Expert Committee Recommendations on the Assessment, Prevention and
Treatment of Child and Adolescent Overweight and Obesity - 2007

# - An Implementation Guide from the Childhood Obesity Action Network -

Overview:

In 2005, the AMA, HRSA and CDC convened an Expert Committee to revise
the 1998 childhood obesity recommendations. The initial recommendations
were released on June 6, 2007 with the complete recommendations
published in December 2007 in a Supplement to Pediatrics ("Assessment of
Child and Adolescent Overweight and Obesity" PEDIATRICS Volume 120,
Supplement 4, December 2007, Pages S163-S288).

In 2006, the National Initiative for Children's Healthcare Quality
(NICHQ) launched the Childhood Obesity Action Network (COAN). With more
than 50 healthcare organizations and 1,500 health professionals, the
network is aimed at rapidly sharing knowledge, successful practices and
innovation. The COAN 10 year goal is to reverse the childhood obesity
epidemic in all 50 states. This Implementation Guide is the first of a
series of products designed for healthcare professionals by COAN to
accelerate improvement in the prevention and treatment of childhood
obesity.

The Implementation Guide combines key aspects of the 2007 Expert
Committee Recommendations with practical tips and practice tools from
the members of COAN. The comprehensive set of practice tools available
to COAN members on the COAN Extranet include some tools developed before
the 2007 Expert Recommendations and there may be some inconsistencies
such as the term *overweight* instead of *obesity* for BMI ≥ 95%ile. The
tools are intended as a source of ideas and to facilitate
implementation. As tools are updated or new tools developed based on the
Expert Recommendations, the Implementation Guide will be updated. The
Implementation Guide defines 3 key steps to the implementation of the
2007 Expert Committee Recommendations:

-   **Step 1 -- Obesity Prevention at Well Care Visits** (Assessment &
    Prevention)

-   **Step 2 -- Prevention Plus Visits** (Treatment)

-   **Step 3 -- Going Beyond Your Practice** (Prevention & Treatment)

## Step 1 -- Obesity Prevention at Well Care Visits (Assessment & Prevention)

+------------+----------------------------+----------------------------+
| **Action   | **Expert Recommendations** | **Action Network Tips and  |
| Steps**    |                            | Tools**                    |
+------------+----------------------------+----------------------------+
| **Assess   | Physicians and allied      | A **presentation** for     |
| all        | health professional should | your staff and colleagues  |
| children   | perform, at a minimum, a   | can help implement obesity |
| for        | yearly assessment.         | prevention in your         |
| obesity at |                            | practice.                  |
| all well   |                            |                            |
| care       |                            |                            |
| visits     |                            |                            |
| 2-18       |                            |                            |
| years**    |                            |                            |
+------------+----------------------------+----------------------------+
| **Use Body | -   **Accurately measure   | BMI is very sensitive to   |
| Mass Index |     height and weight**    | measurement errors,        |
| (BMI) to   |                            | particularly height.       |
| screen for | -   **Calculate BMI**      | Having a standard          |
| obesity**  |                            | measurement protocol as    |
|            | > BMI (English):\[weight   | well as training can       |
|            | > (lb) ÷ height (in) ÷     | improve accuracy. **BMI    |
|            | > height (in)\] x 703      | calculation** tools are    |
|            | >                          | also helpful. Use the CDC  |
|            | > BMI (metric):\[weight    | BMI %ile-for-age **growth  |
|            | > (kg) ÷ height (cm) ÷     | charts**.                  |
|            | > height (cm)\] x 10,000   |                            |
|            |                            |                            |
|            | -   **Plot BMI on BMI      |                            |
|            |     growth chart**         |                            |
|            |                            |                            |
|            | -   Not recommended:       |                            |
|            |     skinfold thickness,    |                            |
|            |     waist circumference    |                            |
+------------+----------------------------+----------------------------+
| **Make a   | -   \< 5%ile Underweight   | Until the BMI 99%ile is    |
| weight     |                            | added to the growth        |
| category   | -   5-84%ile Healthy       | charts, **Table 1** can be |
| diagnosis  |     Weight                 | used to determine the      |
| using BMI  |                            | 99%ile cut-points.         |
| pe         | -   85-94%ile Overweight   |                            |
| rcentile** |                            | **Physicians should        |
|            | -   95-98%ile Obesity      | exercise judgement when    |
|            |                            | choosing how to inform the |
|            | -   ≥ 99%ile               | family. Using more neutral |
|            |                            | terms such as *weight,     |
|            |                            | excess weight, body mass   |
|            |                            | index, BMI, or risk for    |
|            |                            | diabetes and heart         |
|            |                            | disease* can reduce the    |
|            |                            | risk of stigmatization or  |
|            |                            | harm to self-esteem.**     |
+------------+----------------------------+----------------------------+
| **Measure  | -   Use a cuff large       | Diagnose hypertension      |
| blood      |     enough to cover 80% of | using **NHLBI tables**. An |
| pressure** |     the upper arm          | abbreviated table is shown |
|            |                            | below (**Table 2**).       |
|            | -   Measure pulse in the   |                            |
|            |     standard manner        |                            |
+------------+----------------------------+----------------------------+
| **Take a   | -   Obesity                | A child with one obese     |
| focused    |                            | parent has a 3 fold        |
| family     | -   Type 2 diabetes        | increased risk of becoming |
| history**  |                            | obese. This risk increases |
|            | -   Cardiovascular disease | to 13 fold with 2 obese    |
|            |     (hypertension,         | parents. Using a           |
|            |     cholesterol)           | **clinical documentation** |
|            |                            | tool can be helpful.       |
|            | -   Early deaths from      |                            |
|            |     heart disease or       |                            |
|            |     stroke                 |                            |
+------------+----------------------------+----------------------------+
| **Take a   | Take a focused review of   | See **Table 3**. Using a   |
| focused    | systems                    | **clinical documentation** |
| review of  |                            | tool can be helpful.       |
| systems**  |                            |                            |
+------------+----------------------------+----------------------------+
| **Assess   | **Diet Behaviors**         | Using **behavioral risk    |
| behaviors  |                            | assessment** tools can     |
| and        | -   Sweetened-beverage     | facilitate history taking  |
| a          |     consumption            | and save clinician time.   |
| ttitudes** |                            |                            |
|            | -   Fruit and vegetable    |                            |
|            |     consumption            |                            |
|            |                            |                            |
|            | -   Frequency of eating    |                            |
|            |     out and family meals   |                            |
|            |                            |                            |
|            | -   Consumption of         |                            |
|            |     excessive portion      |                            |
|            |     sizes                  |                            |
|            |                            |                            |
|            | -   Daily breakfast        |                            |
|            |     consumption            |                            |
|            |                            |                            |
|            | ## P                       |                            |
|            | hysical Activity Behaviors |                            |
|            |                            |                            |
|            | -   Amount of moderate     |                            |
|            |     physical activity      |                            |
|            |                            |                            |
|            | -   Level of screen time   |                            |
|            |     and other sedentary    |                            |
|            |     activities             |                            |
|            |                            |                            |
|            | ## Attitudes               |                            |
|            |                            |                            |
|            | -   Self-perception or     |                            |
|            |     concern about weight   |                            |
|            |                            |                            |
|            | -   Readiness to change    |                            |
|            |                            |                            |
|            | ## Successe                |                            |
|            | s, barriers and challenges |                            |
+------------+----------------------------+----------------------------+
| **Perform  | Perform a thorough         | See **Table 3**. Using a   |
| a thorough | physical examination       | **clinical documentation** |
| physical   |                            | tool can be helpful.       |
| exa        |                            |                            |
| mination** |                            |                            |
+------------+----------------------------+----------------------------+
| **Order    | **BMI 85-94%ile            | Consider ordering ALT, AST |
| the        | [Without]{.underline} Risk | and glucose tests          |
| a          | Factors**                  | beginning at 10 years of   |
| ppropriate |                            | age and then periodically  |
| laboratory | -   Fasting Lipid Profile  | (every 2 years). Provider  |
| tests**    |     \*                     | **decision support** tools |
|            |                            | can be helpful when        |
|            | **BMI 85-94%ile Age 10     | choosing assessment and    |
|            | Years & Older              | treatment options. Lab     |
|            | [With]{.underline} Risk    | test thresholds are shown  |
|            | Factors**                  | in **Table 6**.            |
|            |                            |                            |
|            | -   Fasting Lipid Profile  | Delivering lab results can |
|            |                            | be one way to open the     |
|            | -   ALT and AST            | conversation about weight  |
|            |                            | and health with a family.  |
|            | -   Fasting Glucose        |                            |
|            |                            | \* The AHA and AAP         |
|            | **BMI ≥ 95%ile Age 10      | recommend screening at 2   |
|            | Years & Older**            | years of age if there is a |
|            |                            | family history of lipid    |
|            | -   Fasting Lipid Profile  | abnormalities or if risk   |
|            |                            | factors are present in the |
|            | -   ALT and AST            | absence of a positive      |
|            |                            | family history.            |
|            | -   Fasting Glucose        |                            |
|            |                            |                            |
|            | -   Other tests as         |                            |
|            |     indicated by health    |                            |
|            |     risks                  |                            |
+------------+----------------------------+----------------------------+
| **Give     | -   Limit sugar-sweetened  | An example from the Maine  |
| consistent |     beverages              | Collaborative:             |
| evid       |                            |                            |
| ence-based | -   Eat at least 5         | -   **5** fruits and       |
| messages   |     servings of fruits and |     vegetables             |
| for all    |     vegetables             |                            |
| children   |                            | -   **2** hours or less of |
| regardless | -   Moderate to vigorous   |     TV per day             |
| of         |     physical activity for  |                            |
| weight**   |     at least 60 minutes a  | -   **1** hour or more     |
|            |     day                    |     physical activity      |
|            |                            |                            |
|            | -   Limit screen time to   | -   **0** servings of      |
|            |     no more than 2         |     sweetened beverages    |
|            |     hours/day              |                            |
|            |                            | Exam and waiting room      |
|            | -   Remove television from | **posters** and family     |
|            |     children's bedrooms    | **education materials**    |
|            |                            | can help deliver these     |
|            | -   Eat breakfast every    | messages and facilitate    |
|            |     day                    | dialogue. Encourage an     |
|            |                            | authoritative parenting    |
|            | -   Limit eating out,      | style in support of        |
|            |     especially at fast     | increased physical         |
|            |     food                   | activity and reduced TV    |
|            |                            | viewing. Discourage a      |
|            | -   Have regular family    | restrictive parenting      |
|            |     meals                  | style regarding child      |
|            |                            | eating. Encourage parents  |
|            | -   Limit portion sizes    | to be good role models and |
|            |                            | address as a family issue  |
|            |                            | rather than the child's    |
|            |                            | problem.                   |
+------------+----------------------------+----------------------------+
| **Use      | Assess self-efficacy and   | A possible dialogue:       |
| Empathiz   | readiness to change. Use   |                            |
| e/Elicit - | Empathize/Elicit -         | ## Empathize/Elicit        |
| Provide -  | Provide - Elicit to        |                            |
| Elicit to  | improve the effectiveness  | "Yours child's height and  |
| improve    | of your counseling.        | weight may put him/her at  |
| the        |                            | increased risk for         |
| eff        | ## Empathize/Elicit        | developing diabetes and    |
| ectiveness |                            | heart disease at a very    |
| of your    | -   Reflect                | early age."                |
| co         |                            |                            |
| unseling** | -   What is your           | "What do make of this?"    |
|            |     understanding?         |                            |
|            |                            | "Would you be interested   |
|            | -   What do you want to    | in talking more about ways |
|            |     know?                  | to reduce your child's     |
|            |                            | risk?"                     |
|            | -   How ready are you to   |                            |
|            |     make a change (1-10    | ## Provide                 |
|            |     scale)?                |                            |
|            |                            | "Some different ways to    |
|            | ## Provide                 | reduce your child's risk   |
|            |                            | are..."                    |
|            | -   Advice or information  |                            |
|            |                            | "Do any of these seem like |
|            | -   Choices or options     | something your family      |
|            |                            | could work on or do you    |
|            | ## Elicit                  | have other ideas?"         |
|            |                            |                            |
|            | -   What do you make of    | ## Elicit                  |
|            |     that?                  |                            |
|            |                            | "Where does that leave     |
|            | -   Where does that leave  | you?"                      |
|            |     you?                   |                            |
|            |                            | "What might you need to be |
|            |                            | successful?"               |
|            |                            |                            |
|            |                            | **Communication            |
|            |                            | guidelines** can helpful   |
|            |                            | when developing            |
|            |                            | communication skills.      |
+------------+----------------------------+----------------------------+

**Step 2 -- Prevention Plus Visits (Treatment)**

+------------+----------------------------+----------------------------+
| **Action   | #                          | **Action Network Tips and  |
| Steps**    | ### Expert Recommendations | Tools**                    |
+------------+----------------------------+----------------------------+
| **Develop  | A staged approach to       | Prevention Plus visits may |
| an office  | treatment is recommended   | include:                   |
| based      | for ages 2-19 whose BMI is |                            |
| approach   | 85-94%ile with risk        | -   Health **education     |
| for follow | factors and all whose BMI  |     materials**            |
| up of      | is ≥ 95%ile.               |                            |
| overweight |                            | -   **Behavioral risk      |
| and obese  | In general, treatment      |     assessment** **and**   |
| children** | begins with Stage 1        |     **self-monitoring**    |
|            | Prevention Plus (**Table   |     tools                  |
|            | 4**) and progresses to the |                            |
|            | next stage if there has    | -   **Action planning**    |
|            | been no improvement in     |     **and goal setting**   |
|            | weight/BMI or velocity     |     tools                  |
|            | after 3-6 months and the   |                            |
|            | family is willing/ready.   | -   **Clinical             |
|            |                            |     documentation** tools  |
|            | The recommended weight     |                            |
|            | loss targets are shown in  | -   **Counseling           |
|            | **Table 5**.               |     protocols**            |
|            |                            |                            |
|            | ##                         | -   Other health           |
|            |  Stage 1 - Prevention Plus |     professionals such as  |
|            |                            |     dietitians,            |
|            | -   Family visits with     |     psychologists and      |
|            |     physician or health    |     health educators       |
|            |     professional who has   |                            |
|            |     had some training in   | Besides behavioral and     |
|            |     pediatric weight       | weight goals, improving    |
|            |     management/behavioral  | self-esteem and self       |
|            |     counseling.            | efficacy (confidence) are  |
|            |                            | important outcomes.        |
|            | -   Can be individual or   | Although weight            |
|            |     group visits.          | maintenance is a good      |
|            |                            | goal, more commonly, a     |
|            | -   Frequency -            | slower weight gain         |
|            |     individualized to      | reflected in a decreased   |
|            |     family needs and risk  | BMI velocity is the        |
|            |     factors, consider      | outcome seen in lower      |
|            |     monthly.               | intensity behavioral       |
|            |                            | interventions such as      |
|            | -   **Behavioral Goals**   | Prevention Plus. Measuring |
|            |     --                     | and plotting BMI after 3-6 |
|            |                            | months is an important     |
|            | ```{=html}                 | step to determine the      |
|            | <!-- -->                   | effectiveness of obesity   |
|            | ```                        | treatment.                 |
|            | -   Decrease screen time   |                            |
|            |     to 2 hr/day or fewer   | ![](media/image1.wmf){wi   |
|            |                            | dth="2.1798611111111112in" |
|            | -   No sugar-sweetened     | heig                       |
|            |     beverages              | ht="2.9868055555555557in"} |
|            |                            |                            |
|            | -   Consume at least 5     |                            |
|            |     servings of fruits and |                            |
|            |     vegetables daily       |                            |
|            |                            |                            |
|            | -   Be physically active 1 |                            |
|            |     hour or more daily     |                            |
|            |                            |                            |
|            | -   Prepare more meals at  |                            |
|            |     home as a family (the  |                            |
|            |     goal is 5-6 times a    |                            |
|            |     week)                  |                            |
|            |                            |                            |
|            | -   Limit meals outside    |                            |
|            |     the home               |                            |
|            |                            |                            |
|            | -   Eat a healthy          |                            |
|            |     breakfast daily        |                            |
|            |                            |                            |
|            | -   Involve the whole      |                            |
|            |     family in lifestyle    |                            |
|            |     changes                |                            |
|            |                            |                            |
|            | -   More focused attention |                            |
|            |     to lifestyle changes   |                            |
|            |     and more frequent      |                            |
|            |     follow-up              |                            |
|            |     distinguishes          |                            |
|            |     Prevention Plus from   |                            |
|            |     Prevention Counseling  |                            |
|            |                            |                            |
|            | ```{=html}                 |                            |
|            | <!-- -->                   |                            |
|            | ```                        |                            |
|            | -   **Weight Goal** --     |                            |
|            |     weight maintenance or  |                            |
|            |     a decrease in BMI      |                            |
|            |     velocity. The long     |                            |
|            |     term BMI goal is       |                            |
|            |     \<85%ile although some |                            |
|            |     children can be        |                            |
|            |     healthy with a BMI     |                            |
|            |     85-94%ile.             |                            |
|            |                            |                            |
|            | -   Advance to Stage 2     |                            |
|            |     (Structured Weight     |                            |
|            |     Management) if no      |                            |
|            |     improvement in         |                            |
|            |     weight/BMI or velocity |                            |
|            |     in 3-6 months and      |                            |
|            |     family willing/ready   |                            |
|            |     to make changes.       |                            |
+------------+----------------------------+----------------------------+
| **Use      | Use patient-centered       | Research suggests that     |
| mo         | counseling -- motivational | motivational interviewing  |
| tivational | interviewing               | may be an effective        |
| in         |                            | approach to address        |
| terviewing |                            | childhood obesity          |
| at         |                            | prevention and treatment.  |
| Prevention |                            | Motivational interviewing  |
| Plus       |                            | is particularly effective  |
| visits for |                            | for ambivalent families    |
| ambivalent |                            | but can also be used for   |
| families   |                            | action planning. Instead   |
| and to     |                            | of telling patients what   |
| improve    |                            | changes to make, you       |
| the        |                            | elicit "change talk" from  |
| success of |                            | them, taking their ideas,  |
| action     |                            | strengths, and barriers    |
| planning** |                            | into account.              |
|            |                            | **Communication            |
|            |                            | guidelines** and           |
|            |                            | **communication training** |
|            |                            | can be helpful with skill  |
|            |                            | development.               |
+------------+----------------------------+----------------------------+
| **Develop  |                            | **Coding strategies** can  |
| a          |                            | help with reimbursement    |
| rei        |                            | for Prevention Plus        |
| mbursement |                            | visits. Advocacy through   |
| strategy   |                            | professional organizations |
| for        |                            | to address reimbursement   |
| Prevention |                            | policies is another        |
| Plus       |                            | strategy.                  |
| visits**   |                            |                            |
+------------+----------------------------+----------------------------+

Step 3 -- Going Beyond Your Practice (Prevention & Treatment)

+------------+----------------------------+----------------------------+
| **Action   | **Expert Recommendations** | **Action Network Tips and  |
| Steps**    |                            | Tools**                    |
+------------+----------------------------+----------------------------+
| **Advocate | The Expert Committee       | Physicians and health      |
| for        | recommends that            | professionals can play a   |
| improved   | physicians, allied         | key role in advocating for |
| access to  | healthcare professionals,  | policy and built           |
| fresh      | and professional           | environment changes to     |
| fruits and | organizations advocate     | support healthy eating and |
| vegetables | for:                       | physical activity in       |
| and safe   |                            | communities, child care    |
| physical   | -   The federal government | settings, and schools      |
| activity   |     to increase physical   | (including after-school    |
| in your    |     activity at school     | programs). **Advocacy      |
| community  |     through intervention   | tools and resources** can  |
| and        |     programs as early as   | be helpful in advocacy     |
| schools**  |     grade 1 through the    | efforts. Partnering with   |
|            |     end of high school and | others and using           |
|            |     college, and through   | evidence-based strategies  |
|            |     creating school        | are also critical to the   |
|            |     environments that      | success of **multi-faceted |
|            |     support physical       | community interventions**. |
|            |     activity in general.   |                            |
|            |                            |                            |
|            | -   Supporting efforts to  |                            |
|            |     preserve and enhance   |                            |
|            |     parks as areas for     |                            |
|            |     physical activity,     |                            |
|            |     informing local        |                            |
|            |     development            |                            |
|            |     initiatives regarding  |                            |
|            |     the inclusion of       |                            |
|            |     walking and bicycle    |                            |
|            |     paths, and promoting   |                            |
|            |     families' use of local |                            |
|            |     physical activity      |                            |
|            |     options by making      |                            |
|            |     information and        |                            |
|            |     suggestions about      |                            |
|            |     physical activity      |                            |
|            |     alternatives available |                            |
|            |     in doctors' offices.   |                            |
+------------+----------------------------+----------------------------+
| **Identify | Promote physical activity  | Public Health Departments  |
| and        | at school and in child     | and Parks and Recreation   |
| promote    | care settings (including   | are good places to start   |
| community  | after school programs), by | looking for community      |
| services   | asking children and        | programs and resources.    |
| which      | parents about activity in  |                            |
| encourage  | these settings during      | You can work on developing |
| healthy    | routine office visits.     | your own partnerships with |
| eating and |                            | community organizations    |
| physical   |                            | (Physical Activity         |
| activity** |                            | Directory template and/or  |
|            |                            | referral forms).           |
+------------+----------------------------+----------------------------+
| **Identify | The Expert Committee       | Stage 2 could be done      |
| or develop | recommends the following   | without a tertiary care    |
| more       | staged approach for        | center if community        |
| intensive  | children between the ages  | professionals from         |
| weight     | of 2 and 19 years whose    | different disciplines      |
| management | BMI is 85-94%ile with risk | collaborated. For example, |
| int        | factors and all whose BMI  | if a physician provided    |
| erventions | is ≥ 95%ile:               | the medical assessment, a  |
| for your   |                            | dietitian provided         |
| families   | -   **Stage 2 - Structured | classes, and the local     |
| who do not |     Weight Management**    | YMCA provided an exercise  |
| respond to |     (Family visits with    | program.                   |
| Prevention |     physician or health    |                            |
| Plus**     |     professional           | Partnering with your       |
|            |     specifically trained   | community tertiary care    |
|            |     in weight management.  | center can be an effective |
|            |     Monthly visits can be  | strategy to develop or     |
|            |     individual or group.)  | link to more intensive     |
|            |                            | weight management          |
|            | -   **Stage 3 -            | interventions (Stages 3    |
|            |     Comprehensive,         | and 4) as well as referral |
|            |     Multidisciplinary      | protocols to care for      |
|            |     Intervention**         | families who do not        |
|            |     (Multidisciplinary     | respond to Prevention Plus |
|            |     team with experience   | visits. Provider           |
|            |     in childhood obesity.  | **decision support** tools |
|            |     Frequency is often     | can be helpful when        |
|            |     weekly for 8-12 weeks  | choosing appropriate       |
|            |     with follow up.)       | treatment and referral     |
|            |                            | options. **Weight          |
|            | -   **Stage 4 - Tertiary   | management protocols and   |
|            |     Care Intervention**    | curriculum** can also be   |
|            |     (Medications -         | helpful when getting       |
|            |     sibutramine, orlistat, | started.                   |
|            |     Very-low-calorie       |                            |
|            |     diets, weight control  |                            |
|            |     surgery - gastric      |                            |
|            |     bypass or banding.)    |                            |
|            |     Recommended for select |                            |
|            |     patients only when     |                            |
|            |     provided by            |                            |
|            |     experienced programs   |                            |
|            |     with established       |                            |
|            |     clinical or research   |                            |
|            |     protocols. Gastric     |                            |
|            |     banding is in clinical |                            |
|            |     trials and not         |                            |
|            |     currently FDA          |                            |
|            |     approved.              |                            |
+------------+----------------------------+----------------------------+
| **Join the |                            | The Childhood Obesity      |
| Childhood  |                            | Action Network has         |
| Obesity    |                            | launched "The Healthcare   |
| Action     |                            | Campaign to Stop the       |
| Network to |                            | Epidemic." **Join the      |
| learn from |                            | network**                  |
| your       |                            | ([www.NICHQ.or             |
| colleagues |                            | g](http://www.NICHQ.org/)) |
| and        |                            | to learn from our national |
| accelerate |                            | obesity experts, share     |
| progress** |                            | what you have learned and  |
|            |                            | access the tools in this   |
|            |                            | guide. ***Together we can  |
|            |                            | make a difference!***      |
+------------+----------------------------+----------------------------+

**Implementation Guide Authors:** Scott Gee, MD, Victoria Rogers, MD,
Lenna Liu, MD, MPH, Jane McGrath, MD

**Implementation Guide Contact:** obesity@nichq.org Revised -- February
28, 2008

**Table 1 -- BMI 99%ile Cut-Points (kg/m^2^) Table 2 -- Abbreviated
NHLBI Blood Pressure Table**

### ![](media/image2.wmf){width="2.625in" height="2.348611111111111in"}

### Table 3 -- Symptoms and Signs of Conditions Associated with Obesity

![](media/image4.wmf){width="6.548611111111111in"
height="2.229861111111111in"}

## Table 4 -- A Staged Approach to Obesity Treatment

![](media/image5.wmf){width="4.176388888888889in" height="1.31875in"}
![](media/image6.wmf){width="2.38125in" height="1.3229166666666667in"}

### Table 5 -- Weight Loss Targets Table 6 -- Laboratory Test Thresholds

![](media/image7.wmf){width="3.0in" height="2.19375in"}

\* If greater loss is noted, monitor for causes of excessive weight loss