For Healthcare Providers
What can I do in my clinic to help prevent and manage the overweight child?
Calculate body mass index with the link to the Centers for Disease Control BMI calculator.This should be done at minimum every year at annual exams although many offices are doing this at every visit. Show families where their child’s BMI plots on the CDC BMI Growth charts.
BMI 85th to 94th percentile = Overweight
BMI 95th to 99th percentile = Obese
Reinforce the 5-2-1-0 rule for all families:
- Eat at least five servings of fruits/vegetables daily
- Allow less than two hours of screen time daily
- Participate in at least one hour of moderate exercise daily
- Drink 0 sweetened beverages daily.
- Assess medical and behavioral risks
- Assess dietary and activity habits
- Assess readiness for change from the family and child and empower your patients with motivational interviewing and target-goal setting.
What does a healthier lifestyle mean to you?
On a scale from 0 to 10, with 10 being the highest, how important is it to you to achieve and maintain a healthy lifestyle? Why not a lower number?
On a scale from 0 to 10, with 10 being the highest, how confident are you that you could make this change? What would it take to get you to a higher number?
These questions are examples of motivational interviewing and allow the parent/patient to come up with solutions to the problem. Click here for more education on motivational interviewing. Follow your patients with a lifestyle log to quickly assess nutrition, activity and behavior and set goals (Specific, Measurable, Achievable, Rewarding, and Trackable) that can be followed.
Consult the expert committee guidelines from the 2007 Pediatrics Supplement and take CME courses on motivational interviewing and childhood obesity (e.g. Discovery Health CME: Health Steps to Treating Childhood Obesity or http://www.motivationalinterview.org )
What do I do when parents feel their child does not have a problem?
Patients/parents conception of overweight may vary based on cultural and community factors. Showing patients/parents where they fall on the BMI curve is the first step. Discussing potential health problems and quality-of-life issues that they encounter is the next step. Continue using motivational interviewing techniques to assess readiness to change.
What do I do when parents insist there is a medical problem causing their weight problem?
Hypothyroidism and endocrine problems are very unlikely to be the cause of obesity in children. Laboratory tests can be ordered to exclude these causes or referral to a subspecialist can be helpful.
What screening laboratory and non-laboratory tests should be considered for overweight children?
For kids of all ages with obesity, consider depression screening and evaluation of self-esteem. The PHQ-9 is one screening tool to use in the office. Another useful tool for assessing psychological impairment is the pediatric symptom checklist .
|Patient Characteristics||Recommended Labs|
|>85th%, age >10, and NO risk factors||Fasting lipid profile every two years|
|85th-94th %, age >10, positive risk factors||Fasting lipid profile every two years
Fasting glucose every two years
AST/ALT every two years
|>95%ile, age >10 years, ± risk factors||Fasting lipid profile every two years
Fasting glucose every two years
AST/ALT every two years
Risk factors include any one of the below:
- Family history of familial hyperlipidemia, early coronary artery disease, or Type 2 Diabetes OR
- Clinical evidence of overweight comorbidities including hypertension, polycystic ovarian syndrome, liver disease, depression, sleep apnea, asthma, orthopedic problems. OR
- Rapidly accelerating BMI of > 3-4 units/year.
How to interpret results:
Total cholesterol levels of >200 mg/dL are high as are Low-density lipoprotein levels of >130 mg/dl. Abnormal triglyceride levels, defined by the National Cholesterol Education Panel as >150 mg/dL for adolescents, and abnormal high-density lipoprotein levels, defined as >40 mg/dL, respond to increased physical activity and dietary changes. Patients with lipid levels that are highly elevated such as an LDL >250 mg/dl or Triglycerides >500 mg/dl, should be referred directly to a pediatric cardiologist or lipid specialist to assess the benefits and risks of medication use. Consult the December 2011 Pediatrics supplement for guidelines on cardiovascular health and risk reduction.
ALT or AST results 2 times normal levels should prompt continued aggressive weight management interventions for three months and recheck. If still elevated, consider referral to pediatric hepatologist.
A fasting glucose level of >126 mg/dL or a random glucose level of >200 mg/dL indicates diabetes and requires referral to a pediatric endocrinologist. Fasting glucose levels of >100 mg/dL are considered prediabetes, indicating future risk for diabetes and should be followed with a two-hour OGTT.
If pubertal and signs of PCOS (amenorrhea or oligomenorrhea and hirsutism), also consider DHEAS, free testosterone, total testosterone, sex hormone binding globulin, 17-OH progesterone, prolactin, insulin level, and/or endocrine consult.
I have tried prevention and intervention, but have been unsuccessful or lack the resources. What can I do?
The following stages of treatment are recommended by the American Academy of Pediatrics (AAP). If Stage I and II have been unsuccessful, physicians should consider referring their patients to a high-intensity program or a tertiary-care center. The OHSU Healthy Lifestyles Clinic offers Stage III treatment.
Stage I: Prevention and motivational interviewing with goal setting
Stage II: Structured weight management program
Stage III: Multidisciplinary team with expertise in childhood obesity (including behavioral counselor, registered dietitian, and exercise specialist)
Stage IV: Referral to tertiary care and consideration for surgery
How do I bill for obesity-related services?
For more information on coding and reimbursement for obesity-related services, visit the American Academy of Pediatrics.
How do I refer my patient to the OHSU Healthy Lifestyles Clinic?To refer a patient, please fax a copy of Chart Notes (ideally indicating what stage of treatment your patient has achieved) and Lab Results to our office at 503 418-2400. In order to expedite a patient consultation, please have your office obtain insurance authorization.