Written by Matthew Haemer, MD, and Renee Porter, RN, CPNP
Obesity affects nearly 14% of children in the state of Colorado and nearly 17% nationwide.1, 2 A recent report from the Centers for Disease Control and Prevention (CDC) showed that while rates of childhood obesity in low-income preschoolers has stabilized or is decreasing in most states, in Colorado, the prevalence of obesity among low-income preschoolers is still rising.3 More than two million children 2 to 18 years of age, or 4% of children in the U.S., are severely obese with a BMI greater than the 99th percentile for age/gender.4
Severely obese children have greatly increased risk of metabolic and cardiovascular abnormalities and are very likely to be obese as adults.5 Intensive intervention is required to help obese children, especially severely obese children, achieve a healthier BMI. While raising awareness of obesity among parents of young children can be challenging, treatment can be more successful when initiated in the preschool years compared to older children.6
Why is obesity different for children?
The obese child or adolescent has medical and psychosocial needs that are different from the adult obese patient. The risks for metabolic, orthopedic and psychological comorbidities vary widely by developmental stage as do treatment approaches. Treatment must be tailored to each child's unique cognitive, emotional and physical development and the environment in which they live. Children require the support of parents, siblings, extended family and extended social systems to be successful at managing their weight. Families hold a wide range of knowledge, attitudes and beliefs about a child’s weight status and what constitutes a healthy lifestyle. It's critical to treat each family with respect and to tailor approaches to the unique needs of each child and family.
Addressing obesity in the primary care setting
Children's Hospital Colorado utilizes the systematic staged approach (stages 1 to 4) from the Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity published as a supplement to PEDIATRICS December 2007.7
The Expert Committee recommends that primary care providers participate in weight management counseling and play a critical role in identifying families who are in a state of readiness-to-change and likely to benefit from referral resources (stage 1). Resources for primary care providers to utilize for treatment within their own practices include the Colorado HealthTeamWorks guidelines, which outline the goal setting process, necessary labs and weight related health conditions. Prior to referring overweight or obese patients without comorbidities, the Expert Committee suggests that primary care providers attempt lifestyle counseling, engage the family in any community-based programs available and consider referring if the child fails to decrease BMI after six months of follow-up (stage 2). There are many helpful resources available in some Colorado communities: The CAFP Fit Family Challenge, the MEND (Mind, Exercise, Nutrition, Do-It)8 program offered as a free program by the Colorado Health Foundation at many YMCAs across the state, and through Denver Health.
Primary care providers can aim to achieve just one or all three of the following goals with children and their families during an office visit that addresses obesity:
- Raise the issue in a non-judgmental and empathetic manner, query the family's level of concern about the weight issue, and disarm a resistant family by asking permission to share the provider's concern about health consequences.
- Work on enhancing a family's intrinsic motivation to make changes by asking the family to describe what changes they are ready to make and why they are important.
- Sustain long-term habit change by encouraging the family to self-monitor specific goals or to complete a specific weight management program. Families with low readiness-to-change may benefit from focusing on their first goal at the first or even several subsequent visits before they are ready to tackle the issue.
Using the term "obesity" to describe a child's unhealthy weight during an office visit has been reported to induce stigma, was offensive to families to a similar degree as the word "fat" and did not enhance motivation to change.9 However, describing a child's weight as "unhealthy" or stating that a child is carrying "too much weight for their health" has been described as motivating and non-offensive to families. It may be helpful to communicate that the increased risk of diabetes or heart disease carried by a child whose BMI is above the 95th percentile can be reversed completely if a healthy BMI is attained by adulthood.10
It's important to understand that by engaging the family to participate in selecting goals for change, the provider can maximize the likelihood that the goals and BMI reduction will be achieved. While providers may offer helpful tips and suggestions when the family requests, this technique should minimize provider frustration and a family's resistance when the provider gives a proscriptive set of instructions.
When families are ready to actively participate in selecting goals to change nutrition and activity habits, an effective technique involves setting specific goals that can be tracked by the child on a calendar daily. It also includes involving the parent to give positive reinforcement and rewarding the child with an activity that gives special attention from a parent or other loved one if the child achieves the goal each week. This approach to counseling is consistent with a family-centered weight management model.
When should patients be referred for specialty care?
According to the expert panel, a child over 2 years of age should be referred for severe obesity for abnormal lab values or comorbidities related to obesity. Referrals are encouraged for children less than 2 years of age with elevated or rapidly increasing weight-for-length.
Children who are severely obese, have severe comorbidities or whose families are highly motivated to participate in an intensive weight management program but without severe obesity, may also be referred at any time to a tertiary care weight management program (stage 3 and 4). The primary care provider should continue following the patient's progress in weight management on a regular basis while the patient is involved in a referral weight management program.
Where should you refer children who are obese, if needed?
Children's Colorado's Lifestyle Medicine Program offers treatment options aimed at meeting the needs of obese children through a family-centered care approach. The program supports children and families in lifelong behavior changes through enhancing motivation, education, skill-building and support.
The Weight Management Specialty Clinic at Children's Colorado has been adapted to meet the demands for treatment of severely obese children in Colorado and surrounding states. This comprehensive program within the Lifestyle Medicine Program stands for Lifestyles Influencing Fitness and Eating. It meets the needs of PCPs, children and families who may need more intensive interventions than the community programs can provide (stage 3 and 4). This might be on a less frequent consultative basis (for out-of-town families) or through frequent engagement of all program resources (Denver Metro area).
Our Program provides medical evaluation and necessary follow-up for each patient. Our medical providers are trained in pediatric obesity management and include pediatricians, pediatric nurse practitioners and a physician assistant. The team provides a thorough evaluation, performs necessary lab tests, orders additional studies to diagnose comorbid conditions as needed and provides timely communication with the PCP. The Program also includes endocrinologists, cardiologists and gastroenterologists for those patients who may need additional diagnostic assessment or rarely, medication treatment, for a comorbid condition.
An essential component of a stage 3 weight management program is the multidisciplinary team of pediatric dietitians, pediatric psychologists and an exercise physiologist, each providing unique and coordinated services within the program. The multidisciplinary team delivers several group options, exercise classes and individual sessions. The program delivers care for out-of-town families through less frequent visits to the Anschutz Medical Campus in Aurora, coordinated with more frequent visits with their PCP, local weight management programs, local dietitians or other community-based resources to complete the treatment plan.
Pediatric experts at Children's Colorado recognize the need for engagement from all sectors in healthcare and the community to tackle this epidemic. Not all families require this Program to treat their child's obesity, as some will succeed with lifestyle changes with support from their primary care provider and other community programs.
Please call our Lifestyle Medicine Program coordinator if you have questions about a particular patient and seek guidance for treatment at 720-777-3352.
- Colorado Children's Campaign. 2009-2013 Kids Count in Colorado! Accessed Feb 26, 2014 2014.
- Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. Feb 26;311(8):806-814.
- Centers for Disease Control. Vital Signs: Progress on Childhood Obesity. Accessed Feb 26, 2014, 2014.
- Skelton JA, Cook SR, Auinger P, Klein JD, Barlow SE. Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr. Sep-Oct 2009;9(5):322-329.
- Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. Jan 2007;150(1):12-17 e12.
- Haemer MA, Ranade D, Baron AE, Krebs NF. A clinical model of obesity treatment is more effective in preschoolers and Spanish speaking families. Obesity (Silver Spring). May, 2013;21(5):1004-1012.
- Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. Dec 2007;120 Suppl 4:S164-192.
- Sacher PM, Kolotourou M, Chadwick PM, et al. Randomized controlled trial of the MEND program: a family-based community intervention for childhood obesity. Obesity (Silver Spring). Feb 2010;18 Suppl 1:S62-68.
- Puhl RM, Peterson JL, Luedicke J. Parental perceptions of weight terminology that providers use with youth. Pediatrics. 2011;128(4):e786-e793.
- Juonala M, Magnussen CG, Berenson GS, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. New England Journal of Medicine. 2011;365(20):1876-1885.