ADOLESCENT OBESITY - TIME FOR A COMMITMENT TO ACTION
A Resource from the American College of Preventive Medicine
A TIME TOOL FOR CLINICIANS
ACPM's Time Tools provide an executive summary of the most up-to-date information on delivering preventive services to patients in the context of a clinical visit. Information presented is based on evidence presented in peer-reviewed journals.Please refer to the Adolescent Obesity Clinical Reference for more information.
The rising prevalence of childhood obesity is one of our most serious and challenging public health problems.
- Nearly one in three adolescents are overweight or obese. In children and adolescents, overweight is defined as a body mass index (BMI) greater than or equal to the 85th percentile (age- and gender-specific) and obese is defined as a BMI greater than or equal to 95th percentile. The rate of obesity among 12- to 19-year-olds has more than tripled in the past 30 years.
- Chronic conditions related to obesity, such as the metabolic syndrome, are becoming more common among children, and are directly related to the degree of overweight. National Health and Nutrition Examination Survey (NHANES) data show that nearly one in three overweight/obese adolescents have the syndrome compared to less than 1% of healthy weight adolescents.
- The psychological impact may be just as damaging as the medical co-morbidities.
- Obese adolescents are more likely to become obese adults. The rising prevalence in childhood obesity may therefore lead to a decline in life expectancy in the U.S. for the first time in 200 years.
- In January, 2010, the United States Preventive Services Task Force published a "B” recommendation for clinicians to screen children and adolescents for obesity and offer them or refer them to comprehensive, intensive interventions to promote improvement in weight status—an update to its previous "I” statement from 2005.
Clinicians are aware of the magnitude of the problem, as well as the usual cause: too few calories expended for the calories consumed. Nonetheless, childhood obesity remains one of the most frustrating and time-consuming conditions for clinicians to address. Fewer than 2 in 5 pediatricians feel "effective,” and fewer than 1 in 8 "highly effective,” at managing childhood obesity. As a result:
- Overweight and obesity often go undiagnosed and ignored. Fewer than half of overweight adolescents have been told by their doctor that they are overweight. Only 30-40% of obese adolescents have been diagnosed as obese.
- Fewer than one in five pediatric health professionals use BMI percentiles to document overweight and obesity.
- Fewer than half of adolescents receive any preventive counseling when they see a doctor; only one in four visits include counseling on exercise or diet.
WHAT CAN WE DO ABOUT IT?
First, establish an office environment that is youth-friendly and obesity-sensitive, and office systems that promote eduction, motivation, and confidence of overweight adolescents.
An office environment that is positive, uplifting, inspiring
- Warm, friendly greeting
- Motivational materials (for a list of suggestions, see resource document)
- Privacy and confidentiality
Communication: engaging and not lecturing
- Use vocabulary that avoids stigmatization
- Build on strengths, abilities, and goals
- Develop rapport, trust
- Address the issues the patient want to work on, simple steps
- Emphasize your belief in them
Office systems that support the process
Network of resources, programs, and specialists
- Opportunities for exercise, recreation, volunteering
- Support self-management
- Classes for patients/families
- Staff trained in various aspects of lifestyle assessment and counseling
- Local specialty health care facilities such as pediatric obesity referral clinics
Second, adopt the use of the four stages of interventions recommended by the American Academy of Pediatrics (AAP) Expert Panel.
GUIDELINES FOR STAGE 1 CONSULT
1. Review Pre-Visit Questionnaire
- Medical assistant reviews/assist completing the pre-visit questionnaire covering symptoms of obesity-related conditions, current behaviors, family history, interests, and goal
1. Obtain BMI. Every opportunity, plotted monthly if possible.
2. Assign weight category based on BMI percentile for age/gender
3. Measure blood pressure (BP). Assign BP category based on BP percentile for age/gender/height. (See The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, pp 10-14)
1. Establish rapport—a caring, trusting relationship with the adolescent.
- Warm greeting using his/her name.
- Express genuine interest in his/her life—identify strengths:
"How do you stay healthy? What are you good at? What do you like to do after school? Who are the important adults in your life? What are your responsibilities at home? What are your goals for the future?”
- Involve parent, if present—same questions as above
- Confirm role as health advisor and advocate, commitment to confidentiality.
2. Describe the objectives of the visit; check BMI, review goals at every visit
- Begin a process to lose some weight and build a healthier lifestyle.
"Does that sound good to you? Are you ready to make a few small changes?”
3. Discuss weight status; explain BMI percentile, health concerns
- "You are at the ____ percentile for your age. This is the range where we start to be concerned about extra weight causing health problems.”
- Elicit concerns: "Do you have any concerns about your weight?”
- Reflect/probe based on response: "What makes you concerned about ____?”
4.Review family history. Review family history of obesity, type 2 diabetes, cardiovascular disease (CVD), hypertension, dyslipidemia, obstructive sleep apnea.
5. Perform Physical Examination and Order Laboratory Tests
- Review signs and symptoms associated with co-morbidities of overweight/obesity
- Order laboratory tests based on body weight category and presence of CVD risk factors
- Consider ordering laboratory tests to rule out other causes of obesity (e.g., TSH, insulin)
Lifestyle Review [Use 5A approach: Assess, Advise, Agree, Assist, Arrange]
6. ASSESS Eating and Activity Behaviors
- Ask about daily habits regarding:
- Consumption—sugar sweetened-beverages, fruit juices, foods with high fructose corn syrup, sports/energy drinks, fruit/vegetables, breakfast habits, dining out, fast food, family meals, snacks
- Expenditure—exercise, recreation, other activity, screen time (TV, computer, games, movies)
- Explain key habits that determine energy balance; emphasize the interaction of all
- Emphasize/congratulate ALL positive behavior(s)
- "It’s great that you just joined the basketball team!”
- Provide neutral feedback for behavior(s) not optimal, elicit a response and reflect/probe.
- "You watch about 4 hours of TV on school days. Would you consider trying to cut that down to 3 hours?”
7. ADVISE behavior changes that could change energy balance
"The habits that are contributing most to your energy surplus are…” [From list of behaviors]
Ask:"Which of these do you think you could change?”
8. AGREE on behavior(s) to focus on. Select one activity for the first visit. Subsequent visits should focus on one activity to change. Highly motivated patients and families may address two behaviors. These evidence-based goals are those with consistent evidence (CE) and those with mixed evidence (ME). Many practitioners use the mnemonic 5-2-1-0, which is incorporated below.
- 5: Increase fruit and vegetable intake to at least 5 per day (ME)
- Eat meals with family 5 to 6 times per week (ME)
- 2: Reduce television/screen time to less than 2 hours per day (CE)
- 1: Increase physical activity to at least 1 hour per day (ME).
- Some children may start with 15 minutes initially and gradually increase to 60 minutes per day.
- 0: Reduce sugar-sweetened beverages gradually to none per day (ME)
- Eat a healthy breakfast every day (ME)
- Eat less fast food (ME)
- Reduce portion sizes
- Reduce snacking while watching TV/screen time
9. ASSIST with planning for the behavior change(s)
- Address importance and confidence for each targeted behavior.
- "How important is it for you to ____?” (0-10 scale)
- Reflect on response: "What would it take to move to a __?”
- "How confident are you that you could succeed?” (0-10 scale)
- Reflect on response: "What would it take for you to move to a __?”
- Probe strategies to increase confidence.
- Probe a SPECIFIC plan: start date, actions, frequency, etc.
- "What would be a good first step? What could you do in the next week, or even the next day, to get started?”
- If no ideas: "If it’s ok with you, I’d like to suggest a few things that have worked for others like you.”
- Agree on a plan and goal to work toward.
- Set a goal that is realistic (i.e., relatively easy to accomplish)
- For example, eat at Burger King only twice this week instead of the usual three times.
- Write the goal down on a prescription pad; give one to the patient and place a copy in the chart.
10. ARRANGE follow-up and close the encounter
- Call the following week to check progress; visit in 4-6 weeks.
- "Let’s schedule a phone call for next week and a visit next month, so we can discuss other thoughts you’ve had and see how your plan is working out.”
- Summarize: "Let’s review what we’ve worked through. You are going to …”
- Show appreciation: "Thank you for being willing to discuss this!”
- Express confidence: "I know that you can do this!”
11. RE-EVALUATE monthly
- Look for small signs of progress. Make adjustments. If poor response after 3-6 months, and the patient and family are motivated, consider moving up to a Stage 2 intervention, either in the office if offered, or by referral to another practice or program.
Pediatric obesity is not an individual child's problem, but a problem that involves the family and the community as well. Counseling patients and their families about adopting healthier diets and engaging in more physical activity is the foundation, but physicians must also get involved in their communities to advocate for programs that promote adolescent health to all children. Ultimately, adolescents must be actively engaged in their own transformation, to make their own decisions.
Supporting references and additional information:
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