Prevention Management Obesity Children Adolescents

Optima Health
Prevention and Management

of
Obesity
Adolescents & Children
“Pediatric Obesity Prevention and Treatment Toolkit”
Available at
http://providers.optimahealth.com/clinicalreference/Pages/default.aspx
Guideline History
Date 1/06, 01/08,
Approved
Date 1/06, 01/08, 1/10, 07/10, 1/12
Revised
Date 10/05, 10/07, 12/09
Reviewed
Next 01/14
Review
Date
Prevention and Management of Pediatric Obesity
TABLE OF CONTENTS
I. Prevention and Management of Obesity (Children & Adolescents)

A. ASSESSMENT AND MANAGEMENT OF OVERWEIGHT CHILDREN & ADOLESCENTS
ALGORITHM……………………………………………………………………………… 1
B. RECOMMENDATIONS FOR LIPID ASSESSMENT…………...………………………. 2
C. MANAGEMMENT RECOMMENDATIONS FOR CHILDREN…………..……………..
BMI-FOR-AGE CLASSIFICATIONS…………………………………………………. 3
CONTRIBUTING FACTORS.…………………………………………………………. 3
HEALTH CONSEQUENCES…….…………………………………………………….. 3
II. Pediatric Obesity Risk Assessment: Steps To Prevention & Treatment
PREVENTION………………………………………………………………….………. 4
STAGE 1: PREVENTION PLUS……………………………………………….……… 4
STAGE 2: STRUCTURED WEIGHT MANAGEMENT………………………………. 4
STAGE 3: COMPREHENSIVE MULTIDISCIPLINARY INTERVENTIONS……….. 5
STAGE 4: TERTIARY CARE………………………………………………………….. 5
III. Appendices
A. PLASMA LIPID, LIPOPROTEIN AND APOLIPOPROTEIN LEVELS……………………... 6
B. SPECIAL RISK CONDITIONS………………………………………………………………... 7
C. RECOMMENDATIONS FOR PHARMACOLOGIC TREATMENT OF DYSLIPIDEMIA… 8
D. MYPYRAMID FOR KIDS/ TIPS FOR FAMILIES………………………..…………………. 9-10

E. GIRLS BODY MASS INDEX-FOR-AGE PERCENTILES GROWTH CHART……………. 11
F. BOYS BODY MASS INDEX-FOR-AGE PERCENTILES GROWTH CHART………….…. 12
G. 5-2-1-0 MESSAGE……………………………………………………………………………… 13
H. PEDIATRIC OBESITY PROGRAMS/ RESOURCES………………………………………… 14-15
I. WEBSITE RESOURCES FOR PARENTS AND CHILDREN…………………………….….. 16
IV. References ……………………………………………………………………………… 17-18

Assessment and Management of Overweight/Obese Children and Adolescents Ages 2 –18 years±
Assess BMI percentile
BMI < 85 % BMI 85% - 94.9% BMI > 95 %

Patient is not Overweight Patient is Overweight
Patient is Obese
Reinforce healthy lifestyle,

nutrition and exercise
guidance.(5-2-1-0 Message)
Labs: Labs: Fasting lipid profile,
See Prevention
Fasting Lipid Profile FBS (Hgb A1c), LFT, GGT, CMP, TSH,
Recommendations.**
(See Table 9-5) CBC, UA, Insulin, Free testosterone (if
Monitor BMI periodically.
hirsute, oligomenorrhea)
Refer to Table 9-5 for
Universal Screening.
Assess readiness to improve weight. Restrict calories.

Increase Physical Activity. Modify individual and family
behavior. Goal: to maintain weight with growth that results in Refer as needed to:
Cardiology- dyslipidemia
decreasing BMI** (Stage 1)
Endocrine- glycosuria or elevated free
testosterone,TSH > 5, FBS > 100,
PCOS
Yes Pulmonary- sleep apnea
BMI decreasing after 6 months
NASH Clinic/GI Clinic- nonalcoholic
steatohepatitis (elevated AT, AST,
No GGT or hyperinsulinemia)
Structured/Comprehensive BMI > 95% Orthopedics- joint problems
Weight Management**± Nephrology- hypertension
(Stage 2 to 4) Psychiatrist/Psychologist-depression
See pg. 4& 5
Drugs if appropriate.
References: **Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity, June 2007
Childhood Obesity Referral Guidelines, CHKD, 2008; Childhood Obesity, The Obesity Society, 2009; Goldfarb, Bruce (2007). ENDO Panel Issues Pediatric Obesity Guidelines, American Diabetes Assoc.
± USPSTF Screening for Obesity in Children and Adolescents Recommendation Statement. Pediatrics. Feb 2010
1
These guidelines are promulgated by Sentara Healthcare (SHC) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these
1
guidelines. The SHC Guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment.
Table 9–5. Evidence-Based Recommendations for Lipid Assessment
Grades reflect the findings of the evidence review.
Recommendation levels reflect the consensus opinion of the Expert Panel.
NOTE: Values given are in mg/dL. To convert to SI units, divide the results for total cholesterol (TC), low-density lipoprotein cholesterol
(LDL–C), high-density lipoprotein cholesterol (HDL–C), and non-HDL–C by 38.6; for triglycerides (TG), divide by 88.6.
Birth–2 years No lipid screening Grade C
Recommend
2–8 years No routine lipid screening Grade B
Recommend
2–8 years Measure fasting lipid profile (FLP) × 2a; average resultsb if: Grade B Strongly
(cont.d) Parent, grandparent, aunt/uncle, or sibling with myocardial infarction (MI), angina, stroke, coronary artery recommend
bypass graft (CABG)/stent/angioplasty at <55 years in males, <65 years in females
2–8 years Parent with TC ≥240 mg/dL or known dyslipidemia Grade B Strongly
(cont.d) recommend
2–8 years Child has diabetes, hypertension, BMI ≥95th percentile or smokes cigarettes Grade B Strongly
(cont.d) recommend
2–8 years Child has a moderate- or high-risk medical condition (Table 9-7) Grade B Strongly
(cont.d) recommend
9-11 years Universal Screening Grade B

Non-FLP: Calculate non-HDL-C: Strongly recommend
Non HDL C = TC - HDL Cc
Non-HDL ≥145 mg/dL, HDL< 40 mg/dL
→FLP × 2, lipid algorithms belowd
OR
FLP:
LDL-C ≥130 mg/dL, non-HDL-C ≥145 mg/dL
HDL-C <40 mg/dL, TG ≥100 mg/dL if < 10 years; ≥130 mg/dL if ≥10 years → Repeat FLP after 2 weeks but
within 3 months → lipid algorithms belowd
12-16 years No routine screeninge Grade B
Recommend
12-16 years Measure FLP × 2f, average results, if new knowledge of: Grade B Strongly
(cont.d) Parent, grandparent, aunt/uncle or sibling with MI, angina, stroke, CABG/ stent/angioplasty, sudden death at recommend
< 55 years in males, < 65 years in females
12-16 years Parent with TC ≥240 mg/dL or known dyslipidemia Grade B Strongly
(cont.d) recommend
12-16 years Patient has diabetes, hypertension, BMI ≥85th percentile or smokes cigarettes Grade B Strongly
(cont.d) recommend
12-16 years Patient has a moderate- or high-risk medical condition (Table 9–7) Grade B Strongly
(cont.d) recommend
17-21 years Universal screening once in this time period: Grade B
Recommend
Non-FLP: Calculate non-HDL–C:
Non-HDL–C = TC – HDL–Cg
17–19 years:
Non-HDL–C ≥145 mg/dL, HDL–C<40 mg/dL
→FLP × 2, lipid algorithm below (Figure 9–1)
OR
FLP:
LDL–C ≥130 mg/dL, non-HDL–C ≥145 mg/dL
HDL–C < 40 mg/dL, TG ≥130 mg/dL → Repeat FLP after 2 weeks but within 3 months→ lipid algorithms in Figures 9–
1 and 9–2.
20–21 years:
Non-HDL–C ≥190 mg/dL, HDL–C < 40 mg/dLh
→ FLP × 2i average results → Adult Treatment Panel III (ATP III) management algorithm
OR
FLP:
LDL–C ≥160 mg/dL, non-HDL–C ≥190 mg/dL
HDL–C <40 mg/dL, TG ≥150 mg/dL → Repeat FLP after 2 weeks but within 3 months, average results → ATP III
management algorithm
Sources: National Heart Lung and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and
Adolescents:Summary Report. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm. Accessed January 12, 2012.
2
These guidelines are promulgated by Sentara Healthcare (SHC) as recommendations for the clinical management of specific conditions. Clinical data in a
particular case may necessitate or permit deviation from these guidelines. The SHC Guidelines are institutionally endorsed recommendations and are not
intended as a substitute for clinical judgment.
Prevention and Management of Obesity (Children)
BMI-For Age Classifications
Weight Status Percentile Range
Underweight BMI-for-age < 5th percentile
Healthy BMI-for-age 5th percentile to 85th percentile
Overweight BMI-for-age 85th percentile to < 95th percentile
Obese BMI-for-age > 95th percentile
Source: Center for Disease Control. Overweight and Obesity.2011. Available at:
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. Accessed December 6, 2011.
Contributing Factors
1. Genetic Factors
2. Behavioral Factors
Energy intake: large portion sizes, eating meals away from home, frequent snacking on energy-
dense foods and consuming beverages with added sugar
Physical activity: effects body weight, blood pressure, bone strength
Sedentary behavior: due to increased TV, video, computer time
3. Environmental Factors
Within the home: parent child interactions, parental role-modeling habits
Within child care: setting where physical activity and eating habits are developed
Within schools: sugary drinks and less healthy foods on campuses
Within the community: lack of access to affordable healthy food choices, lack of sidewalks, safe
bike paths, and parks
Source: Center for Disease Control. Overweight and Obesity. 2011. Available at:
http://www.cdc.gov/obesity/childhood/problem.html. Accessed December 6, 2011
Health Consequences
Childhood overweight is associated with various health-related consequences. Overweight children and adolescents
may experience immediate health consequences and may be at risk for weight-related health problems in adulthood.
1. Psychosocial Risks
Low self-esteem • Depressive symptoms
Hindered academic and social functioning • Risk for eating disorders
2. Cardiovascular Disease Risks
High cholesterol
High blood pressure
Abnormal glucose tolerance
3. Additional Health Risks
Asthma • Orthopedic problems
Hepatic Steatosis • Early Puberty
Sleep Apnea • Type 2 Diabetes
Sources:
Centers for Disease Control. Overweight and Obesity. 2011. Available at: http://www.cdc.gov/obesity/childhood/basics.html. Accessed
December 6, 2011.
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Pediatric Obesity Risk Assessment: Steps to Prevention and Treatment
Prevention
Recommend primary care providers assess all children 2-18 years at least yearly for an obesity risk
assessment (including BMI percentile and BMI weight category diagnosis).
Healthy nutrition and activity 5210 message*:

5 Eat fruits and vegetables at least 5 or more times on most days
2 Limit screen time to 2 hours or less/day
1 Moderate to vigorous physical activity for at least one hour or more every day
0 No sugary drinks. Instead of sweetened drinks, try water and low-fat milk.
Stage 1: Prevention Plus

Recommend monthly follow-up assessment with primary care provider.
Goal: Weight maintenance or decrease in BMI as age increases
Dietary habits and physical activity:

Include 5210 message*
Behavioral Counseling:
Eat a healthy breakfast every day
Limit meals eaten outside of the home
Eat family meals at home 5-6 times a week
After 3-6 months, if no improvement in BMI /weight and family is willing/ready, advance to Stage 2
Stage 2: Structured Weight Management

Recommend monthly follow up assessment by primary care provider or healthcare professional
with specific training in weight management.
Goal:
Weight maintenance resulting in a decreasing BMI with increasing age and height. Weight not
to exceed 1lb/month in children 2-11 years or an average of 2 lbs/wk in older
overweight/obese children and adolescents.
Dietary and physical activity behaviors:

Daily diet plan of a balanced macronutrient diet, emphasizing foods high in water or fiber
content
Planned daily meals and snacks
Planned physical activity for at least 60 minutes/day
Decrease television or screen time to 1 hour or less/day
Increased monitoring using logs (e.g. screen time, physical activity, dietary intake)
After 3-6 months, if no improvement in BMI/weight, advance to Stage 3
Refer to the AAP publication for evidence based recommendations for diet and nutrition:
http://pediatrics.aappublications.org/site/misc/2009-2107.pdf
4
Stage 3: Comprehensive, Multidisciplinary Intervention **
Childhood obesity weight management center with an experienced multidisciplinary team
Goal: Weight maintenance or gradual weight loss until BMI less than 85th percentile not to exceed 1
lb/month in children aged 2-5 years, or 2 lbs/wk in older obese children and adolescents.
Eating and Activity: same as in Stage 2
Behavioral Counseling:
Structured program in behavioral modification, including food and activity monitoring,
and creation of short-term diet and physical activity goals.
Participation of parents/primary caregivers of children under age 12 years in behavioral
modification approaches.
Stage 4: Tertiary Care Intervention **
Pediatric Obesity Referral Clinic, Hospital or similar setting with expertise in the treatment of
severely obese children.
Recommended for children with BMI > 95% with significant co-morbidities unsuccessful with Stages
1-3 and children with BMI >99% who have shown no improvement under Stage 3
Multidisciplinary team with expertise in pediatric obesity and it’s co morbidities using clinical
protocols established by a physician, dietitian and mental health care provider/ social worker/
or psychologist
Ongoing diet and activity counseling
Consideration of medication, meal replacements, very low calorie diet, and bariatric weight
control surgery
SCREENING FOR OBESITY IN CHILDREN AND ADOLESCENTS:

CLINICAL SUMMARY OF USPSTF RECOMMENDATION
Screen children aged 6 y and older for obesity. Offer or refer for intensive counseling
Recommendation and behavioral interventions.
Timing of screening No evidence was found on appropriate screening intervals.
Refer patients to comprehensive moderate-to high-intensity programs that include
Interventions dietary, physical activity, and behavioral counseling components.
Moderate- to high intensity programs were found to yield modest weight changes.
Balance of Harms Limited evidence suggests that these improvements can be sustained over the year
and Benefits after treatment. Harms of screening were judged to be minimal.
Relevant USPSTF Recommendations on other pediatric and behavioral counseling topics can be found at
recommendations www.preventiveservices.ahrq.gov
Sources:
American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity. 2009. Available at:
www.aap.org/obesity/health_professionals.html?technology=0. Accessed December 7, 2009.
Barlow SE, Expert Committee. Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and Adolescent
Overweight and Obesity. Pediatrics: 2007; 120 (supp 4):S164-S192.
*Maine Center for Public Health. Maine Youth Overweight Collaborative: Keep ME Healthy Project. 2007. Available at:
www.mcph.org/Major_Activities/KeepMEHealthy.htm. Accessed December 7, 2009.
** Moderate to high-intensity programs involve more than 25 hours of contact with the child and/or family over 6-month period. This was shown to
result in significant weight loss and decrease in BMI by the end of 12 months in obese individuals ages 6-18 years. (U.S. Preventive Services Task
Force. Pediatrics, Feb 2010.)
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APPENDIX A
Table 9–1. Acceptable, Borderline-High, and High Plasma Lipid, Lipoprotein and Apolipoprotein
Concentrations (mg/dL) For Children and Adolescents*
NOTE: Values given are in mg/dL; to convert to SI units, divide the results for TC, LDL-C, HDL-C and non-
HDL-C by 38.6; for TG, divide by 88.6.
Category Acceptable Borderline High+

TC < 170 170-199 ≥ 200
LDL-C < 110 110-129 ≥ 130
Non-HDL-C < 120 120-144 ≥ 145
ApoB < 90 90-109 ≥ 110
TG
0-9 years < 75 75-99 ≥ 100
10-19 years < 90 90-129 ≥ 130
+
Category Acceptable Borderline Low
HDL-C > 45 40-45 < 40
ApoA-I >120 115-120 <115
*
Values for plasma lipid and lipoprotein levels are from the National Cholesterol Education Program (NCEP) Expert Panel on Cholesterol Levels in
Children. Non-HDL-C values from the Bogalusa Heart Study are equivalent to the NCEP Pediatric Panel cut points for LDL-C. Values for plasma apoB
and apoA-1 are from the National Health and Nutrition Examination Survey III.
+
The cut points for high and borderline-high represent approximately the 95th and 75th percentiles, respectively. Low cut points for HDL-C and apoA-
1 represent approximately the 10th percentile.
Table 9-2. Recommended Cut Points for Lipid and Lipoprotein Levels (mg/dL) in Young Adults*
Category Acceptable Borderline High High

TC <190 190-224 ≥225
LDL-C <120 120-159 ≥160
Non-HDL-C <150 150 -189 ≥190
TG <115 115-149 ≥150
Category Acceptable Borderline Low Low

HDL-C >45 40-44 < 40
*
Values provided are from the Lipid Research Clinics Prevalence Study. The cut points for TC, LDL-C and non-HDL-C represent the 95th percentile
for 20-24 year old subjects and are not identical with the cut points used in the most recent NHLBI adult guidelines, ATP III, which are derived from
combined data on adults of all ages. The age-specific cut points given here are provided for pediatric care providers to use in managing this young adult
age group. For TC, LDL-C and non-HDL-C, borderline high values are between the 75th and 94th percentile, while acceptable are < 75th percentile.
The high TG cut point represents approximately the 90th percentile with borderline high between the 75th and 89th percentile and acceptable < 75th
percentile. The low HDL-C cut point represents roughly the 25th percentile, with borderline low between the 26th and 50th percentile and acceptable >
the 50th percentile.
Sources:
National Heart Lung and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents:Summary
Report. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm. Accessed January 12, 2012.
These Guidelines are promulgated by Sentara Healthcare (SHC) as recommendations for the clinical management of specific conditions. Clinical data in a particular case
may necessitate or permit deviation from these Guidelines. The SHC Guidelines are institutionally endorsed recommendations and are not intended for clinical judgment.
APPENDIX B
Table 9–7 Special Risk Conditions
High Risk:
Diabetes mellitus, type 1 and type 2

Chronic kidney disease/end-stage renal disease/post renal transplant
Postorthotopic heart transplant
Kawasaki disease with current aneurysms
Moderate Risk:
Kawasaki disease with regressed coronary aneurysms

Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
Human immunodeficiency virus infection
Nephrotic syndrome
Conclusions and Grading of the Evidence Review for Dietary Management of Dyslipidemia
A diet with total fat at 25-30% of calories, saturated fat less than 10% of calories, and cholesterol
intake less than 300 mg/d, as recommended by the original NCEP Pediatric Panel, has been shown to
safely and effectively reduce the levels of TC and LDL-C in healthy children. (Grade A) There is some
evidence this is also the case when the diet begins in infancy and is sustained throughout childhood
into adolescence (Grade B). The Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) described
in Section 5. Nutrition and Diet of these Guidelines, has this composition.
In children with identified hypercholesterolemia and elevated LDL-C, a more stringent diet with
saturated fat ≤ 7% of calories and dietary cholesterol limited to 200 mg/d has been shown to be safe
and modestly effective in lowering the LDL-C level. (Grade A) (CHILD 2 – LDL , Table 9–8)
Use of dietary adjuncts such as plant sterol or stanol esters up to 20 g/d can safely enhance LDL-C
lowering effects short term in children with FH. (Grade A) However, long-term studies on the safety
and effectiveness of plant sterol and stanol esters have not been completed. Their use is therefore
usually reserved for children with primary elevations of LDL-C who do not achieve LDL-C goals with
dietary treatment alone. Such an approach may lower LDL-C sufficiently to avoid the necessity of
drug treatment. Food products containing plant stanol esters, such as some margarine, are marketed
directly to the general public. In two short-term trials, they have been shown to be safe with minimal
LDL-lowering effects in healthy children. (Grade B)
Evidence for use of other dietary supplements is insufficient for any recommendation. (No grade)
In children with elevated TG, reduction of simple carbohydrate intake and weight loss are associated
with decreased TG levels.(Grade B) Reduction of simple carbohydrate intake needs to be associated
with increased intake of complex carbohydrates and reduced saturated fat intake. When TG elevation
is associated with obesity, decreased calorie intake and increased activity levels are of paramount
importance. The CHILD 2 -TG diet in Table 9–8 is recommended as the primary diet therapy in this
setting.
A behavioral approach that engages the child and family delivered by a registered dietitian has been
shown to be the most consistently effective approach for achieving dietary change. (Grade B)
The approach to management of dyslipidemias is staged, as in the original NCEP Pediatric Panel
recommendations.
Sources:
National Heart Lung and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents:Summary
Report. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm. Accessed January 12, 2012.
APPENDIX C
Table 9–9. Evidence-Based Recommendations for Pharmacologic Treatment of Dyslipidemia
Grades reflect the findings of the evidence review.
Recommendation levels reflect the consensus opinion of the Expert Panel.
When medication is recommended, this should always be in the context of the complete cardiovascular risk profile of the
patient and in consultation with the patient and the family.
NOTE: Values given are in mg/dL. To convert to SI units, divide the results for total cholesterol (TC), low-density lipoprotein cholesterol
(LDL–C), high-density lipoprotein cholesterol (HDL–C), and non-HDL–C by 38.6; for triglycerides (TG), divide by 88.6.
Birth–10 years Pharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial Grade C
hypercholesterolemia, primary hypertriglyceridemia with TG ≥500 mg/dL) or a high-risk condition (Tables 9–6 and 9–7) Recommend
or evident cardiovascular disease; all under the care of a lipid specialist.
≥10–21 years Detailed family history (FHx) and risk factor (RF) assessment required before initiation of drug therapy. * High- to Grade C Strongly
moderate-level RFs and risk conditions (RCs) in Tables 9–6 and 9–7. recommend
≥10–21 years LDL–C:
(cont.d)
≥10–21 years If average LDL–C ≥250 mg/dL*, consult lipid specialist. Grade B Strongly
(cont.d) recommend
≥10–21 years If average LDL–C ≥130–250 mg/dL, or non-HDL ≥145 mg/dL: Grade A Strongly
(cont.d) Refer to dietitian for medical nutrition therapy with Cardiovascular Health Integrated Lifestyle Diet (CHILD 1) recommend
→ CHILD 2-LDL (Table 9–8) × 6 months → repeat fasting lipid panel (FLP)
≥10–21 years Repeat FLP:
(cont.d)
≥10–21 years → LDL–C <130 mg/dL, continue CHILD 2- LDL, reevaluate in 12 months Grade A Strongly
(cont.d) recommend
≥10–21 years → LDL–C ≥190** mg/dL, consider initiation of statin therapy per Tables 9–11 and 9–12 Grade A Strongly
(cont.d) recommend
≥10–21 years → LDL–C ≥130–189 mg/dL, FHx (-), no other RF or RC, continue CHILD 2-LDL, reevaluate q. 6 months Grade B
(cont.d) Recommend
≥10–21 years → LDL–C = 160–189 mg/dL + FHx positive OR ≥1 high-level RF/RC OR ≥2 moderate-level RFs/RCs, Grade B
(cont.d) consider statin therapy per Tables 9–11 and 9–12 Recommend
≥10–21 years → LDL–C ≥130–159 mg/dL + ≥2 high-level RFs/RCs OR 1 high-level + 2 moderate-level RFs/RCs, consider Grade B
(cont.d) statin therapy per Tables 9–11 and 9–12 Recommend
≥10–21 years Children on statin therapy should be counseled and carefully monitored per Table 9–12. Grade A Strongly
(cont.d) recommend
≥10–21 years Detailed FHx and RF/RC assessment required before initiation of drug therapy. *** High- and moderate-level RFs/RCs in Grade C Strongly
Tables 9–6 and 9–7† recommend
≥10–21 years TG:
(cont.d)
≥10–21 years If average TG ≥500 mg/dL, consult lipid specialist Grade B
(cont.d) Recommend
≥10–21 years If average TG ≥100 mg/dL in a child <10 years, ≥130 mg/dL in a child age 10–19 years, <500 mg/dL:
(cont.d)
≥10–21 years Refer to dietitian for medical nutrition therapy with CHILD 1 → CHILD 2-TG (Table 9–8) × 6 months Grade B Strongly
(cont.d) recommend
≥10–21 years Repeat fasting lipid profile:

(cont.d)
≥10–21 years → TG <100 (130) mg/dL, continue CHILD 2-TG, monitor q. 6–12 months Grade BStrongly
(cont.d) recommend
≥10–21 years → TG >100 (130) mg/dL, reconsult dietitian for intensified CHILD 2 TG diet counseling Grade C
(cont.d) Recommend
≥10–21 years → TG ≥200–499 mg/dL, non-HDL ≥145 mg/dL, consider fish oil +/- consult lipid specialist Grade D
(cont.d) Recommend
≥10–21 years Non-HDL-C:
(cont.d)
≥10–21 years Children ≥10 years with non-HDL–C ≥145 mg/dL after LDL–C goal achieved may be considered for additional treatment Grade D
(cont.d) with statins, fibrates, or niacin in conjunction with a lipid specialist. Optional
Sources: National Heart Lung and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and
Adolescents:Summary Report. Available at: http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm. Accessed January 12, 2012.
8
APPENDIX D
These Guidelines are promulgated by Sentara Healthcare (SHC) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these
Guidelines. The SHC Guidelines are institutionally endorsed recommendations and are not intended for clinical judgment.
APPENDIX E
10
These Guidelines are promulgated by Sentara Healthcare (SHC) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these
Guidelines. The SHC Guidelines are institutionally endorsed recommendations and are not intended for clinical judgment.
APPENDIX F
11
These Guidelines are promulgated by Sentara Healthcare (SHC) as recommendations for the clinical management of specific conditions. Clinical data in a
particular case may necessitate or permit deviation from these Guidelines. The SHC Guidelines are institutionally endorsed recommendations and are not
intended for clinical judgment.
APPENDIX G
12
APPENDIX H
13
APPENDIX I-1
Resources
Optima Health provides these resources for informational purposes only and does not officially sponsor or endorse these resources.
For further program information, please contact these programs directly as program specifics may change. For program eligibility for Optima
Health members, please contact Medical Care Services at 1-800-229-5522 or 757-552-7540.
Pediatric Obesity Programs

Care Connections for Children Program is sponsored by the VDH and provides a statewide network of
regional programs that provides counseling, information, education, community support, referrals and
resources to children with special health care needs. This free program is a good resource for children with
additional medical or behavioral problems associated with obesity.
Central Care Connections for Children
Phone: (804) 827-1795 or toll-free (866)737-5965
Children’s Hospital of the King’s Daughters (Norfolk, VA)

Healthy You Weight Management Program- Twice weekly 10 week lifestyle class (diet and food planning,
physical activity and emotional support) and exercise sessions, half day assessment clinics, and mental
health evaluation and support. (Fee for service but scholarships and sliding fee scales are available.)
Requires a physician referral.
For more information, class dates and locations, or to register:
Contact Babs Benson, RN, Healthy You Program Manager
Phone: (757) 668-7035
Web address: www.chkd.org/healthy_you
Email: careconnect@mcvh-vcu.edu
(EFNEP) Expanded Food and Nutrition Education Program provided by Virginia Cooperative
Extension. This free comprehensive nutrition education program encourages healthy eating habits and
assists limited-resource groups, families and individuals by teaching nutrition information, skills to stretch
food resources, and food related skills.
For more information about the program:www.csrees.usda/nea/food/efnep/efnep.html
Virginia Contact:
Mary McFerren, Project Director, EFNEP
Phone: (540) 231-9429
Email: mmcferre@vt.edu
Faces of Hope (Richmond, VA)

In-home fitness, nutrition, and prevention program for children who are dealing with overweight issues.
Medicaid accepted.
Contact: Jeannette Cordor, CEO
Phone: (804) 592-4751
Web address: www.thefacesofhope.org
Potomac Hospital (Woodbridge, VA)

Create Your Weight for Children: A Healthy Way to Weight Management (Ages 7 -12)
Create Your Weight for Teens: A Healthy Way to Weight Management (Ages 13-17)
Registered dietitians teach children, teens and their parents how to make changes to control weight
throughout their lifetime. (fee) For class dates: http://ph.mdatech.com/classes/classregistrationform.asp
Contact: Potomac Health Connection (703) 221-2500
14
APPENDIX I-2
University of Virginia Children’s Fitness Clinic (Charlottesville, VA)

Six month behavior modification program to help overweight children make healthy lifestyle changes. The
first visit is a 2hr evaluation, a nurse practitioner completes a physical exam, blood work is done, exercise
physiologist assesses and creates 30-day goals, RD assesses and creates 30-day goals with patient and
family. Patient returns every 30 days for evaluation on progress towards goals and goals are reset
accordingly. Child’s BMI must be 85th percentile or higher. Some insurances accepted.
Location: Kluge Children’s Rehabilitation Center
Contact: Susan Cluett, NP, Program Director
Phone: (434) 982-1607 or 1(800) 251-3627 ext. 2-1607
Email: uva-cfc@virginia.edu
Weight Watchers
In most instances, children ages 10-16 may join weight Watchers with a doctor’s note identifying the
weight goal for the child. In addition, a parent or guardian must sign the Health Notice portion of the
Registration Form.
For meeting locations and more information: www.weightwatchers.com
Nutritional Counseling
Sentara Medical Nutrition Therapy (MNT)
MNT is used to treat patients with diabetes, obesity, cardiovascular disease and many other diseases and
conditions. A physician referral is required for a dietary consult with a registered dietitian.
Sentara Hilltop Therapy Center (757) 252-4800
Indian River Therapy Center (757) 252-5300
Sentara Williamsburg Regional Medical Center Health Education Center
(757) 984-7106
Sentara CarePlex Hospital (757) 727-7496
For more information visit: http://www.sentara.com/Services/Nutrition/Pages/NutritionCounseling.aspx
Surgery*
Clinical Trials for adolescent studies related to obesity surgery (ie. laparoscopic gastric banding
surgery) www.clinicaltrials.gov
Clinical research study for weight management for children: Teen-LABS

(Teen- Longitudinal Assessment of Bariatric Surgery) www.cincinnatichildrens.org
*Although bariatric surgery is being performed on an increasing number of adolescents, it’s safety and
efficacy has not been established. Bariatric surgery is still under investigation for this population and for
those reasons is not a covered benefit for members under age 18.
Coding
Obesity and Related Co-Morbidities Coding Fact Sheet for Primary Care Pediatricians
http://www.aap.org/obesity/pdf/ObesityCodingFactSheet0208.pdf
15
APPENDIX J
Website Resources for Parents and Children
Information and special sections for kids
www.bestbonesforever.gov ☺
Bone health campaign to help build strong bones. Interactive website with games, recipes,
and activities. (Sponsored by Centers for Disease Control and Prevention)
www.dole.com/DoleHTMLSuperKids/tabid/1173/Default.aspx ☺
Vegetable and fruit tips, fitness ideas, recipes, games, music, comics (Sponsored by Dole Food Company)
www.fruitsandveggiesmatter.gov
Healthy recipes and 30 budget grocery tips (Sponsored by Centers for Disease Control & Prevention)
www.dcr.virigina.gov/state_parks/state_park.shtml
Virginia State Parks- locations, programs, events, fitness activities
www.healthiergeneration.org/teens.aspx ☺
Games and videos about healthy lifestyle with tips to encourage children to make healthy food choices and
exercise.
www.kidnetic.com ☺
Interactive games and fun recipes that parents and kids make together. Facts about physical activity, healthy
eating and self-esteem in children. (Sponsored by International Food Information Council)
www.kidshealth.org ☺
Physician-approved health information about children and teens. Recipes and exercise information. (Sponsored
by the Nemours Foundation)
www.letsgo.org
Resources for parents who are interested in increasing healthy eating and physical activity in their families. 5210
message. (Sponsored by Healthy Maine Partnership)
www.mypyramid.gov/kids/☺
Personalized eating plans and interactive tools for kids 6-10 to help make food choices for a healthier lifestyle.
(Sponsored by the U.S. Department of Agriculture)
www.nutritionexplorations.org/index.php☺
Practical up-to-date information to balance good nutrition and a busy family schedule, including recipes, snack
and meal tips. Provides children with recipes and nutrition-related games. (Sponsored by the National Dairy
Council)
www.shapeup.org/publications/99.tips.for.family.fitness.fun
99 Tips for Family Fitness Fun (Sponsored by National Assoc. for Sport and Physical Education, C. Everett
Koop Foundation, Foundation for Health Enhancement)
Max’s Magical Delivery: Fit for Kids DVD

Free interactive 30 minute DVD for children 5-9 and their parents about healthy living with small achievable
steps to encourage healthy habits in their families.
Call 1-800-358-9295 or Email AHRQ@ahrq.hha.gov
Sponsored by Agency for Healthcare Research and Quality (AHRQ)
16
Pediatric Obesity References
American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity. 2009. Available at:
www.aap.org/obesity/health_professionals.html?technology=0. Accessed December 7, 2009.
American Heart Association. Cholesterol and Atherosclerosis in Children: AHA Scientific Position. 2010. Available at
www.americanheart.org/presenter.jhtml?identifier=4499. Accessed December 18, 2009.
American Family Physician. Childhood Obesity: Highlights of AMA Expert Committee Recommendations. 2008. Available at:
http://www.aafp/afp/2008/0701/p56.html. Accessed December 7, 2009.
American Medical Association. Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child and
Adolescent Overweight and Obesity. 2007. Available at: http://ww.ama-
ssn.org/ama1/pub/upload/mm/433/ped_obesity_recs.pdf. Accessed December 7, 2009.
America’s Health Insurance Plans. Facing the Challenge of Unhealthy Weight Recommendations for the Health Care
Community. 2008. Available at: http://www.ahip.org/redirect/AHIP_ObesityWhitePaper.pdf. Accessed December 7,
2009.
Barlow SE, Expert Committee. Expert Committee Recommendations on the Assessment, Prevention, and Treatment of Child
and Adolescent Overweight and Obesity. Pediatrics: 2007; 120 (supp 4):S164-S192.
Center for Disease Control and Prevention.. Overweight and Obesity: BMI-for-Age Classifications. 2011. Available at:
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. Accessed December 6,
2011.
Center for Disease Control and Prevention. Body Mass Index-for-Age Percentiles. 2009. Available at:
http://www.cdc.gov/growthcharts. Accessed December 7, 2009.
Center for Disease Control and Prevention. Overweight and Obesity: Contributing Factors. 2011.Available at:
http://www.cdc.gov/obesity/childhood/problem.html. Accessed December 6, 2011.
Center for Disease Control and Prevention. Overweight and Obesity: Health Consequences. 2011. Available at:
http://www.cdc.gov/obesity/childhood/basics.html. Accessed December 6, 2011.
Children’s Hospital of the King’s Daughters. Childhood Obesity Referral Guidelines. 2008. Available at:
http://www.chkd.org/Services/HealthyYou/Referral.aspx. Accessed December 7, 2009.
Daniels S.R., Greer F.R., and the Committee on Nutrition (2008). Lipid Screening and Cardiovascular Health in Childhood.
Pediatrics. 122; 198-2008. DOI: 101542/peds.2008-1349.
Maine Center for Public Health. Maine Youth Overweight Collaborative: Keep ME Healthy Project. 2007. Available at:
www.mcph.org/Major_Activities/KeepMEHealthy.htm. Accessed December 7, 2009.
National Heart Lung and Blood Institute. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction
in Children and Adolescents:Summary Report. Available at:
http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm. Accessed January 12, 2012.
Onkingco, Ramon (2012). Personal Communication. January 2012
Sentara Health Plans. (2009) Bariatric Surgery: Surgical Policy 32. Accessed December 7, 2009 from Sentara E-share.
Sentara Health Plans. (2009). Nutritional Counseling: Medical Policy 06. Accessed December 7, 2009 from Sentara E-share.
Spear BA, Barlow S, Ervin C, et al. Recommendations for Treatment of Child and Adolescent Overweight and Obesity.
Pediatrics: 2007: 120 (suppl 4): S254-88.
17
Pediatric Obesity References continued
The Obesity Society. Childhood Overweight. 2009. Available at: http://www.obesity.org/information/childhood-overweight.asp.

Accessed December 7, 2009.
U.S. Preventive Services Task Force. Screening and Interventions for Overweight in Children and Adolescents:
Recommendation Statement. AHRQ Publication No. 05-0574-A, July 2005. Agency for Healthcare Research and
Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf05/choverwt/choverrs.htm
Accessed January 2010.
U.S. Preventive Services Task Force. Screening for Obesity in Children and Adolescents. Recommendation Statement.
Pediatrics 125:2, 2010.
18

Prevention Management Obesity Children Adolescents

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Prevention and Management

“Pediatric Obesity Prevention and Treatment Toolkit”

I. Prevention and Management of Obesity (Children & Adolescents)

B. RECOMMENDATIONS FOR LIPID ASSESSMENT…………...………………………. 2

C. MANAGEMMENT RECOMMENDATIONS FOR CHILDREN…………..……………..

II. Pediatric Obesity Risk Assessment: Steps To Prevention & Treatment

STAGE 1: PREVENTION PLUS……………………………………………….……… 4

STAGE 2: STRUCTURED WEIGHT MANAGEMENT………………………………. 4

STAGE 3: COMPREHENSIVE MULTIDISCIPLINARY INTERVENTIONS……….. 5

STAGE 4: TERTIARY CARE………………………………………………………….. 5

B. SPECIAL RISK CONDITIONS………………………………………………………………... 7

C. RECOMMENDATIONS FOR PHARMACOLOGIC TREATMENT OF DYSLIPIDEMIA… 8

D. MYPYRAMID FOR KIDS/ TIPS FOR FAMILIES………………………..…………………. 9-10

IV. References ……………………………………………………………………………… 17-18

Assess BMI percentile

BMI < 85 % BMI 85% - 94.9% BMI > 95 %

Reinforce healthy lifestyle,

Assess readiness to improve weight. Restrict calories.

9-11 years Universal Screening Grade B

Healthy nutrition and activity 5210 message*:

Stage 1: Prevention Plus

Dietary habits and physical activity:

Stage 2: Structured Weight Management

Dietary and physical activity behaviors:

Stage 4: Tertiary Care Intervention **

SCREENING FOR OBESITY IN CHILDREN AND ADOLESCENTS:

Category Acceptable Borderline High+

Category Acceptable Borderline High High

Category Acceptable Borderline Low Low

Table 9–7 Special Risk Conditions

Diabetes mellitus, type 1 and type 2

Kawasaki disease with regressed coronary aneurysms

≥10–21 years Repeat fasting lipid profile:

Pediatric Obesity Programs

Children’s Hospital of the King’s Daughters (Norfolk, VA)

Faces of Hope (Richmond, VA)

Potomac Hospital (Woodbridge, VA)

University of Virginia Children’s Fitness Clinic (Charlottesville, VA)

Clinical research study for weight management for children: Teen-LABS

Max’s Magical Delivery: Fit for Kids DVD

Onkingco, Ramon (2012). Personal Communication. January 2012

The Obesity Society. Childhood Overweight. 2009. Available at: http://www.obesity.org/information/childhood-overweight.asp.

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