Weight Management: Implications For Your Practice

from Practice Update, Spring 2004

The number of overweight children and adolescents has increased at an alarming rate over the last two decades, nearly doubling in that short amount of time. Current data from the Centers for Disease Control and Prevention indicate that approximately 10 percent of all two to five year olds and 15 percent of all six to 19 year olds are at, or above, the 95th percentile for BMI, classifying them as overweight. Even higher rates are shown among certain economic and minority populations. Extrapolations from national averages indicate that primary care practices in the Rocky Mountain region have nearly 200 overweight patients per provider.

Over the last two decades, studies have revealed that excessive weight in childhood and adolescence can lead to overweight and medical complications in adulthood. It is estimated that the probability of childhood overweight persisting into adulthood increases from approximately 20 percent at four years of age to 80 percent by adolescence. Overweight children are more likely to encounter problems with cardiovascular health, endocrine function, orthopedic abnormalities, pulmonary health and mental health. Studies show that overweight children are perceived as less desirable as friends and more likely to have psychosocial problems.

The increased health risk and impending health-care costs as overweight children age into adulthood make it imperative for the pediatric community to take a leading role in recognition and prevention of pediatric overweight. Early identification of overweight and high risk behaviors is vital to preventing the medical and psychosocial complications associated with it.

Using the Body Mass Index

Prevention of overweight involves tracking patients over time using the Body Mass Index. BMI is the ratio of weight in kilograms to squared height in meters. In children and adolescents, at risk for overweight is defined as the 85th to 95th percentile for age. Overweight is defined as greater than the 95th percentile for age. Nancy Krebs, MD, Medical Director for Nutrition Services at The Children’s Hospital explains, “The BMI gives the clinician a number to plot as an age and sex specific percentile. This provides a way to judge weight in relation to height. It is also essential in tracking trends over time and aiding in early recognition of worrisome trends for excessive weight gain. Prevention is crucial in addressing the alarming rates of childhood obesity.”

Body Mass Index (BMI) For Children and Adolescents

Weight in kilograms ÷ Height in meters² = BMI

• Underweight = BMI for age < 5th percentile
• At Risk for Overweight = BMI for age > 85th percentile
• Overweight = BMI for age > 95th percentile

Dr. Krebs continues, “It is ideal for a child’s weight and height to follow percentiles at the same rate. A more rapid weight gain versus a steady height gain will produce an increased BMI. Tracking a patient’s BMI will generally raise a red flag before the provider can see a weight problem in a patient. By the time the provider visually recognizes a weight problem, the patient is probably more overweight than suspected and the window for early intervention may have passed.”

Prevention and Early Recognition

The important task of determining when a patient is at risk for overweight can take place in the primary care setting. The frequency of visits and emphasis on prevention and education make the primary care setting an appropriate place to begin early screening and recognition of high risk behaviors for overweight in childhood and adolescence.

Studies show a correlation between genetic, biological, psychologic, sociocultural and environmental factors and development of childhood overweight. Recognizing these factors can be essential in preventing overweight in children and adolescents. Dr. Krebs explains, “Primary care providers should not be afraid to raise the issue of family lifestyles in the office setting. A general review of eating habits and physical activity patterns combined with a BMI assessment will help clinicians to identify risk and provide targeted anticipatory guidance to these patients. Key messages that are appropriate for all children and their families include cutting back on TV and video games, encouraging active play, eating more fruits and vegetables and limiting soda and juice intake.”

When communicating concerns to parents, it is helpful to use growth charts and plot where their child’s or adolescent’s height and weight lie. This will help illustrate why you are concerned and give parents an opportunity to identify their child’s risk behaviors. It also facilitates the primary care provider’s participation in developing a family-centered plan for change. Marilyn Day, MS, RD, Co-Director of The Children’s Hospital Heart Institute Shapedown® and Lipid clinics explains, “Self-esteem is crucial to a child’s ability to manage a healthful lifestyle. Parents often have difficulty knowing how to approach a weight problem with their children and can benefit from a trusted physician’s sensitive input.”

In 2003, the Committee on Nutrition from the American Academy of Pediatrics released a list of recommendations for the prevention of pediatric overweight and obesity. Dr. Krebs chaired the committee that developed the recommendations. Recommendations include focusing on family history and habits, calculating and plotting the BMI once a year for all children and adolescents, and recommending healthy lifestyle alternatives for children and their families.

When To Refer

Children and adolescents with severe overweight often have a combination of medical and/or psychosocial complications that are best evaluated in a specialized setting. There are several weight management options available at The Children’s Hospital that can provide time and specialized expertise. Each of the weight management options available at Children’s offers a family-centered care approach with a common goal of providing kids and families the opportunity to make life-long changes. The weight management programs at The Children’s Hospital are dedicated to working closely with the primary care providers who will be able to reinforce long-term changes.

When referring a patient to a weight management program, include patient records such as comprehensive growth charts, laboratory/ diagnostic test and studies, and pertinent history/treatment information. This will aid in providing the most appropriate treatment option and plan of care.

Information in this article has been adapted from the following:

• American Academy of Pediatrics Committee on Nutrition (August 2003). Prevention of Pediatric Overweight and Obesity. Pediatrics. 2003; 112, 424-430
• BMI for Children and Teens. Centers for Disease Control. Retrieved March 1, 2004  from www.cdc.gov .
• Ogden , C., Flegal, K., Carroll, M., Johnson, C. (October 2002). Prevalence of Trends in Overweight Among US Children and Adolescents, 1999-2000. Journal of American Medical Association. 2002; 288, 1728-1732.

“There is growing evidence that unhealthy lifestyles can negatively impact our long-term health. Obesity in adults is associated with early morbidity and mortality from a variety of chronic diseases, including heart disease, diabetes and some cancers. Since these diseases can have their beginnings early in life, our goal is to help future generations make respon-sible decisions for their health by practicing healthier choices during childhood.”
– Marilyn Day, MS, RD,Co-Director of The Children’s Hospital Heart Institute Shapedown® and Lipid clinics

American Academy of Pediatrics Recommendations for Prevention of Pediatric Overweight and Obesity

• Identify and track patients at risk by virtue of family history, birth weight, or socioeconomic, ethic, cultural, or environmental factors.
• Calculate and plot BMI once a year in all children and adolescents
• Use change in BMI to identify rate of excessive weight gain relative to linear growth.
• Encourage, support and protect breastfeeding.
• Encourage parents and caregivers to promote healthy eating patterns by offering nutritious snacks, such as vegetables and fruits, low-fat dairy foods and whole grains; encouraging children’s autonomy in self-regulations of food intake and setting appropriate limits on choices; and modeling healthy food choices
• Routinely promote physical activity, including unstructured play at home, in school, in childcare settings and throughout the community.
• Recommend limitations of television and video time to a maximum of two hours per day.
• Recognize and monitor changes in obesity-associated risk factors for adult chronic disease, such as hypertension, dyslipidemia, hyperinsulinemia, impaired glucose tolerance and symptoms of obstructive sleep apnea syndrome.

From the Prevention of Pediatric Overweight and Obesity, Pediatrics. 2003; 112,424-430