Management of Childhood Obesity in Pediatric Practice

Management of Childhood Obesity in Pediatric Practice

CHRISTINE L. WILLIAMS," LYNN ANN CAMPANARO, MARGARET SQUILLACE, AND MARGUERITE BOLLELLA

Child Health Center American Health Foundation

I Dana Road Valhalla, New York 10595

INTRODUCTION

Obesity is one of the most common health problems facing the pediatrician today, and also the most frustrating. It is frustrating because it is difficult to define the problem, difficult to understand its etiology, and difficult to predict its natural history over time. Despite the confusion, pediatricians are faced with obesity in one in four of their patients, and superobesity in one in ten.'J Rather than improve, the prevalence of childhood obesity continues to climb,3 reflecting our inability to develop and apply a rational clinical approach to preventing and treating this disorder. Such failure, if unchecked, will lead to diminished quality of life for our children, and decreased morbidity and mortality during their adult years.

Obesity prevention and treatment strategies can be incorporated into the routine of pediatric practice; however, implementation depends on the degree to which the physician is concerned about obesity as a health problem; the knowledge and skills the pediatrician has with respect to nutrition and exercise counseling and behavior modification; and the amount of staff time available to provide needed treatment and follow-up of obese children and their families. The goal of this article is to describe a strategy for evaluating, treating, and following the progress of obese children and adolescents in a pediatric office setting.

Diagnosis of Obesily

Physicians can usually diagnose obesity visually during a physical examination. Beyond this, a variety of measurements can help determine the degree of overweight and excess body fat. There are some children who may be technically overweight because of increased lean body mass (muscle and bone), and conversely extremely in- active children who are not technically overweight may actually be overfat. Therefore a combination of measures that evaluate weight for height as well as body fat would provide the physician with a better basis on which to make a clinical diagnosis of obesity.

"Author to whom correspondence should be addressed. Tel.: (914) 789-7218; fax: (914) 592- 6317; e-mail: [email protected].

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226 ANNALS NEW YORK ACADEMY OF SCIENCES

Height and weight should be measured carefully (shoes and heavy outer clothing removed). The values should be plotted on standard growth charts, with the parents' heights and weights recorded along the right-hand margin for comparison. The mean body weight for the child's height should be compared with the child's actual weight to determine the percent overweight. A child whose actual weight is 20% or more above the mean weight for height would be classified obese; and 40% or more would be superobese. Most standard growth charts also have a weight-for-height chart on the reverse side. Children whose weight for height is above the 90th percentile on this chart are considered obese.

Height and weight measures may also be used to calculate body mass index (BMI) or Ponderal Index (PI), which also provide indices relating weight to height of the child. A BMI above the 90th percentile, or a Ponderal Index above the 85th percentile have been suggested as criteria for obesity in children. Several of the most common criteria used in clinical practice to determine weight status and degree of obesity are summarized as follows." * Obesity:

> 120% of mean body weight for height > 90% of weight for height > 85% of triceps skinfold > 85% Ponderal Index (kg/m3) > 90% Body Mass Ihdex (kg/m2)

Superobesity.

> 140% of mean body weight for height > 95% of weight for height > 95% of triceps skinfold > 95% Ponderal Index (kg/m3) > 95% Body Mass Index (kg/ni2)

Skinfold thickness measured with calipers (e.g., Lange) provide a more direct measure of subcutaneous body fat and are useful as an adjunct to height and weight measures, especially in very muscular children. The triceps skinfold thickness is the site most commonly measured, although others are also helpfbl (bicep, subscapular, and suprailiac). The biceps and triceps skinfold measures help estimate peripheral body fat, whereas subscapular and suprailiac skinfolds are a better reflection of central fat deposits. Skinfolds provide useful information during longitudinal follow-up of children with a variety of nutritional problems. Measures above the 85th percentile for age and sex suggest obesity, and norms are readily available for interpretation of data. It is also possible to estimate percent body fat from sums of several skinfold measures. TABLE 1 provides norms for triceps skinfold thickness for children and adolescents.8

Waist and hip circumference can easily be determined by tape measure, since a ratio of the two helps assess body-fat distribution. Excess central obesity (W:H ratio greater than 1) may be associated with a clustering of negative health-risk factors, including hypertension, hypertriglyceridemia, and glucose intolerance.

WILLIAMS ei al.: CHILDHOOD OBESITY 221

TABLE 1. Triceps-Skinfold Measure: 85th-percentile Lev- els by Age and Sex of Child (mm Skinfold Thickness)"

Age (Yr) Male (mm) Female (mm) 2 3 4 5 6 7 8 9

10

13.0 12.5 12.0 11.5 12.0 12.0 16.5 16.0 20.0

13.5 12.5 13.0 14.0 14.5 15.0 16.0 20.0 21.0

"National Center for Health Statistics. M. E Najjar and M. Row- land, Anthropometric Reference Data and Overweight. United States. 197C1980. Vital and Health Statistics, Ser. 11, No. 238.

Note: Triceps-skinfold measures at or above the 85th-percentile value listed here may indicate an increased amount of body fat.

DHHS Pub. NO. (PHS) 87-1688.

When considering height and weight changes, the rate of gain should be considered, that is, pounds gained per inch of growth. At the 50th percentile a child gains about 4 to 5 pounds for an inch of height. A sudden increase in pounds gained for inches grown should trigger investigation into possible causes. More often, however, the weight has gradually been crossing over upward percentile zones with a steeper slope compared with the height, which has been tracking rather evenly within a percentile zone.

Normal periods of rapid growth are expected, such as the prepubertal increase in body fat, and the pubertal growth spurt. Significant pubertal increases in height and weight occur around 12 years of age for girls and 14-15 years for boys. Weight increases of 1&20 Ib/yr at peak adolescent growth may be appropriate if correspond- ing changes in height are proportionate.

Farnib History

The pediatrician should begin with a review of the family history, including current and past weight status of the parents and siblings. A family history of coronary heart disease, cancer, diabetes, thyroid disorders, hyperlipidemia, and hypertension should also be explored, as well as any endocrine and genetic conditions. Family history should also include psychosocial aspects of family life, including marital status and relationships of the parents, and of the grandparents; child-care arrangements; family meal patterns; and recreational habits.

The clustering of obesity in families reflects both genetic and environmental factors. A young obese child with two obese parents will be more likely to remain obese


TABLE 2. Endocrine and Genetic Causes of Obesity

Endocrine causes Cushing's syndrome-hypercortisolism Hypothyroidism Primary hyperinsulinism-insulinoma, Beckwith-Weidemann Pseudohypoparathyroidism

Prader-Willi: deletion of 15q chromosome Al strom Laurence-Moon-Biedl C arpernter Cohen

Other causes Acquired hypothalamic syndrome-infection, trauma, tumor, vascular lesion

Genetic causes

without treatment, compared with ;in obese child of lean parents.' A treatment plan for the parents and child may be appropriate if several family members are obese.

Causes of Obesity

Physicians should consider the possibility that the child's obesity is due to an un- derlying endocrine problem or to a genetic disorder. In addition, psychological problems and medication patterns should be reviewed to explore contributory causes. Ge- netic and endocrine disorders are responsible for less than 10% of childhood obesity; however, they must be carefully ruled out since they require different modes of therapy (TABLE 2). Children with genetic forms of obesity often have short stature, mental retardation, retarded bone age, and may have other physical defects as well. Obesity among other family members is uncommon. In contrast, exogenous obesity is char- acterized by normal or tall stature (usually >50th%), normal intelligence and physical examination, and a history of obesity among other family members (TABLE

Evaluation of the obese child should also include assessment of cardiovascular 3).10."

TABLE 3. Differential Diagnosis of Childhood Obesity

Endocrine/Genetic vs. Exogenous

Family: Obesity not common Obesity common in

Height: Short child Tall child (>so%) IQ: IQ often low Normal IQ Bone age: Bone age retarded Normal bone age Physical: Defects common Normal physical exam

family

WILLIAMS et al.: CHILDHOOD OBESITY 229

disease risk factors including usual level of physical activity, psychological problems, and possible orthopedic disorders.

Cholesterol

According to the recommendations of the National Cholesterol Education Pro- gram expert panel on children and adolescents,'2 all obese children over 2 years of age should be screened for elevated blood cholesterol (2 170 mgidL). Although obese children on the average will have higher mean blood cholesterol levels than nonobese children, many other obese children with normal total cholesterol levels (<170 mgidL) will have other lipid abnormalities such as a low HDL-cholesterol or elevated trigly~erides.'~

Blood Pressure

Care should be taken to measure blood pressure with the appropriate size cuff, since an undersized cuff will give a falsely elevated reading. Obese children and adolescents will have higher mean blood pressure than nonobese children; therefore, careful determination of blood pressure is important in determining overall therapeu- tic strategie~.'~

Physical Activity

It is important to determine the usual level of physical activity for obese children, since lack of activity may be a major etiologic factor in the child's obesity; prescription of increased physical activity will be an important part of treatment; and lack of physical activity is an independent risk factor for coronary heart disease. The child may be asked to keep a record of physical activity for 3 to 7 days, or answer questions on school physical education, afterschool sports and activities, and weekendsummer activities. Many children only report school physical education, which is often limited to once or twice a week.

Cigarette Smoking

The smoking status of adolescents should be determined, since smoking is a strong independent risk factor for coronary heart disease. Along with obesity, elevated blood pressure, and elevated blood cholesterol, the pediatrician could be dealing with significantly increased risk of premature coronary disease. Cigarette smoking will also depress HDL-cholesterol levels, levels that may already be low among obese adolescents. Adolescent girls, in particular, may start smoking in an attempt to lose weight, and physicians should stress the hazards of the habit and offer help with smoke cessation.


Diabetes

Although overt type I1 diabetes mellitus is relatively uncommon during childhood and adolescence, studies have shown that obese adolescents have higher fasting blood glucose and insulin levels, and higher peak glucose and insulin levels after a glucose load.15

Psychological Problems

Obese children may be depressed, have a negative self-image, and be obsessively preoccupied with their weight. They may become more passive and withdraw from their peers.l6-I8 These attributes aren’t surprising, since society has a negative view of obese individuals and blames them for causing the problem by overeating. Preschool children dislike obese children more than children with a variety of physical handicaps.19 Pediatricians confronted by a withdrawn and depressed obese child may need to address the psychological problems before weight control can be initiat- ed.

Orthopedic and Dermatologic Problems

Children with severe degrees of obesity may suffer from a variety of orthopedic problems, especially of the legs. These problems may include tibia1 torsion-bowed legs (Blount’s disease) and hip, ankle, foot weight-stress symptoms.20 Obese children may also suffer from skin problems such as heat rash, intertrigo, and monilial der- matitis more frequently than lean children. Striae are common in obese children also, as elastic fibers in the skin are stretched and broken.

TREATMENT OF OBESITY

In initiating an obesity treatment program, the physician should first set a reasonable goal for the child or adolescent.2’ Actual weight minus mean weight for height will give a rough idea as to number of pounds overweight. If the number of excess pounds is great, however, the goal of reaching mean or “ideal” body weight may appear impossible. Smaller goals, such as an initial 5 or 10 pound loss may be prefer- able since it appears to be an easier target to achieve. A rate of loss goal of one pound per week should also be discussed, so that the child can think about achieving the goal by a particular calendar month.

An ideal weight-loss program for children would consist of the items listed below:

Controlled weight loss at about 1 lb per week No deceleration of height growth Metabolically safe Minimal hunger Lean body mass preserved No psychological problems

WILLIAMS et al.: CHILDHOOD OBESITY 23 1

Most treatment programs for obesity in childhood and adolescence consist of the following components: (1) a diet that reduces the daily caloric intake below the child’s usual intake; (2) an increase in physical activity; (3) some behavior-modification techniques; and (4) parental support and/or active participation. All of these components can be delivered in at least a modified way in the pediatrician’s office.

Dietary Assessment and Treatment

Dietary assessment and treatment help to assess the child’s and family’s diet from quantitative and qualitative perspectives. This is facilitated by asking the child or parent to keep a food diary for 3 to 7 days before the office visit. Alternatively, a recall of foods eaten within the past 24 hours, or a food frequency checklist where the child checks off how often he or she consumes the food items listed may be utilized. Food records can be analyzed using a variety of computer software packages, although such analysis in a general pediatric practice setting may be impractical because of the time required to learn and perform the a n a l y ~ e s . ~ ~ - ~ ~

Food records, however, may be used in a qualitative manner by simply reviewing them for patterns and problem foods. Family eating patterns should be explored: Which meal (if any) does the family eat together, and who usually prepares the food for the family? Does the family appear to eat a high-fat diet? How many times a week does the family eat out at a fast-food chain or restaurant? Or at the other end of the spectrum, Is this a family on food stamps? Is the family living in a welfare hotel and lack cooking facilities?

The child’s eating patterns may also be explored when reviewing the food record: Is this a child that usually eats breakfast? Does the child bring lunch to school or eat the school lunch? What are usual snacks the child eats, and how often are they eaten? Does the child eat more calories as snacks than as meals? How many fruits and vegetables does the child eat per day? Does the child eat adult-size portions at dinner and ask for second helpings? Does the teenager have a job in a bakery or fast-food restaurant?

DIETARY PRESCRIPTION

A reasonable goal will be to have the child lose one pound per week until the first goal is reached. To lose one pound, 3500 kilocalories must be eliminated through a combination of decreased caloric intake (diet) and increased caloric expenditure (exercise).

The average 9- to 10-year-old child takes in 2000 kcal/day (TABLE 4). Thus, plac- ing the obese child >age 10 on a 1500 kcal diet should result in a one pound a week weight loss since this represents a 500 calorie per day decrease. Older teens (especially boys) who may have been consuming as many as 3000 kcaliday may have to be brought down gradually to 2500, then 2000, and perhaps even 1500 kcal/day, depending on motivation and desire to lose slowly or more rapidly. Conversely, children <10 may need fewer than 1500 calories to lose weight.25

Implementation of the diet requires an understanding of portion size and allow-


TABLE 4. Dietary Prescription

Servings per Day

Grains (servings) 5 6 I 8 80 callserving Meat (ounces) 5 5 6 6 60 calloz Vegetables (servings) 3 3 3 3 <25 callserving Fruit (pieces) 3 3 3 4 60 callserving Milk“ (glasses) 2 3 3 3 90 callserving Fat (teaspoons) 3 4 4 5 5 dtSP

CaIoriesD 1200 1400 1500 1700

Fat: 25-30% calories; carbohydrate 50-55%; protein 20-25%.

“Skim milk *Percentage of calories from fat depends on the type of meat served and whether or not skim milk or a higher fat milk is used.

TABLE 5. Portion Sizes and Food Exchanges

Grains: 80 calories uer serving

1 slice regular bread 1/2 hamburger or hot dog roll 2 large or 4 small crackers 1/2 cup pasta, rice, potatoes

Meat: 60 calories per ounce

2 slices diet bread 1/2 English muffin 3 cups air-popped popcorn 1/2 cup cooked cereal

1 oz lean meat, fish, or poultry (no skin) 1 egg = 2 tablespoons peanut butter 1/2 cup cooked dried beans, peas, lentils

Vegetables: 1&25 calories per serving

1/2 cup cooked = 1 cup raw vegetable

Fruits: 60 calories per serving

1 medium apple, pear, orange 1/2 cup cooked, canned fruit 1 slice melon

1 /2 banana, grapefruit 3/4 glass juice

Milk and Milk Products: 90 calories per serving

1 cup low-faunonfat milk 1 oz low-fat cheese 1/4 cup low-fat ricotta cheese

Fats and Oils: 45 calories (5 g) per senling)

1 cup low-fat or nonfat yogurt 1/2 cup low-fat cottage cheese

1 tsp margarine 1 tsp mayonnaise

2 tsp “diet” margarine 2 tsp “low-fat” mayonnaise .~

1 tsp oil 1 slice crisp bacon


able food exchanges. These are explained in detail in a variety of booklets such as Exchange Lists for Weight TABLE 5 provides a partial list of exchanges that can be provided to children along with the number of exchanges recommended for each food group, as described in TABLE 4. An advantage to using this system is that many of the mothers will have used it previously if they belonged to Weight Watchers.

Dietary fiber is also useful in the treatment of childhood obesity, since it displaces nutrients in the diet (especially fat) and therefore reduces the caloric density of the diet. In addition, fiber tends to slow down ingestion of food (since it requires more chewing), and helps promote a feeling of safety, due to the additional bulk of high fiber foods in the stomach, and delayed gastric e m ~ t y i n g . ~ ~ - ~ ~ Studies suggest that children who consume the highest amounts of dietary fiber, consume the lowest amounts of dietary fat, and since each gram of fat in the diet produces 9 calories as opposed to only 4 calories for carbohydrate or protein, the advantages of reducing fat in order to reduce calories is o b v i o u ~ . ~ ~ * ~ ~

Children should consume an amount of fiber equivalent to their age plus 5-10 grams per day (FIG. 1). This level has been suggested to be safe for children and also to confer related health benefits. The “Age + 10” upper level of fiber intake should be a goal for children who are obese or who are gaining weight too rapidly for their height v e l o ~ i t y . ~ ~ , ~ ’ TABLE 6 lists high-fiber foods commonly consumed by children.

Some consideration may need to be made to increase protein intake during caloric restriction to avoid negative nitrogen balance and loss of lean body mass.32 This is because excess weight is not all excess fat. Up to 50% of excess weight may be fat- free mass in some obese individuals, although this is highly variable from person to person. Obese children on average have increased lean body mass (muscle and bone needed to support the excess weight). Basal metabolic rate (BMR) is also higher in

Age of child

Ages5 Age+lO

FIGURE 1. Recommended dietary fiber goal for children. “age+S to age+lO” g/d.


TABLE 6. High-fiber Foods Commonly Included in the Diets of U.S. Children

Approximate Grams Food Source Serving Size Dietary Fiber

Beans 1 cup, baked 13 Chili wheans 1 cup I Almonds 2 oz, dry roasted I Peanuts 2 oz, dry roasted 4 Peanut butter 2 tbsp 2 Cereal 1 cup >2“ Whole wheat bread 2 slices 4

Broccoli Corn Popcorn Potato

0.5 cup 2 0 .5 cup 3 2 cups, popped 2 1 medium, baked 2 (3.5 wlskin)

Sweet potato 1 medium 3 carrot 1 medium (raw) 3

Strawberries Pear Banana Blueberries

Apricots Kiwi Apple sauce

Apple

1 cup 1 medium 1 large 1 cup I medium

1 large 0.5 cup

10 dried halves

“Dietary fiber content of cereal varies widely from very low ( 4 g/cup) to very high (>I0 g/cup). Best “fiber choice” for children has 3 or more g/cup. Other suggestions: “Trail mix” of raisins, peanuts, dates, cereal; and whole-grain crackers with 2-3 g of fibedV2-o~ serving brown rice with 4 g dietary fibedcup.

obese children compared with lean children, although when corrected for body sur- face, they are the same.

Successful implementation of the diet also requires application of behavior-modification strategies, and, depending on the age of the child, significant positive parental involvement to increase the likelihood of success in reaching dietary goals.

EXERCISE PRESCRIPTION

Although it is theoretically possible to achieve weight loss with reduced calorie intake alone, there are compelling reasons for combining caloric reduction with increased caloric expenditure through physical activity. Indeed, the most successful weight-reduction programs appear to be those that have combined diet with exercise within a matrix of behavior r n ~ d i f i c a t i o n . ~ ~ - ~ ~

The best rationale for combining diet and exercise is based on consideration of the

WILLIAMS eta/.: CHILDHOOD OBESITY 235

metabolic aspects of dieting. Caloric restriction often results in a drop in BMR, mak- ing it harder to lose weight. In addition, caloric restriction may result in a loss of lean body mass. In one study, 37% of weight lost represented loss of lean body mass3’ This can be avoided by increasing physical activity that increases BMR and lean body mass. BMR often remains elevated for several hours after vigorous exercise. Therefore, effective weight reduction is most likely to occur when a combination of diet and exercise is recommended.

The pediatrician who recommends increased physical activity will need to provide the child with specific guidelines, including type, duration, and intensity of activities recommended. This information can be provided in the form of a handout. In addition, a simple exercise log with a “contract” on the front can help to get the child started on the exercise program.

The physician will need to take into consideration the need to have the obese child increase the level of activity very gradually, so that initial failure and discouragement do not sabotage both exercise and dietary resolve. Orthopedic problems may also limit the type of activities prescribed, and innovative solutions may be required.

A reasonable goal for most children might be to aim for an added 20 to 30 minutes per day of moderate physical activity in addition to whatever exercise the child might get in school physical education classes. Twenty minutes of walking, dancing, swimming, or cycling, or 10 minutes of running might bum off 100 calories or more. The more calories expended, the less restrictive the diet must be to lose one pound per week. The goal of eliminating 500 calories per day can be achieved through any combination of reduced caloric intake and increased physical activity (the “design it yourself” diet). Children may be able to lose weight with exercise alone if compen- satory caloric increase does not occur. It is often helpful to have the child keep a 7- day diary of physical activity as well as food intake, which is monitored on a weekly basis by the physician or nurse.

BEHAVIOR-MODIFICATION STEPS

Self-monitoring

Self-monitoring is an important element in all behavioral programs and is typical- ly the first behavior change requirement. We ask the child (or parent of a young child) to keep a careful record of food intake and physical activity. This helps to increase awareness of the actual amounts of food being eaten, problem periods during the day, and patterns of overeating. The nurse or physician might ask the child to mark foods that are high in fat or sugar with a highlight marker; they can then use this information to teach about nutrition. Goals can be set for the next week and rewards established for reaching the goal.

Nutrition Education

Educating the child and parents in basic nutrition concepts is an important part of the behavioral plan. Some of the key concepts taught are as follows: ( 1 ) the compo-


nents of a healthy, balanced diet for children over 2 years of age-with 30% calories or less from fat, 20% from protein, and the rest from carbohydrate; (2) how to read food labels; (3) the importance of dietary fiber; (4) energy balance (3500 calories = 1 lb); and (5) caloric density (1 gram of fat produces 9 calories versus 1 gram of carbohydrate or protein, which produce 4 calories). If the child is also hypercholes- terolemic, special care should be taken to reduce saturated fat intake to less than 10% of calories. An obese child with elevated blood pressure for age should be helped to avoid excessive sodium consumption.

Stimulus Control

Stimulus control involves limiting the amount of high-calorie foods kept in the house: (1) purchase very small quantities of these foods, if at all, and (2) store such foods out of sight. In addition, efforts should be made to help the child avoid situa- tions where overeating may be a prominent theme. The child should eat all meals in the designated dining area (dining room or kitchen) at mealtimes and designated snack times, and not while watching television, doing homework, or other activities. Food is served once and the serving dishes are then removed. The child is not verbally encouraged to eat, and may leave the table before eating all the food on the plate.

Eating Behavior

Obese children and adolescents often eat rapidly, as do obese adults. Modification of eating behavior involves taking smaller bites of food, putting down the fork be- tween bites, chewing food longer, and leaving food on the plate at the end of the meal.

Physical Activity

Increasing physical behavior will be one of the most important behavioral changes targeted in a weight-management program. Children should be helped to increase physical activity behaviors by (1) helping set their own activity goal each week; (2) signing a contract to perform the activity; (3) monitoring performance of the activity; and (4) determining self-rewards for reaching the activity goal.

Family activity patterns should be reviewed, including the number of hours of television watched. In one study, the TV viewing habits of 12- to 17-year-old teens were positively correlated with obesity. Twenty percent of teens who watched >5 hours of TV per day were obese, compared with 10% of teens who watched < l hour of TV per day.33

Am'tude Change

At the weekly or biweekly visits the child can be helped to change negative self- statements into positive ones. For example, if children overeat, they should be en-


couraged not to call themselves a failure, but instead to tell themselves that they are going to keep on trying and do better the next time. They can also be helped to cope with the negative remarks that other children make about their weight.

Reinforcement and Rewards

Performance of targeted behaviors by the child should be rewarded. This may include verbal praise by parent, physician, and office staff. It may also consist of tangi- ble rewards predetermined by the parents. Ultimately the child can learn to verbally and tangibly reward his or herself for doing well.

DISCUSSION

Improving the success rate of pediatric weight-control programs depends on a multitude of variables. Pediatricians can improve success rates among their patients if they (1) set realistic goals for weight change that may include a decrease, a slower rate of gain, or even maintaining the current weight; ( 2 ) provide specific recommendations to the child and family, including diet and exercise prescriptions, and behavior-change guidelines; (3) prescribe a balanced low-fat, high-fiber diet, estimated at about 500 cal/d less than the usual caloric intake for a 1 Ib/week weight loss; (4) prescribe an increase in daily physical activity and emphasize its importance as much as diet; ( 5 ) provide support for modifying eating and activity behaviors; (6) provide nutrition education for the child and parents, either in the physician’s office or through referral to a registered dietitian.

Failure of obesity treatment in pediatrics is common, and may be due to a variety of causes. One common cause is delay in initiating treatment or referral, based on a belief that the child will “outgrow the problem.” Unfortunately, age and severity of obesity not only increase the likelihood of persistence into adulthood, but also decrease the likelihood that weight control will be successhl. Approximately one- fourth of obese infants will remain so as adults, whereas as many as 80% of obese adolescents will remain so as adult^.^^^^^ In a Swedish study one-third of children who were 120% of ideal body weight normalized with follow-up; however, none of those who were 160% or greater than ideal body weight did Thus, younger and less obese children are more likely to normalize as they grow older, while older, more obese adolescents are less likely to do so.

Another reason for treatment failure reflects the need for long-term follow-up and treatment, which may be logistically and financially difficult for parent and child. The child may lose interest; parents may not be able to work it into their schedules unless hours are flexible; third-party payers may rehse to reimburse for treatment of obesity, even in childhood. Lack of family involvement and support will spell failure for some children, especially if this is seen as a punitive measure for the child while the rest of the family continues to eat whenever, whatever, and how much they choose.

Negative counseling techniques can discourage follow-up visits. Parents already feel guilty that they somehow are responsible for their child’s obesity. Children are blamed for their obesity by other children and adults. Thus, treatment must focus on


positive feelings and achievement of goals rather than on accusations of cheating and underreporting of food intake.

Other reasons for failure include (1) lack of specificity of recommendations; (2) lack of flexibility-same diet for all; (3) lack of equal emphasis on increasing physical activity; (4) lack of behavior modification strategies; and (5) lack of a mainte- nance phase.

SUMMARY

Evaluation of obese children and adolescents in the pediatric office or clinic should include baseline assessment of weight for height and body fatness; rule out endocrine and genetic causes of obesity; and evaluate other health-risk factors, such as those for cardiovascular disease, cancer, diabetes, and hypertension.

Treatment of obesity is most successful if realistic goals are set; a balanced low- fathigh-fiber diet is stressed; a safe rate of weight loss of 1 to 2 pounds per week is achieved through a moderate reduction of caloric intake (approximately 20-25% decrease); increased physical activity is stressed as much as diet; parental support is strong; and behavior therapy is provided during the course of treatment to help both child and parent achieve the diet, exercise, and behavior goals.

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Management of Childhood Obesity in Pediatric Practice