Endocrinol Metab. 2008;
syndrome. Pediatrics. 2011;127(1):
21(4):339–348 727. Mauras N, DelGiorno C, Hossain J,
195–204
718. Burgert TS, Duran EJ, Goldberg-Gell R, et al. Metformin use in children with
708. Haliloglu B, Bereket A. Hypothalamic obesity and normal glucose toler-
et al. Short-term metabolic and car-
obesity in children: pathophysiology to ance–effects on cardiovascular
diovascular effects of metformin in
clinical management. J Pediatr Endo- markers and intrahepatic fat.
markedly obese adolescents with nor-
crinol Metab. 2015;28(5-6):503–513 J Pediatr Endocrinol Metab. 2012;25
mal glucose tolerance. Pediatr Diabe-
709. Cortese S, Vincenzi B. Obesity and tes. 2008;9(6):567–576 (1-2):33–40
ADHD: clinical and neurobiological im- 728. Pastor-Villaescusa B, Ca~nete MD,
719. Casteels K, Fieuws S, van Helvoirt M,
plications. Curr Top Behav Neurosci. et al. Metformin therapy to reduce Caballero-Villarraso J, et al. Metformin
2012;9:199–218 weight gain and visceral adiposity in for obesity in prepubertal and puber-
710. Kelly AS, Auerbach P, Barrientos-Perez children and adolescents with neuro- tal children: a randomized controlled
M, et al; NN8022-4180 Trial Investiga- genic or myogenic motor deficit. Pe- trial. Pediatrics. 2017;140(1):e20164285
tors. A randomized, controlled trial of diatr Diabetes. 2010;11(1):61–69 729. Chanoine JP, Hampl S, Jensen C,
liraglutide for adolescents with obe- 720. Clarson CL, Mahmud FH, Baker JE, Boldrin M, Hauptman J. Effect of
sity. N Engl J Med. 2020;382(22): et al. Metformin in combination with orlistat on weight and body
2117–2128 structured lifestyle intervention im- composition in obese adolescents: a
711. Corcoran C, Jacobs TF. Metformin. proved body mass index in obese ado- randomized controlled trial. JAMA.
StatPearls. Available at: https:// lescents, but did not improve insulin 2005;293(23):2873–2883
pubmed.ncbi.nlm.nih.gov/30085525/. resistance. Endocrine. 2009;36(1): 730. Ozkan B, Bereket A, Turan S, Keskin S.
Accessed May 2, 2022 141–146 Addition of orlistat to conventional

by guest
treatment in adolescents with severe 741. Dewberry LC, Jalivand A, Gupta R, 751. Kebbe M, Perez A, Ball GDC. Is there a
obesity. Eur J Pediatr. 2004;163(12): et al. Weight loss and health status 5 role for shared decision-making in pe-
738–741 years after adjustable gastric banding diatric weight management? Obes Res
731. Kelly AS, Bensignor MO, Hsia DS, et al in adolescents. Obes Surg. 2020;30(6): Clin Pract. 2018;12(2):246–248
Varghese for the Trial Investigators. 2388–2394 752. Christison AL, Vaidya S, Tinajero-Deck
Phentermine/topiramate for the treat- 742. Himpens J, Cadiere GB, Bazi M, Vouche L, Hampl SE. Application of the medical
ment of adolescent obesity. N Engl J M, Cadiere B, Dapri G. Long-term out- neighborhood to children with severe
Med Evid. 2022;1(6) comes of laparoscopic adjustable gas- obesity. Child Obes. 2018;14(7):461–467
732. Olbers T, Beamish AJ, Gronowitz E, tric banding. Arch Surg. 2011;146(7): 753. Moore J, Haemer M, Mirza N, et al.
et al. Laparoscopic Roux-en-Y gastric 802–807 Pilot testing of a patient decision aid
bypass in adolescents with severe 743. Zitsman JLDM, DiGiorgi MF, Fennoy I, for adolescents with severe obesity in
obesity (AMOS): a prospective, 5-year, Kopchinski JS, Sysko R, Devlin MJ. Ado- us pediatric weight management pro-
Swedish nationwide study. Lancet Dia- lescent laparoscopic adjustable gas- grams within the COMPASS Network.
betes Endocrinol. 2017;5(3):174–183 tric banding (LAGB): prospective Int J Environ Res Public Health. 2019;
733. Pratt JSA, Browne A, Browne NT, et al. results in 137 patients followed for 3 16(10):1776
ASMBS pediatric metabolic and bariat- years. Surg Obes Relat Dis. 2015;11(1): 754. Turer CB, Monta~no S, Lin H, Hoang K,
ric surgery guidelines, 2018. Surg 101–109 Flores G. Pediatricians’ communication
Obes Relat Dis. 2018;14(7):882–901 744. G€othberg G, Gronowitz E, Flodmark CE, about weight with overweight Latino
734. Inge TH, Courcoulas AP, Jenkins TM, et al. Laparoscopic Roux-en-Y gastric children and their parents. Pediatrics.
et al; Teen-LABS Consortium. Weight bypass in adolescents with morbid 2014;134(5):892–899
loss and health status 3 years after obesity–surgical aspects and clinical 755. Daniels SR, Hassink SG; Committee on
bariatric surgery in adolescents. N outcome. Semin Pediatr Surg. 2014; Nutrition. The role of the pediatrician
Engl J Med. 2016;374(2):113–123 23(1):11–16 in primary prevention of obesity.
735. Michalsky MP, Inge TH, Jenkins TM, Pediatrics. 2015;136(1):e275–e292
745. O’Brien PE, Sawyer SM, Laurie C, et al.
et al; Teen-LABS Consortium. Cardio- Laparoscopic adjustable gastric band- 756. Hart LC, Patel-Nguyen SV, Merkley MG,
vascular risk factors after adolescent ing in severely obese adolescents: a Jonas DE. An evidence map for
bariatric surgery. Pediatrics. randomized trial. JAMA. interventions addressing transition
2018;141(2):e20172485 2010;303(6):519–526 from pediatric to adult care: a
736. Inge TH, Courcoulas AP, Jenkins TM, systematic review of systematic
746. Olbers T, Gronowitz E, Werling M, et al.
et al; Teen–LABS Consortium. Five-year reviews. J Pediatr Nurs. 2019;48:
Two-year outcome of laparoscopic 18–34
outcomes of gastric bypass in adoles- Roux-en-Y gastric bypass in adoles-
cents as compared with adults. N Engl cents with severe obesity: 757. American Academy of Pediatrics;
J Med. 2019;380(22):2136–2145 results from a Swedish Nationwide American Academy of Family Physi-
737. Alqahtani A, Elahmedi M, Qahtani AR. Study (AMOS). Int J Obes. 2012;36(11): cians; American College of Physicians-
Laparoscopic sleeve gastrectomy in 1388–1395 American Society of Internal Medicine.
children younger than 14 years: refut- A consensus statement on health care
747. Olbers T, Beamish AJ, Gronowitz E, transitions for young adults with spe-
ing the concerns. Ann Surg. 2016;
et al. Laparoscopic Roux-en-Y gastric cial health care needs. Pediatrics.
263(2):312–319
bypass in adolescents with severe 2002;110(6 Pt 2):1304–1306
738. Alqahtani AR, Elahmedi M, Abdurabu obesity (AMOS): a prospective, 5-year,
HY, Alqahtani S. Ten-year outcomes of 758. Schultz AT, Smaldone A. Components
Swedish nationwide study. Lancet Dia- of interventions that improve transi-
children and adolescents who under- betes Endocrinol. 2017;5(3):174–183
went sleeve gastrectomy: weight loss, tions to adult care for adolescents
comorbidity resolution, adverse 748. Ryder JR, Gross AC, Fox CK, et al. Fac- with type 1 diabetes. J Adolesc Health.
events, and growth velocity. J Am Coll tors associated with long-term weight- 2017;60(2):133–146
Surg. 2021;233(6):657–664 loss maintenance following bariatric 759. Shrewsbury VA, Baur LA, Nguyen B,
surgery in adolescents with severe Steinbeck KS. Transition to adult care
739. Olshansky SJ, Passaro DJ, Hershow
obesity. Int J Obes. 2018;42(1):102–107 in adolescent obesity: a systematic re-
RC, et al. A potential decline in life ex-
pectancy in the United States in the 749. Hardin AP, Hackell JM; Committee on view and why it is a neglected topic.
21st century. N Engl J Med. 2005; Practice and Ambulatory Medicine. Int J Obes. 2014;38(4):475–479
352(11):1138–1145 Age limit of pediatrics. Pediatrics. 760. Uzark K, Yu S, Lowery R, et al. Transi-
2017;140(3):e20172151 tion readiness in teens and young
740. Chang S-H, Stoll CRT, Song J, Varela JE,
Eagon CJ, Colditz GA. The effectiveness 750. Association of Maternal and Child adults with congenital heart disease:
and risks of bariatric surgery: an up- Health Programs. Standards for Sys- can we make a difference? J Pediatr.
dated systematic review and meta- tems of Care for Children. Washington, 2020;221:201–206.e1
analysis, 2003-2012. JAMA Surg. DC: Association of Maternal and Child 761. Hankins JS, Osarogiagbon R,
2014;149(3):275–287 Health Programs; 2014 Adams-Graves P, et al. A transition

by guest
pilot program for adolescents with Services. Coverage of Certain Preven- standard for publishing on racial
sickle cell disease. J Pediatr Health tive Services Under the Affordable health inequities. Available at: https://
Care. 2012;26(6):e45–e49 Care Act. Final rules. Fed Regist. www.healthaffairs.org/do/10.1377/
762. Saulsberry AC, Hodges JR, Cole A, 2015;80(134):41317–41347 forefront.20200630.939347/. Accessed
Porter JS, Hankins J. Web-based 770. Staiano A, Marker A, Liu M, Hayden E, March 1, 2021
technology to improve disease knowl- Hsia D, Broyles S. Childhood obesity 781. Cabana MD, Rand CS, Powe NR, et al.
edge among adolescents with sickle screening and treatment practices of Why don’t physicians follow clinical
cell disease: pilot study. JMIR Pediatr pediatric healthcare providers. J La practice guidelines? A framework for
Parent. 2020;3(1):e15093 State Med Soc. 2017;169(1):2–10 improvement. JAMA. 1999;282(15):
1458–1465
763. Blum RW, Garell D, Hodgman CH, et al. 771. Gortmaker SL, Wang YC, Long MW,
Transition from child-centered to adult et al. Three interventions that reduce 782. Ayash CR, Simon SR, Marshall R, et al.
health-care systems for adolescents childhood obesity are projected to Evaluating the impact of point- of-care
with chronic conditions. A position pa- save more than they cost to imple- decision support tools in improving di-
per of the Society for Adolescent Medi- ment. Health Aff (Millwood). 2015; agnosis of obese children in primary
cine. J Adolesc Health. 1993;14(7): 34(11):1932–1939 care. Obesity (Silver Spring). 2013;
570–576 21(3):576–582
772. Kenney EL, Barrett JL, Bleich SN, Ward
764. Chu PY, Maslow GR, von Isenburg M, ZJ, Cradock AL, Gortmaker SL. Impact 783. Sharifi M, Franz C, Horan CM, et al.
Chung RJ. Systematic review of the im- of the healthy, hunger-free kids act on Cost-effectiveness of a clinical child-
pact of transition interventions for obesity trends. Health Aff (Millwood). hood obesity intervention.
adolescents with chronic illness on 2020;39(7):1122–1129 Pediatrics. 2017;140(5):e20162998
transfer from pediatric to adult 773. Kristensen AH, Flottemesch TJ, Macio- 784. Agency for Healthcare Research and
healthcare. J Pediatr Nurs. 2015;30(5): sek MV, et al. Reducing childhood obe- Quality. The healthy weight care assis-
e19–e27 sity through U.S. federal policy: a tant. Available at: https://cds.ahrq.gov/
765. Cairo SB, Majumdar I, Pryor A, Posner microsimulation analysis. Am J Prev cdsconnect/artifact/healthy-weight-
A, Harmon CM, Rothstein DH; Delivery Med. 2014;47(5):604–612 care-assistant. Accessed October 5,
of Surgical Care Committee of the 2022
774. Mackey ER, Burton ET, Cadieux A, et al.
American Academy of Pediatrics Sec- Addressing structural racism is criti- 785. Bronder KL, Dooyema CA, Onufrak SJ,
tion on Surgery. Challenges in transi- cal for ameliorating the childhood obe- Foltz JL. Electronic health records to
tion of care for pediatric patients sity epidemic in black youth. Child support obesity-related patient care:
after weight-reduction surgery: a sys- Obes. 2022;18(2):75–83 results from a survey of United States
tematic review and recommendations physicians. Prev Med. 2015;77:41–47
for comprehensive care. Obes Surg. 775. Odulana A, Basco WT, Bishu KG, Egede LE.
Dietary and physical activity counseling 786. Harrison MR, Lundeen EA, Belay B,
2018;28(4):1149–1174 Goodman AB. Clinical decision sup-
trends in U.S. children, 2002-2011. Am J
766. Leyser A, Taube-Schiff M, Daniel KS, Prev Med. 2017;53(1):9–16 ports in electronic health records to
Toulany A. Transition of care in obesity promote childhood obesity-related
management: bridging the gap 776. Imoisili OE, Goodman AB, Dooyema care: results from a 2015 survey of
between pediatric and adult health CA, Harrison MR, Belay B, Park S. healthcare providers. Clin Nutr Res.
care services. Can J Diabetes. Screening and referral for child- 2019;8(4):255–264
2015;39(1):S15 hood obesity: adherence to the U.S.
787. Temple MW, Sisk B, Krams LA,
Preventive Services Task Force rec-
767. White PH, Cooley WC; Transitions Clini- Schneider JH, Kirkendall ES, Lehmann
ommendation. Am J Prev Med.
cal Report Authoring Group; American CU. Trends in use of electronic health
2019;56(2):179–186
Academy of Pediatrics; American Acad- records in pediatric office settings.
emy of Family Physicians; American 777. Fowler LA, Grammer AC, Staiano AE, J Pediatr. 2019;206:164–171.e2
College of Physicians. Supporting the et al. Harnessing technological solu-
788. Marcus MD, Foster GD, El Ghormli L.
health care transition from adoles- tions for childhood obesity prevention
Stability of relative weight category
cence to adulthood in the medical and treatment: a systematic review
and cardiometabolic risk factors
home. Pediatrics. 2018;142(5): and meta-analysis of current applica-
among moderately and severely obese
e20182587 tions. Int J Obes. 2021;45(5):957–981
middle school youth. Obesity (Silver
768. Yanovski SZ, Yanovski JA. Long-term 778. Ramsetty A, Adams C. Impact of the Spring). 2014;22(4):1118–1125
drug treatment for obesity: a system- digital divide in the age of COVID-19.
789. American Diabetes Association. 3.
atic and clinical review. JAMA. 2014; J Am Med Inform Assoc. 2020;27(7): Prevention or delay of type 2 diabetes:
311(1):74–86 1147–1148 standards of medical care in diabetes-
769. Department of the Treasury, Internal 779. Dorsey ER, Topol EJ. State of telehealth. 2019. Diabetes Care. 2019;42
Revenue Service; Department of Labor, N Engl J Med. 2016;375(2):154–161 (Suppl 1):S29–S33
Employee Benefits Security Administra- 780. Boyd RW, Lindo EG, Weeks LD, 790. Hannon TS, Janosky J, Arslanian SA.
tion; Department of Health and Human McLemore MR. On racism: a new Longitudinal study of physiologic

by guest
insulin resistance and metabolic 795. Sheka AC, Adeyi O, Thompson J, 799. Burrello J, Erhardt EM, Saint-Hilary G,
changes of puberty. Pediatr Res. Hameed B, Crawford PA, Ikramuddin S. et al. Pharmacological treatment of
2006;60(6):759–763 Nonalcoholic steatohepatitis: a review. arterial hypertension in children and
791. Moran A, Jacobs DR Jr, Steinberger J, JAMA. 2020;323(12):1175–1183
adolescents: a network meta-analysis.
et al. Insulin resistance during puberty: 796. Corey KE, Rinella ME. Medical and Hypertension. 2018;72(2):306–313
results from clamp studies in 357 chil- surgical treatment options for nonal-
dren. Diabetes. 1999;48(10):2039–2044 coholic steatohepatitis. Dig Dis Sci. 800. Cheung AH, Zuckerbrot RA, Jensen PS,
2016;61(5):1387–1397 Laraque D, Stein REK; GLAD-PC Steering
792. Kleber M, Lass N, Papcke S, Wabitsch
M, Reinehr T. One-year follow-up of 797. Lavine JE, Schwimmer JB, Van Natta Group. Guidelines for adolescent de-
untreated obese white children and ML, et al; Nonalcoholic Steatohepa- pression in primary care (GLAD-PC):
adolescents with impaired glucose titis Clinical Research Network. Ef- part II. treatment and ongoing man-
tolerance: high conversion rate to nor- fect of vitamin E or metformin for agement. Pediatrics. 2018;141(3):
mal glucose tolerance. Diabet Med.
treatment of nonalcoholic fatty liver e20174082
2010;27(5):516–521
disease in children and adoles-
793. Weiss R, Taksali SE, Tamborlane WV, 801. Wall M, McDermott MP, Kieburtz KD,
cents: the TONIC randomized con-
Burgert TS, Savoye M, Caprio S. Pre- et al; NORDIC Idiopathic Intracranial
trolled trial. JAMA. 2011;305(16):
dictors of changes in glucose toler- Hypertension Study Group Writing
1659–1668
ance status in obese youth. Diabetes Committee. Effect of acetazolamide on
Care. 2005;28(4):902–909 798. Schwimmer JB, Ugalde-Nicalo P, Welsh
visual function in patients with idio-
794. Tamborlane WV, Barrientos-Perez M, JA, et al. Effect of a low free sugar
diet vs usual diet on nonalcoholic fatty pathic intracranial hypertension and
Fainberg U, et al; Ellipse Trial Investiga-
liver disease in adolescent boys: a mild visual loss: the idiopathic intra-
tors. Liraglutide in children and ado-
lescents with type 2 diabetes. N Engl J randomized clinical trial. JAMA. 2019; cranial hypertension treatment trial.
Med. 2019;381(7):637–646 321(3):256–265 JAMA. 2014;311(16):1641–1651

by guest

2023 - Clinical Practice Guideline For The Evaluation - AAP

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2023 - Clinical Practice Guideline For The Evaluation - AAP

Uploaded by

Copyright:

Available Formats

CLINICAL PRACTICE GUIDELINE Guidance for the Clinician in Rendering Pediatric Care

Clinical Practice Guideline for the

2 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 3

4 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 5

6 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 7

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 9

F.3. Groups 3 Through 5 Extraction

Because of small numbers, the

F4. KQ2 Extraction (Comorbidity Studies) FIGURE 2

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 11

Aggregate Evidence Quality Grade B

12 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 13

14 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 15

16 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 17

18 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 19

20 FROM THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 2 Genetic Syndromes Associated With Obesity

PEDIATRICS Volume 151, number 2, February 2023 21

22 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 23

24 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 25

26 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Aggregate Evidence Quality Grade B

PEDIATRICS Volume 151, number 2, February 2023 27

28 FROM THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 5 Assessment Components

PEDIATRICS Volume 151, number 2, February 2023 29

30 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 31

32 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 33

Aggregate Evidence Quality Grade B.

34 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Aggregate Evidence Quality Grade C.

PEDIATRICS Volume 151, number 2, February 2023 35

Aggregate Evidence Quality Grade A

36 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 37

TABLE 9 Other Risk Factors for Prediabetes and T2DM90,358,415,419

38 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Aggregate Evidence Quality Grade B.

TABLE 10 Criteria for Diagnosing Prediabetes and T2DM90

PEDIATRICS Volume 151, number 2, February 2023 39

40 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Aggregate Evidence Quality Grade C

PEDIATRICS Volume 151, number 2, February 2023 41

obesity fosters earlier detection of definitions of “elevation,” “stage 1 determine accurate BP

42 FROM THE AMERICAN ACADEMY OF PEDIATRICS

TABLE 14 Deﬁnitions and Criteria for PCOS

PEDIATRICS Volume 151, number 2, February 2023 43

44 FROM THE AMERICAN ACADEMY OF PEDIATRICS

PEDIATRICS Volume 151, number 2, February 2023 45

Aggregate Evidence Quality Grade B

Perform comprehensive patient history

Evaluate for comorbidities0