Evaluation and Treatment Guidelines
Any child between the ages of 2 and 19 with a BMI of >95th percentile for age can be referred to our program. Children who are overwwight with a BMI > 85th percentile for age can be referred if there are associated medical risks such as a strong family history of heart disease or diabetes. A child with dyslilidemia or hypertension or increased truncal obesity can be referred to our program with a lower BMI. If you would like to refer one of your patients to our program, please contact our offices at 855-681-8700.
Screening by BMI
Screening consists of height and weight measurement and calculation of Body Mass Index (Wt/Ht2):
| BMI | Diagnosis | Treatment Guidelines |
|---|---|---|
| BMI >95 percentile | OVERWEIGHT | In depth medical Assessment & treatment |
| BMI 85-95th percentile | At Risk of Overweight | Start dietary & activity intervention |
| BMI < 85th percentile | Normal | Continue preventive strategies |
Preventive strategies
Monitor BMI at all visits
Medical Assessment
Medical History
- Severe Headache
- Blurring of Vision
- Snoring During Sleep
- Oligomenorrehea/amenorrehea
- Hip or Knee Pain
- Chest Pain, Exertional Dyspnea
- Syncope
Family History (age < 55 years)
- Diabetes
- Obesity
- Hypertension
- Heart Attack
- Stroke
- Dyslipidemias
Dietary History
- Intake of liquid calories, juice, soda, sweetened beverages
- Examples of breakfast, lunch, dinner and snacks (daily eating habits and dietary details)
Activity History
- Sedentary activity time, time for TV, computer/video games, homework
- Physical activity, gym, outdoor activity, special activities
Examination
- Height(cm), Weight(kg), BMI, B.P.(Average of 3 B.P.)
- Waist circumference(cm)
- Hip circumference(cm)
- Cardiac examination
- Fundus examination (if headaches)
- Acanthosis nigricans
- Hirsuitism
- Enlarged tonsils, adenoids
- General physical examination
Known Complications of Obesity
Acute Complications
- Obstructive sleep apnea
- Psuedotumor cerebral
- Slipped Capital Femoral Epiphysis
Chronic Complications
- Dyslipidemia: (look for age-related values)
- increased triglycerides
- increased LDL
- decreased HDL
- Hyperinsulinemia >15miu/ml
- Hypertension (systolic or diastolic BP>90th percentile for age)
- Glucose intolerance or Type 2 diabetes
- Poly Cystic Ovarian Syndrome
- Metabolic Syndrome
The Metabolic Syndrome
3 or more of the following:
- Fasting plasma glucose >100mg/dl
- Hypertriglyceridemia: >90th percentile for age
- Low HDL cholesterol
- Hypertension: BP >90th percentile for age
- Central adiposity: waist circumference >90th percentile for age sex and race
Management of Metabolic Syndrome
- Low carbohydrate diet – Limit consumption of sweetened beverages
- Glucose Intolerance or Type 2 – Consider OGT & Metform in therapy after consultation with obesity experts
- Daily physical activity with target weight loss of 5-10 % in 6 months to 1 year period
- Persistent lifestyle changes
Management
Anthropometric & Metabolic Assessment
- BMI, BMI Z scores, waist & hip circumference, BP (average of 3 readings)
- Fasting lipid profile, fasting glucose and insulin, LFT’s, CRP, HbA1C, Urine for microalbuminuria
- PFTs if indicated or symptoms
- Evaluation for sleep apnea if symptoms with lateral neck X-ray and sleep studies
- Evaluation for pseudotumor cerebri if associated with headaches
- Baseline EKG; Echo if morbidly obese, abnormal EKG or associated risk factors such as hypertension, strong (+) family history, symptoms, etc.
Identification of Complications
- Treat urgent/care complication if any
- Identify chronic complications
- Assess for the presence of Metabolic Syndrome – 3 or more of the following risk factors:
- Elevated BP>90th Percentile for age
- TG>90th percentile for age
- HDL< 40mg/dl
- Waist circumference >90th percentile for age & race specific
Interventions
- Start early interventions
- Promote breastfeeding
- No fruit juice till 6 mths of age
- Stop all sweetened beverages
- Based on new food pyramid and low glycemic index foods, limit starch to whole grain products, only 1 per meal
- No white bread, ready to eat cereals, potatoes, cakes, and cookies
- Low-fat milk products 2-4 servings/day
- 3-5 servings of fruits and vegetables
- Olive oil/canola oil, and handful of nuts
- Drink 6-8 glasses of water daily
Activity
- Limit TV watching time to less than 2 hours per day
- Prescription for regular physical activity at home – stationary bike, Jump rope, exercise videotape
- Join a recreation center or gym
Behavior Therapy
- Family involvement and understanding
- Desire to make a change
- Small permanent changes at a time
- Continued reinforcement – not limited to few weeks
Weight Goals
BMI: 85th – 95th Percentile
- Weight Maintenance
- Change of lifestyle
BMI > 95th Percentile
No Complications
- Weight Maintenance
- Long-term to achieve Weight loss
Complications
- Weight Loss of half a pound per week
Prevention Strategies
- Promote breastfeeding
- No fruit juice until 6 months of age
- Not more than 1 cup of juice in daily diet
- Avoid sweetened beverages at all times
- Cut down refined starch, baked products, bread
- Limit TV watching/computer games etc. to less than 2 hrs/daily
- 1 hour of daily physical exercise or activity
- Never use food as reward
- Parental involvement, and to be role models
- Offer only healthy options
- Constant reinforcement of these behaviors at school and home
Lifestyle guidelines
- Eat 3 meals a day, if desired 2 snacks & 6-8 glasses of water
- Limit fruit juice to no more than 1 cup per day. Limit caffeine-containing beverages
- Eliminate sugar-laden beverages
- Limit starch to 1 serving per meal, limit starch that converts to sugar easily
- Select 2-4 servings of fresh fruits a day, limit dried fruit
- Select 3-5 servings of vegetables a day
- Select lean sources of proteins, 2-3 servings per day.include more fish and tuna
- Select skim or 1% low-fat milk, 2-3 cups a day. Lite or nonfat yogurt. Low-fat hard cheese
- Select olive or canola oil, eliminate saturated, hydrogenated or partially hydrogenated oils
- Limit fast food to once a week, skip the fries, coke, shakes etc.
- Do 1 hour of physical activity a day
- Get a scale and check your weight once every other week
References
- August, G. P., Caprio, S., Fennoy, I. L., Freemark, M. B., Kaufman, F. R., Lustig, R. H., et al. (2008). Prevention and treatment of pediatric obesity: an Endocrine Society clinical practice guideline based on expert opinion. J. Clin. Endocrinol. Metab., 93, 4576-4599.
- Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report Barlow S E Pediatrics 2007; 120:S164-S192