Obesity in Pediatrics
AAP Recommendations
To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child';s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient's age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts. Below are their findings:
Assessment of Child and Adolescent Overweight and Obesity
Accurate appropriate assessment of overweight and obesity in children and adolescents is a critical aspect of contemporary medical care. However, physicians and other health care professionals may find this a somewhat thorny field to enter. The BMI has become the standard as a reliable indicator of overweight and obesity. The BMI is incomplete, however, without consideration of the complex behavioral factors that influence obesity. Because of limited time and resources, clinicians need to have quick, evidence-based interventions that can help patients and their families recognize the importance of reducing overweight and obesity and take action. In an era of fast food, computers, and DVDs, it is not easy to persuade patients to modify their diets and to become more physically active. Because research concerning effective assessment of childhood obesity contains many gaps, this report is intended to provide a comprehensive approach to assessment and to present the evidence available to support key aspects of assessment. The discussion and recommendations are based on >300 studies published since 1995, which examined an array of assessment tools. With this information, clinicians should find themselves better equipped to face the challenges of assessing childhood overweight and obesity accurately.
Recommendations for Prevention of Childhood Obesity
The majority of US youth are of healthy weight, but the majority of US adults are overweight or obese. Therefore, a major health challenge for most American children and adolescents is obesity prevention—today, and as they age into adulthood. In this report, we review the most recent evidence regarding many behavioral and practice interventions related to childhood obesity, and we present recommendations to health care providers. Because of the importance, we also suggest approaches that clinicians can use to encourage obesity prevention among children, including specific counseling strategies and practice-based, systems-level interventions. In addition, we suggest how clinicians may interact with and promote local and state policy initiatives designed to prevent obesity in their communities.
Recommendations for Treatment of Child and Adolescent Overweight and Obesity
In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not only address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.
Blood Pressure
The US Department of Health and Human Services, National Institute of Health, and Nation Heart, Lung, and Blood Institute put out a report entitled, The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. The purpose of this report is to update clinicians on the latest recommendations concerning the diagnosis, evaluation, and treatment of hypertension in children; recommendations are based on English-language, peer-reviewed, scientific evidence (from 1997 to 2004) and the consensus expert opinion of the NHBPEP Working Group.
This report includes new data from the 1999–2000 National Health and Nutrition Examination Survey (NHANES), as well as revised blood pressure (BP) tables that include the 50th, 90th, 95th, and 99th percentiles by sex, age, and height. Hypertension in children and adolescents continues to be defined as systolic BP (SBP) and/or diastolic BP (DBP) that is, on repeated measurement, at or above the 95th percentile for sex, age, and height. BP between the 90th and 95th percentile in childhood is now termed “prehypertension” and is an indication for lifestyle modifications.
New guidelines are provided for the staging of hypertension in children and adolescents, as well as updated recommendations for diagnostic evaluation of hypertensive children. In addition, the report evaluates the evidence of early target-organ damage in children and adolescents with hypertension; provides the rationale for early identification and treatment; and provides revised recommendations, based on recent studies, for the use of antihypertensive drug therapy. Treatment recommendations also include updated evaluation of nonpharmacologic therapies to reduce additional cardiovascular risk factors. The report describes how to identify hypertensive children who need additional evaluation for sleep disorders that may be associated with BP elevation .
Growth and BMI Charts
Growth charts consist of a series of percentile curves that illustrate the distribution of selected body measurements in children. Pediatric growth charts have been used by pediatricians, nurses, and parents to track the growth of infants, children, and adolescents in the United States since 1977.
CDC recommends that health care providers:
Use the WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age in the U.S.
Use the CDC growth charts for children age 2 years and older in the U.S.
BMI-for-age charts are recommended to assess weight in relation to stature for children ages 2 to 20 years. The weight-for-stature charts are available as an alternative to accommodate children ages 2-5 years who are not evaluated beyond the preschool years. However, all health care providers should consider using the BMI-for-age charts to be consistent with current recommendations.
· Boys Stature-for-age and Weight-for-age
· Boys BMI-for-age
· Girls Stature-for-age and Weight-for-age
· Girls BMI-for-age
Growth charts are not intended to be used as a sole diagnostic instrument. Instead, growth charts are tools that contribute to forming an overall clinical impression for the child being measured.
AAP Recommendations
To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child';s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient's age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts. Below are their findings:
Assessment of Child and Adolescent Overweight and Obesity
Accurate appropriate assessment of overweight and obesity in children and adolescents is a critical aspect of contemporary medical care. However, physicians and other health care professionals may find this a somewhat thorny field to enter. The BMI has become the standard as a reliable indicator of overweight and obesity. The BMI is incomplete, however, without consideration of the complex behavioral factors that influence obesity. Because of limited time and resources, clinicians need to have quick, evidence-based interventions that can help patients and their families recognize the importance of reducing overweight and obesity and take action. In an era of fast food, computers, and DVDs, it is not easy to persuade patients to modify their diets and to become more physically active. Because research concerning effective assessment of childhood obesity contains many gaps, this report is intended to provide a comprehensive approach to assessment and to present the evidence available to support key aspects of assessment. The discussion and recommendations are based on >300 studies published since 1995, which examined an array of assessment tools. With this information, clinicians should find themselves better equipped to face the challenges of assessing childhood overweight and obesity accurately.
Recommendations for Prevention of Childhood Obesity
The majority of US youth are of healthy weight, but the majority of US adults are overweight or obese. Therefore, a major health challenge for most American children and adolescents is obesity prevention—today, and as they age into adulthood. In this report, we review the most recent evidence regarding many behavioral and practice interventions related to childhood obesity, and we present recommendations to health care providers. Because of the importance, we also suggest approaches that clinicians can use to encourage obesity prevention among children, including specific counseling strategies and practice-based, systems-level interventions. In addition, we suggest how clinicians may interact with and promote local and state policy initiatives designed to prevent obesity in their communities.
Recommendations for Treatment of Child and Adolescent Overweight and Obesity
In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not only address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.
Blood Pressure
The US Department of Health and Human Services, National Institute of Health, and Nation Heart, Lung, and Blood Institute put out a report entitled, The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. The purpose of this report is to update clinicians on the latest recommendations concerning the diagnosis, evaluation, and treatment of hypertension in children; recommendations are based on English-language, peer-reviewed, scientific evidence (from 1997 to 2004) and the consensus expert opinion of the NHBPEP Working Group.
This report includes new data from the 1999–2000 National Health and Nutrition Examination Survey (NHANES), as well as revised blood pressure (BP) tables that include the 50th, 90th, 95th, and 99th percentiles by sex, age, and height. Hypertension in children and adolescents continues to be defined as systolic BP (SBP) and/or diastolic BP (DBP) that is, on repeated measurement, at or above the 95th percentile for sex, age, and height. BP between the 90th and 95th percentile in childhood is now termed “prehypertension” and is an indication for lifestyle modifications.
New guidelines are provided for the staging of hypertension in children and adolescents, as well as updated recommendations for diagnostic evaluation of hypertensive children. In addition, the report evaluates the evidence of early target-organ damage in children and adolescents with hypertension; provides the rationale for early identification and treatment; and provides revised recommendations, based on recent studies, for the use of antihypertensive drug therapy. Treatment recommendations also include updated evaluation of nonpharmacologic therapies to reduce additional cardiovascular risk factors. The report describes how to identify hypertensive children who need additional evaluation for sleep disorders that may be associated with BP elevation .
Growth and BMI Charts
Growth charts consist of a series of percentile curves that illustrate the distribution of selected body measurements in children. Pediatric growth charts have been used by pediatricians, nurses, and parents to track the growth of infants, children, and adolescents in the United States since 1977.
CDC recommends that health care providers:
Use the WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age in the U.S.
- Birth to 24 months: Boys Weight-for-length percentiles and Head circumference-for-age percentiles
- Birth to 24 months: Boys Length-for-age percentiles and Weight-for-age percentiles
- Birth to 24 months: Girls Weight-for-length percentiles and Head circumference-for-age percentiles
- Birth to 24 months: Girls Length-for-age percentiles and Weight-for-age percentiles
Use the CDC growth charts for children age 2 years and older in the U.S.
BMI-for-age charts are recommended to assess weight in relation to stature for children ages 2 to 20 years. The weight-for-stature charts are available as an alternative to accommodate children ages 2-5 years who are not evaluated beyond the preschool years. However, all health care providers should consider using the BMI-for-age charts to be consistent with current recommendations.
· Boys Stature-for-age and Weight-for-age
· Boys BMI-for-age
· Girls Stature-for-age and Weight-for-age
· Girls BMI-for-age
Growth charts are not intended to be used as a sole diagnostic instrument. Instead, growth charts are tools that contribute to forming an overall clinical impression for the child being measured.