This report includes the latest recommendations and current standards endorsed by the AAP and CDC. The report summarizes a shift from the simple identification of obvious obesity to universal assessment, universal preventive health messages, and early intervention.5 The universal assessment uses BMI calculation as the main starting point and recommends that this be done at each well-child visit and/or at least yearly. Once the BMI is established, the medical, behavioral, and attitude risks are specific to the current BMI, and the prevention and intervention recommendations are delineated. Social and environmental components are considered in the prevention and intervention plans.

Stepped approach

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The ECRs use a stepped approach to provide detailed assessment and treatment strategies for childhood overweight and obesity. With recommendations based on high-quality evidence whenever possible and expert opinion when needed, the report is inclusive of a wide spectrum of information on childhood overweight and obesity for any provider seeing patients aged 2 to 19 years. The report is divided into prevention, assessment, and treatment recommendations. The following sections discuss the specific recommendations. The steps of the recommendations are summarized in Figure 2.43 

Prevention strategies

Prevention strategies are critical to addressing the childhood obesity epidemic. The report emphasizes the importance of educating families about consistent early efforts so that the recommendations are initiated in early childhood. This message is based on the belief that prevention efforts are easier to implement than the weight management and weight loss measures necessary once overweight or obesity occurs. The evidence supports the following prevention strategies: (1) limiting the consumption of sugar-sweetened beverages; (2) consuming a diet in line with the quantities of fruits and vegetables recommended by the U.S. Department of Agriculture (Table); (3) limiting television and screen time to less than 2 hours per day; (4) eating breakfast daily; (5) limiting dining out, particularly in fast food establishments; (6) encouraging family meals; (7) limiting portion size; and (8) involving the entire family in lifestyle changes. Various educational programs address these prevention strategies based on the 5-2-1-0 Campaign by the Maine Youth Overweight Collaborative, which is an easy way to educate families: 5 servings of fruits and vegetables, less than 2 hours of television time, 1 hour of physical activity, and 0 servings of sugar-sweetened beverages.34 

The ECRs also include the following prevention recommendations based on available data and expertise: (1) eating a diet high in fiber, with calcium and balanced in macronutrients; (2) encouraging only breastfeeding until 6 months of age and then breastfeeding along with solid foods through 12 months of age; (3) moderate to vigorous physical activity for 60 minutes per day; and (4) limiting the consumption of energy-dense foods (ie, processed foods, fast food, nuts, trail mix). The report includes additional information about implementing strategies for prevention, such as patient-centered communication and the roles of the family, provider’s office, school, and community. It is important that these prevention strategies be communicated to all children and adolescents at every well-child appointment regardless of their weight or BMI.

Assessment strategies

Assessment strategies are anchored in the annual well-child visit and start with the premise that weight, height, and BMI for age should be calculated annually. In addition, it is stressed that the BMI percentile should be plotted on current, standardized growth charts annually. The BMI percentile should be used to make an appropriate weight category diagnosis as follows: below 5th percentile, underweight; 5th through 84th percentiles, healthy weight; 85th through 94th percentiles, overweight; 95th through 98th percentiles, obesity; 99th percentile and above, severe obesity. The use of annual measurements allows important trending analysis to identify concerning changes in a timely manner. Recommendations also include a yearly qualitative assessment of dietary and behavioral patterns to reflect the prevention strategies noted above.

The ECRs recommend certain medical and behavioral risk assessments for children whose BMI is at or above the 85th percentile. Specifically, medical risks include future or persistent obesity, future or current obesity-related medical conditions, and current obesity-related medical conditions. Parental obesity is also a strong risk factor for childhood obesity and should lead to enhanced efforts to establish healthful behaviors. Weight-related problems should be screened via a thorough review of systems and physical examination to include the following: sleep; the respiratory, gastrointestinal, cardiovascular, endocrine, and nervous systems; and the skin. Psychiatric and orthopedic evaluations should also be conducted. A family history of cardiovascular disease or type 2 diabetes would be considered a medical risk. 

Specific laboratory testing is delineated in the ECRs and is based on BMI percentile category in conjunction with risk factors. The goal of laboratory testing is to identify nonalcoholic fatty liver disease, abnormal cholesterol levels, and type 2 diabetes mellitus. For patients with a BMI in the 85th through 94th percentiles, lipid panel testing is recommended. If risk factors are present, the fasting glucose, alanine transaminase (ALT), and aspartate transaminase (AST) levels should be measured every 2 years in patients aged 10 years or older. For patients with a BMI in the 95th percentile or higher who are older than 10 years, the ECRs include a lipid panel as well as measurement of the fasting glucose, ALT, and AST levels regardless of risk factors (Figure 2).

Patient-centered communication

Prevention and assessment recommendations provide clear and concise talking points for providers when they are discussing weight-related issues with children and parents. However, as discussed above, it is imperative to be aware of a family’s cultural values and beliefs to provide culturally competent care. For example, families may differ in their beliefs about what is an attractive or healthy weight. Also, physical activity and lifestyle habits may be influenced by religion, environment, or culture. To gain trust and develop a positive relationship with patients and their parents, you must become familiar with their values and circumstances. Knowledge of the motivational interviewing principles should be integrated with a culturally competent care model in which the provider identifies the family’s cultural beliefs and values. 

The ECRs include specific patient-centered communication techniques, based on motivational interviewing, that can be incorporated in a provider’s dialogue with patients and families during a discussion of weight issues. The communication recommendations include the following: (1) nondirective questioning, (2) reflective listening, (3) comparison of values and current health practices, and (4) importance/confidence rulers. Nondirective questioning helps the clinician avoid a directive style approach and allows parents or patients to explain their position on the issue. An example of a nondirective question is, “What concerns, if any, do you have about your child’s weight?” Reflective listening occurs when the provider summarizes the patient’s or parent’s response without judgment. It helps the patient or parent to understand and resolve ambivalence by hearing his or her thoughts verbalized. The provider can help identify conflicting values and current health practices and may offer an opportunity to discuss alternative health behaviors. Lastly, using importance and confidence rulers allows parents or patients to come up with their own solutions. The following dialogue illustrates this technique: “On a scale of 0 through 10, how important is it for you to sit down for a family meal together? On a scale of 0 through 10, how confident are you that you could have a family dinner four nights per week?”

With these communication strategies and examples, providers can encourage internal motivation among patients and families. Goal setting, monitoring for identified behavior changes, and the use of positive reinforcement become the role of the provider as patients and their families direct their own behavior changes. 

Treatment strategies

Treatment strategies are outlined in detail in the ECRs and are based on a staged approach. Stage 1 is the prevention plus tier and is the first step in the treatment algorithm. Essentially, this stage focuses on the basic healthy dietary and physical activity habits that are highlighted in the prevention strategies. Again, the focus here is consuming more than 5 servings of fruits and vegetables daily, minimizing the consumption of sugar-sweetened beverages, limiting television viewing time to less than 2 hours daily, eating at home more often, eating as a family unit, eating breakfast daily, and increasing physical activity to 60 minutes daily. These patients should be seen at more frequent intervals to closely monitor their progress, make appropriate adjustments, reinforce education, and encourage motivation. 

Stage 2, structured weight management, should be instituted when the interventions in stage 1 fail to stabilize or reverse the BMI values as desired. In this stage, the same targeted behaviors of stage 1 are used along with additional support services and a more structured approach, including planned diets and structured meal plans. Patients also should be advised to restrict television viewing to less than 1 hour daily and set physical activity requirements for 60 minutes per day. Behaviors should be monitored through daily logs, and the addition of clinical dietician referrals, family counseling sessions, and/or physical therapy sessions should be considered. Ideally, patients at this stage should be seen monthly, and group sessions may be effective.

If a patient’s response to stage 2 interventions is not adequate, a transition to stage 3, comprehensive multidisciplinary intervention, may be required. Stage 3 and stage 4 are generally considered beyond the scope of primary care. Full details are available within the ECRs but are not included in this article because targeted behaviors and interventions are intensified to a degree ideally managed by a specialist. A comprehensive, multidisciplinary approach is essential. Tertiary care interventions in stage 4 include pharmacologic management, highly restrictive diets, and possibly weight control surgery. It is important for primary care providers to be familiar with available resources in their community should any patients require this level of intervention.

A provider toolkit is included. This toolkit summarizes prevention and assessment approaches through stage 2 in the treatment algorithm (Figure 2). 

Click to enlarge

Conclusion

Preventive health services, such as the well-child visit, provide an optimal opportunity to detect overweight and obesity early and provide education and counseling. Nurse practitioners and physician assistants are involved in immunization, well-child visits, screening examinations, and parental education, and the addition of a BMI assessment is simple and easy to do. Well-child visits are recommended annually for children aged 2 through 19 years.44 With such frequent visits, this is an important time to set the stage for discussions regarding BMI, physical activity, diet, and behaviors—four components that are often cited as top contributors to the childhood obesity epidemic.2 Obesity prevention efforts should be instituted at the beginning of the relationship and continued at every well-child visit. Furthermore, it is critical to enhance providers’ knowledge of this epidemic and the ECRs. 

Although the problem of childhood overweight and obesity seems overwhelming, the educational tool proposed here will effectively pare down the issue to items that can be addressed by the primary care practitioner. Despite the fact that many factors are involved that go far beyond the scope of a clinic visit, we can make a difference at every well-child visit by consistently following the ECRs and identifying at-risk children. We owe it to our patients and our communities, and ultimately our nation’s health depends on it. 

Leslie Peek, MSN, APRN, NP-C, is a family nurse practitioner for Northern Nevada Medical Group in Reno, Nevada.

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From the November 01, 2016 Issue of Clinical Advisor