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Prepared for your next patient.

Pediatric
Obesity in
Primary Care
Sandra G. Hassink, MD, FAAP
Director, Nemours Obesity
Initiative
Alfred I. duPont Hospital for
Children

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Disclaimers
Statements and opinions expressed are those of the authors
and not necessarily those of the American Academy of
Pediatrics.
Mead Johnson sponsors programs such as this to give
healthcare professionals access to scientific and educational
information provided by experts. The presenter has complete
and independent control over the planning and content of the
presentation, and is not receiving any compensation from Mead
Johnson for this presentation. The presenters comments and
opinions are not necessarily those of Mead Johnson. In the
event that the presentation contains statements about uses of
drugs that are not within the drugs' approved indications,Mead
Johnson does not promote the use of any drug for indications
outside the FDA-approved product label.

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Objectives
Increase awareness on childhood obesity
among pediatricians sothey can work with
their patients andparents to identify at-risk
patients and take preventiveor corrective
action.

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Childhood Obesity
Epidemic Widespread in population (adults
and children)
Progressive Childhood obesity becomes
adult obesity
Alters Development Physically,
emotionally, psychosocially
Chronic disease Lifelong morbidity
accelerates adult disease into childhood
Increases morbidity/mortality First
generation to have shorter lifespan than
parents

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Obesity and Normal Development

Deconditioned
Derailed from normal activity
Depressed, teased and bullied
Disease burden
Decreased quality of life
Diminished educational and job
opportunities

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Trends in Obesity Among Children

and Adolescents: United States, 1963
2008

Note: Obesity is defined as body mass index (BMI) greater than or equal to sex- and age-specific 95th
percentile from the 2000 CDC Growth Charts.
CDC/NCHS, National Health Examination Surveys II (ages 611), III (ages 1217), and National Health and Nutrition Examination
Surveys (NHANES) 19992000, 20012003, 20032004, 20052006, and 20072008.

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Prevalence of Obesity* and Overweight

Among Children Aged 25 Years, by Race
and Ethnicity

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Prevalence of Obesity in Infancy

Birth to 1 year

11.1% of children 011 months were >95%

weight/length.

1 to 2 years

17.0% of children 1223 months were >95%

weight/length.

2 to 3 years

12.9% of children 2435 months had a BMI >95%.

3 to 4 years

15.2% of children 3647 months had a BMI >95%.

Centers for Disease Control and Prevention. 2009 Pediatric Surveillance. National Summary of Trends in Growth Indicators by Age.
Children Aged <5 Years. Available at http://www.cdc.gov/pednss/pednss_tables/pdf/national_table20.pdf.

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Obesity Trajectory
Phase I Steady increase in childhood
obesity
Phase II Emergence of serious obesity
related comorbidities
Phase III Medical complications lead to life
threatening diseasedeath in middle age
Phase IV Acceleration of obesity epidemic
by transgenerational transmission

Ludwig DS. Childhood obesitythe shape of things to come. N Engl J Med. 2007;357(23):2325-2327.

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Age-adjusted Percentage of U.S. Adults

Who Were Obese or Who Had
Diagnosed Diabetes

CDCs Division of Diabetes Translation. National Diabetes Surveillance System. Available at http://www.cdc.gov/diabetes/statistics.

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Expert Committee
Recommendations
Purpose:
Update pediatric obesity prevention
June
2007
and treatment recommendations.
Focus

Pediatric practice change

Universal prevention
Parents/families as partners in lifestyle change
Obesity in the context of the Chronic Disease
model
Connections to the community

Medical Home
Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.

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Expert
Committee
Assessment
BMI/nutrition/activity/readiness to
change
Recommendations

Evidence based/evidence informed/expert opinion

on high risk behavior for obesity
Stepwise approach to prevention and treatment
Addressed obesity management in primary and
tertiary care
Multidisciplinary approach
Family centered/parenting/motivational
interviewing
Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.

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Expert Committee
Recommendations

Assessment
Prevention
Prevention Plus
Structured Weight Management
Comprehensive Multidisciplinary Protocol
Tertiary Care Protocol

Assessment of Child and Adolescent Overweight and Obesity. Pediatrics. 2007;120(Supplement 4):163-288.

Universal Assessment of Obesity Risk: Steps to Prevention

and Treatment
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American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart.

Elk Grove Village, IL: American Academy of Pediatrics; 2008.

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Recommendations with Consistent

Evidence
Multiple studies show consistent association
between recommended behavior and either
obesity risk or energy balance.
Limit consumption of sugar sweetened
beverages.
Limit TV (0 hours <2 years, <2 hours >2 years
old).
Remove TV from primary sleeping area.
Eat breakfast daily.
Limit eating out.
Encourage family meals.
Limit portion size.

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Recommendations with Mixed

Evidence

Some studies demonstrated evidence for

weight or energy balance benefit but
others did not or the studies were too few
or too small.
5 or more fruits and vegetable servings/day (9
age appropriate servings recommended)

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Recommendations Where Evidence

Suggests

Studies have not examined association with

weight or energy balance, or the studies were
too few or too small, but expert committee
thinks it could support healthy weight and would
not be harmful

Eat a diet rich in calcium.

Eat a diet high in fiber.
Eat a diet with balanced macronutrients (food groups).
Breastfeeding
Promote moderate-vigorous activity 60 minutes a day.
Limit consumption of energy dense foods.

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Assessment of Obesity
Calculate, chart, and classify BMI for all
children 218 years of age at least yearly.
Assess dietary patterns.
Assess activity/inactivity.
Assess readiness for change.
Assess obesity related comorbidities.
Assess ongoing progress.

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BMI Calculate, Chart,

Classify

BMI is a screening measure, determines

further evaluation
BMI based on age and gender and is a
population based reference
Underweight BMI <5%
Normal weight BMI 5%84%
Overweight BMI >85%94% (IOM
classification)
Obese BMI 95%99% (IOM classification)
Morbid (severe) obesity BMI >99%

Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and
Adolescents: The Bogalusa Heart Study. J Pediatr. 2007;150(1):12-17.

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Prevention
All children are considered at risk for
obesity.
Message at well visits
Simple
Consistent
Cumulative prevention

Gateway message to nutrition, activity,

and high risk behavior

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BMI 99th Percentile Cut-Points

(kg/m2)

American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of
Pediatrics; 2008.

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Weight Loss Targets

American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of
Pediatrics; 2008.

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BMI
Children with a BMI >99% have a greater
rate of cardiovascular risk factors.
Children (age 12) with a BMI >99%
followed into adulthood (age 27).
100% BMI >30
90% with BMI >35
65% with BMI >40

Freedman DS, Mei Z, Srinivasan SR, et al. Cardiovascular Risk Factors and Excess Adiposity Among Overweight Children and
Adolescents: The Bogalusa Heart Study. J Pediatr. 2007;150(1):12-17.

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Prevention of BMI 5%84%

Promote breastfeeding.
Diet and physical activity

5 or more servings of fruits and vegetables per

day
2 or fewer hours of screen time per day, and no
television in the room where the child sleeps
1 hour or more of daily physical activity
No sugar-sweetened beverages

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Prevention BMI 5%84%

Portions
Age appropriate
Parents provide, child decides
1015 minute increments of exercise

Structure

Breakfast
Family dinners, no TV
Limit fast food
Outdoor time

Balance
Food groups
Limit refined sugar
Screen time alternatives

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Prevention
Self-efficacy and readiness to change

Minimum
Once steps
a Year
at Well Visits
Small incremental
for change
Family support
Positive
Self monitoring
Setbacks are normal, trouble shoot, support return to
plan
Identify high risk nutritional/activity behaviors

Universal Assessment of Obesity Risk: Steps to Prevention

and Treatment
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American Academy of Pediatrics. Pediatric Obesity Clinical Decision

Support Chart.
Elk Grove Village, IL: American Academy of Pediatrics; 2008.

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Prevention Plus BMI >85%

Build on prevention.
Eating behaviors
Family meals should happen at least 5 to 6
times per week.
Allow the child to self-regulate his or her
meals and avoid overly restrictive behaviors
Parents provide, child decides.
Structure activity.

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Prevention Plus BMI >85%

Within this category, the goal should be
weight maintenance with growth that
results in a decreasing BMI as age
increases.
Monthly follow-up for 3 to 6 months; if no
improvement go to Stage 2.

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Assess Dietary Patterns

Additional practices to be considered for
evaluation during the qualitative dietary
assessment include:
Excessive consumption of foods that are high
in energy density
Meal frequency and snacking patterns
(including quality)

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Dietary Assessment

Consumption of sugar sweetened beverages

Daily breakfast
Eating out
Family meals
Portion size
5 or more servings of fruits and vegetables
Calcium
Fiber
Balanced macronutrients (food groups)
Energy dense foods
Readiness to change

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Assess Physical
Activity/Inactivity
Screen time
TV in room
Daily activity
Self-efficacy and readiness to change
Physical (built) environment
Social/community support for activity
Barriers to physical activity
Assess patients and familys activity and
exercise habits.
Assess outdoor activity.

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Physical Activity/Inactivity
Advise 60 minutes of at least moderate
physical activity per day and 20 minutes
of vigorous activity 3 times a week.
Refer to community activity programs.
Encourage development of family activities.
Consider pedometer use.

Decrease level of sedentary behavior.

Limit screen time to <2 hours per day.
No TV/computer in bedroom.

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Structured
Weight
Dietary and physical activity behaviors
Management
Development of a plan for utilization of a
balanced macronutrient diet emphasizing
low amounts of energy-dense foods
Increased structured daily meals and
snacks
Supervised active play of at least 60
minutes a day
Screen time of 1 hour or less a day

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Structured
Weight (eg,
Management
Increased monitoring
screen time,
physical activity, dietary intake, restaurant
logs) by provider, patient, and/or family
This approach may be amenable to group
visits with patient/parent component,
nutrition, and structured activity.

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Structured
Weightthat
Management
Weight maintenance

Decreases BMI as age and height increases

Weight loss should not exceed

1 lb/month in children aged 211 years

or
An average of 2 lb/week in older
overweight/obese children and adolescents

If no improvement in BMI/weight after 3 to

6 months, patient should be advanced to
Stage 3.

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Family History
Focused family history
Obesity, type 2 diabetes, cardiovascular
disease (particularly hypertension), and
early deaths from heart disease or stroke

Family history may be the touch point

for emphasizing family involvement.

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Review of Systems
Obesity Assessment: Findings on Review of Systems and Possible
Etiologies

American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics;
2008.

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Severe Obesity Related

Hyperglycemic
Emergencies
hyperosmolar state
DKA
Pulmonary emboli
Cardiomyopathy of
obesity

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Comorbidities Requiring Immediate

Attention
Pseudotumor cerebri
Slipped capital
femoral epiphysis
Blounts disease
Sleep apnea
Asthma
Nonalcoholic
hepatosteatosis
Cholelithiasis

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Chronic Obesity Related Comorbid

Conditions
Insulin resistance
(metabolic
syndrome)
Type II diabetes
Polycystic ovary
syndrome
Hypertension
Hyperlipidemia
Psychological

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Physical Examination
Obesity Assessment: Physical Examination Findings and
Possible Etiologies

American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of Pediatrics;
2008.

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Laboratory Evaluation
BMI >85% <94%
Fasting lipid profile, AST, ALT q 2 years

BMI >95%
Fasting lipid profile, AST, ALT q 2 years, fasting
glucose

Laboratory evaluation as always depends

on clinical assessment.

Medical Screening by BMI Category

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American Academy of Pediatrics. Pediatric Obesity Clinical Decision Support Chart. Elk Grove Village, IL: American Academy of
Pediatrics; 2008.

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Comprehensive Multidisciplinary
Protocol
Multidisciplinary obesity care team

Physician, nurse, dietician, exercise trainer, social

worker, psychologist

Eating and activity goals are the same as in

Stage 2.
Activities within this category should also
include:
Structured behavioral modification program,
including food and activity monitoring and
development of short-term diet and physical
activity goals

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Comprehensive Multidisciplinary
Protocol

Behavior modification

Involvement of primary caregivers/families in

children under age 12 years
Training of primary caregivers/families for all
children

Goal
Weight maintenance or gradual weight loss until
BMI is <85th percentile and should not exceed 1
lb/month in children aged 25 years, or 2
lb/week in older obese children and adolescents

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Tertiary Care Protocol

Referral to pediatric tertiary weight
management center with access to a
multidisciplinary team with expertise in
childhood obesity and which operates
under a designed protocol
Continued diet and activity counseling
and the consideration of such additions
as meal replacement, very-low-calorie
diet, medication, and surgery

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Partnership with Families

Families have a critical role in influencing a
childs health.
Effective interaction with families is the
cornerstone of lifestyle change.

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Communication
Positive discussion of what healthy lifestyle
changes families can make (evidence base)
Allow for personal family choices.
Have families set specific achievable goals
and follow up with these on revisits.
Be aware of cultural norms, significance of
meals and eating for family/community,
beliefs about special foods, and feelings
about body size.
Motivational interviewing

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www.aap.org/bookstore

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www.aap.org/obesity/letsmove/index.cfm

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