Pediatric Obesity: Weight Management at Children's Hospital Colorado

Overview

Pediatric obesity (defined as body mass index (BMI) greater than the 95th percentile for age/gender) affects nearly 14 percent of children in the state of Colorado and nearly 17 percent nationwide. Approximately four percent of children in the US, more than 2 million children, are considered severely obese (BMI greater than the 99th percentile for age/gender). Severely obese children are at elevated risk of illnesses comorbid with obesity during childhood and are very likely to be obese as adults.  Intensive intervention is often required to minimize health risks in severely obese children. Children's Hospital Colorado offers the region's only comprehensive pediatric Weight Management Program for children. Through different clinics and programs, we offer services tailored to differing degrees of obesity severity and across all ages from infants to teens. Our weight management programs follow the 2007 Expert Committee Recommendations on the assessment and treatment of pediatric obesity published as a supplement to Pediatrics Dec. 2007.

Our programs extend from the basic to the most intensive stages in the step-wise approach. Treatment recommendations are shared with both the family and the referring provider and the primary care provider is encouraged to be involved with periodic weight checks, following up treatment of comorbidities and reviewing interim progress toward goals set by Weight Management Program providers; this partnership is central to the success of each patient.

Why are pediatric patients different?

The obese child or adolescent has different needs than the adult obese patient. Treatment must be tailored to each child's unique cognitive, emotional and physical development, and the environment in which he or she lives. Children require the support of parents, siblings, extended family and extended social systems to be successful at managing their weight. The level of responsibility a child can be expected to demonstrate regarding food choices and self-management increases gradually with age, but also differs between children of the same age based on each child's unique development. Recognizing that families hold a wide range of knowledge, attitudes and beliefs about a child's weight status and what constitutes a healthy lifestyle, we believe it is very important to treat each family with respect and tailor our approach to each child's needs.

When should patients be referred?

Children's Hospital Colorado Weight Management Program follows the guidelines for a staged approach to treatment from the Expert Committee Recommendations. Indications for referral include: severe obesity (Table 1); abnormal lab values (recommended labs can be found in reference above); unexplained rapid weight gain; and co-morbidities related to obesity. We encourage primary care providers to participate in weight management counseling and to provide anticipatory guidance aimed at preventing obesity to all children. Prior to referring overweight or mildly obese patients without severe co-morbidities, we suggest primary care providers attempt lifestyle counseling and consider referring if the child fails to decrease BMI after six months of follow-up. Good progress in weight control can often be made by offering families a menu of high-yield behavior changes from which to choose and encouraging families to monitor progress toward behavior change goals on a daily basis. (see Expert Committee Recommendations for target behaviors: e.g. sugar sweetened beverages or sedentary time.) Those children who are severely obese, have severe comorbidities, or whose families are highly motivated to participate in an intensive weight management program, may be referred at any time. Due to high demand, there is a wait list to be seen in some clinics within our program, so primary care providers are encouraged to maintain engagement with the patient both during the waiting period and following the initial visit.

Table 1. Cutoff points for 99th percentile BMI according to age and gender
The data were derived from 500 children in each year from 5 through 11 years of age and 850 children in each year from 12 through 17 years of age (adapted from Freedman et all, 24 with permission). Cut-off points are at the midpoint of the child's year (e.g. 5.5 years).

What clinic is most appropriate for an individual patient?

The staff at Children's Hospital Colorado Weight Management Program apply the Medical Home model for the pediatric obese patient. Therefore referral, communication and follow up by the primary care provider will be central for the treatment and success of these patients. All weight management services are currently provided at Children's Hospital Colorado main campus.

Treatment options are aimed at meeting the needs of overweight and obese children through a family-centered care approach. We support children and families in life-long behavior changes through education, enhancing motivation and support. We collaborate with the following subspecialties to provide coordination of care for the comorbidities of obesity as needed:

• Nutrition
• Hepatology/Gastroenterology
• Neurology
• Endocrinology
• Cardiology
• Sleep Disorders Clinic
• Pulmonary

Children's Hospital Colorado also offers specialized treatment, including in the inpatient setting, for severely obese children who suffer from severe or life-altering co-morbidities.

The Weight Management nurse coordinator can assist in determining the appropriate clinic for an individual patient. Treatment options include: diets tailored to individual family needs, and medications.

Our program is offered through a spectrum of clinics (Table 2) designed to meet the needs of individual patients based on age, developmental status, or primary comorbidities some defined by laboratory values. Patients may be referred from a Weight Management Clinic to other specialties for further evaluation of their obesity related comorbidities as needed, including sleep apnea, non-alcoholic fatty liver disease, hypertension and severe hyperlipidemia.

Table 2:

The GoodLIFE (Lifestyles Influencing Fitness and Eating) Clinic

The GoodLIFE 1 and 2 Clinics are general weight management clinics that do not require specific laboratory abnormalities or severity of obesity to be referred. The GoodLIFE 1 Clinic is for children 0-11 years, and older children whose developmental age is below that of a teenager. The GoodLIFE 2 Clinic is for adolescents, ages 12 and up. Both clinics offer families individual recurring visits focusing on lifestyle management employing the expertise of specialists in nutrition, exercise and behavior. Children seen in these clinics are offered weekly group fitness classes led by our exercise physiologist in addition to individual office visits that typically occur every 1-3 months.

Metabolic Syndrome Clinic

The Metabolic Syndrome Clinic assesses and treats children and adolescents with the Metabolic Syndrome, Type 2 Diabetes, Polycystic Ovarian Syndrome and other endocrine disorders associated with obesity. The Metabolic Syndrome Clinic also utilizes a multidisciplinary approach and follows patients every 1-6 months (depending on the severity of their co-morbidities). Lab work will be reviewed to determine if a referral is appropriate for this clinic.

Lipid Clinic

The Lipid Clinic evaluates and recommends treatment for children who have specific lipid abnormalities, including familial hyperlipidemia or weight related lipid abnormalities.

Shapedown Program

The Shapedown Program is Children's Hospital Colorado's lifestyle program that operates on a 10-week fixed schedule of group classes. This program fits the intermediate stages of the Expert Committee guidelines. Shapedown is appropriate for obese and overweight children who do not require specific comorbidity management. It is also available to families participating in one of our clinics as additional support. Participating families should be interested in recurring group visits which mostly happen on weekend days. The program director also offers dietary advice in individual sessions to families unable to participate in a group program for children 2-5 years old.

What pediatric conditions or diseases are treated?

In our Weight Management Clinics, we assess, evaluate, treat, and recommend appropriate referrals for conditions that include the following among overweight (BMI 85-95th percentile) and obese children (BMI greater than 95th percentile):

• Abnormal lipids
• Restricted diet/"Picky Eaters"
• High blood pressure
• Polycystic Ovarian Syndrome (PCOS)
• Pulmonary hypertension
• Type 2 diabetes
• Obstructive Sleep Apnea (OSA)
• Orthopedic problems (Blounts, SCFE)
• Metabolic syndrome
• Disordered eating
• Insulin resistance
• Non-Alcoholic Fatty Liver Disease (NAFLD)

Special needs obese children:

• Children with physical disabilities, including non-ambulatory
• Down's Syndrome
• Prader Willi Syndrome
• Autism
• Other genetic syndromes associated with obesity

Consultation and appointments

Physicians and healthcare providers can call One Call at (720) 777-3999 or (800) 525-4871 for 24-hour consultation, referral or admission assistance.
Contact Renee Porter, CPNP, Obesity Nurse Coordinator at (720) 777-3352 for referral, consultation or triage to the appropriate clinic. Renee can also assist with the need to triage urgent appointments.