![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Evaluation and treatment of childhood obesity.

#### BIBLIOGRAPHIC SOURCE(S)

University of Texas at Austin, School of Nursing, Family Nurse
Practitioner Program. Evaluation and treatment of childhood obesity.
Austin (TX): University of Texas at Austin, School of Nursing; 2004 May.
30 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Childhood obesity

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nursing\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Dietitians\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To assist in early identification and screening of obesity in
    children

-   To provide health care providers with guidance requiring current
    standards of screening, evaluation, and treatment of obesity in the
    pediatric population

#### TARGET POPULATION

Patients aged 3 to 17

**Note**: This guideline is not directed to the treatment of pregnant
patients.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Screening/Diagnosis]{.underline}**

**Subjective Assessment**

1.  Present history

2.  Symptoms

3.  Past medical history

4.  Medication history

5.  Family history

6.  Ethnicity

7.  School/social environments

8.  Psychosocial history

9.  Substance abuse history

10. Dietary history

11. Reproductive history (menses history for females and secondary
    sexual characteristics for boys and girls)

12. Family support

**Objective Assessment**

1.  Body mass index (BMI)

2.  Blood pressure

3.  Complete physical exam, including skin and orthopedic assessment

**Diagnostic Procedures**

1.  BMI

2.  Hypertension (HTN) measurement (blood pressure)

> Laboratory studies including measurement of hemoglobin A1C and thyroid
> stimulating hormone (TSH), lipid panel, complete metabolic panel, and
> urinalysis

3.  Other tests based on positive findings in history and physical
    examination:

    -   12-lead electrocardiogram and/or echocardiogram

    -   complete blood count (CBC)

    -   urine microalbumin

    -   pulmonary function test

    -   chest x-ray

    -   skin fold measurements

    -   sleep studies

4.  Categorization of weight according to BMI as optimal, at-risk of
    overweight, and/or overweight as defined by greater than or equal to
    85^th^ percentile, and/or greater than 95^th^ percentile,
    respectively, according to growth charts for age, sex, and ethnicity
    (as defined by the Centers for Disease Control and Prevention
    \[CDC\])

5.  Follow-up recommendations based on screening measurement

6.  Unique screening considerations include polycystic ovarian syndrome
    (PCOS) and genetic screening for disease processes such as
    Prader-Willi syndrome, Blount\'s disease, pseudotumor cerebri,
    gallbladder disease, metabolic syndrome, fatty liver, slipped
    capital femoral epiphysis (SCFE).

**[Counseling/Management/Treatment]{.underline}**

1.  Assessment and counseling for exercise program (as defined by the
    CDC)

2.  Limiting television and/or video games to two hours per day.

3.  Blood cholesterol management

4.  Blood pressure elevation management

5.  Diabetes management (hemoglobin A1C)

6.  Implementation of exercise plan

7.  Cigarette smoking cessation

8.  Diet teaching

9.  Pharmacological treatment with referral as necessary

10. Referral to appropriate specialty as needed

11. Promotion of healthy family behavior change

#### MAJOR OUTCOMES CONSIDERED

-   Body mass index (BMI)

-   Morbidity and mortality

-   Psychological/Social measures as defined by the Primary Care
    Evaluation of Mental Disorders Questionnaire

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Online searches of PubMed, Medline, CINAHL, NIH, CDC, American Academy
of Pediatrics, American Heart Association, American Bariatric Society,
and Healthy People 2010 databases were performed using the major
keywords of childhood obesity screening, childhood overweight
guidelines, pediatric obesity, pediatric and/or childhood body mass
index (BMI), overweight treatment for childhood and/or pediatric
obesity, childhood obesity demonstration grants and/or controlled trials
published in the last 5 years.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Subjective Review\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Grade A**: Randomized clinical trials\
**Grade B**: Well-designed clinical trials\
**Grade C**: Panel consensus

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus\
Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendations**

**Level I**: Usually indicated, always acceptable, and considered useful
and effective.

**Level IIa**: Acceptable, of uncertain efficacy, and may be
controversial. Weight of evidence in favor of usefulness/efficacy.

**Level IIb**: Acceptable, of uncertain efficacy, and may be
controversial. May be helpful, not likely to be harmful.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Comparison with Guidelines from Other Groups\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A draft of the guideline was developed by a group of Family Nurse
Practitioner (FNP) students and submitted for review to the FNP program
faculty for review. Revisions were made after recommendations were
received.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the strength of the recommendations (I, IIa, and IIb) and
classification of the evidence (Grades A, B, and C) are provided at the
end of the \"Major Recommendations\" field.

**[Major Recommendations]{.underline}**

-   Screening children for overweight by using body mass index (BMI) is
    the standard obesity measurement and should be obtained at each
    health care encounter for children older than 2 years of age using
    the National Center for Health Statistics age and gender-specific
    percentile curves up to 20 years of age (See appendix I of the
    original guideline document titled \"Flow Chart - Children and
    Adolescents\"). (**Level I**)

-   BMI reading greater than or equal to the 95^th^ percentile for age
    and gender is overweight. A BMI between the 85^th^ and 95^th^
    percentile for age and gender is considered at-risk for overweight
    and should be evaluated for hypertension (HTN), dyslipidemia, and
    diabetes. (**Level I**)

-   A BMI greater than or equal to 95^th^ percentile for age and sex
    should be further evaluated for exogenous causes of obesity and for
    complications caused by overweight status. (**Level I**)

-   Early intervention begins with children greater than or equal to
    two. (**Level I**)

-   The family must be ready for change, as a lack of readiness could
    lead to failure. Probe for readiness to change. (**Level IIa**)

-   Providers should educate the family on medical complications related
    to overweight including HTN, dyslipidemia, heart disease, and
    diabetes. (**Level I**)

-   Providers should educate the family on psychosocial complications
    related to obesity such as depression, confidence issues, and poor
    self-esteem. (**Level I**)

-   The entire family and/or all caregivers should be involved in the
    development and implementation of the program. (**Level I**)

-   The family should be in agreement with the interventions. (**Level
    I**)

-   Treatment programs should emphasize long-term permanent changes, not
    rapid weight loss or short-term diets and exercise programs.
    Persuade the family to seek small, gradual, but lifelong changes.
    (**Level I**)

-   Support family activities that provide everyone with exercise
    (promote inclusiveness). (**Level I**)

-   Low fat, low cholesterol, reduced sugar diet per age weight and
    nutritional requirements
    ([www.health.gov/dietaryguidelines](http://www.health.gov/dietaryguidelines))
    (**Level I**)

-   Encourage planned meals, especially eating breakfast. Discourage
    skipping meals. (**Level I**)

-   Discourage eating while watching television. (**Level I**)

-   Avoid the use of food as a reward or punishment. (**Level I**)

-   Stock refrigerator with healthy food and drink choices. (**Level
    I**)

-   Encourage 30 to 60 minutes of moderate physical activity most days
    of the week. (**Level I**)

-   Promote a variety exercise to prevent boredom or overtraining.
    (**Level I**)

-   Clinicians should maintain an open and accepting relationship to all
    family members involved. (**Level I**)

-   If necessary, utilize a multi-disciplinary approach for
    comprehensive management. (**Level I**)

-   Consider cultural norms and socioeconomic status. (**Level I**)

**Medical Evaluation**

***Purpose***

-   Rule out secondary causes of childhood obesity: genetic causes
    include Prader-Willi, Bardet-Biedl, and Cohen diseases;
    endocrinologic causes are hypothyroid and Cushing syndrome.

-   Assess psychological causes of obesity in patients and family
    members. These include low self-esteem, eating disorders, and
    depression.

-   Assess for complications associated with obesity such as sleep
    apnea, metabolic syndrome, fatty liver, cholelithiasis, type II
    diabetes, polycystic ovary syndrome (PCOS), Blount\'s disease, and
    slipped capital femoral epiphysis (SCFE).

***Management/Treatment***

If a child is identified at-risk for overweight or overweight, the
provider will:

-   Complete the Weight Management Plan for Children and Adolescents
    (See Appendix 2 of the original guideline document titled
    \"Overweight and obesity in children and adolescents: a guide for
    general practitioners.\").

-   Assess risk factors related to food and activity levels.

-   Identify and rule out a mental health disorder that may be related
    to exacerbating child\'s eating habits and activity (Psychological
    tool -- Primary Care Evaluation of Mental Disorders Questionnaire:
    Brief Patient Health Questionnaire). (See appendix 3 of the original
    guideline document).

-   Introduce patient and family to Centers for Disease Control and
    Prevention (CDC) Body and Mind \"Motion Commotion\" Physical
    Activity Assessment Tool.

-   Using the CDC Body and Mind Fit 4 Life Guideline will counsel family
    and patients of risks associated with overweight status.

-   Counsel patient and family on dietary choices and relationship to
    overweight status.

-   Evaluate cultural aspects of the family´s beliefs on diet, exercise,
    and concept of obesity.

-   Counsel patient on exercise versus sedentary (computers, games,
    television) habits and the relationship to childhood overweight
    status.

-   Teach patient and family how to support and maintain the challenges
    of initiating a diet and exercise plan.

-   Encourage total family involvement in healthy living and eating.

-   Establish activity calendar.

-   Refer to registered dietician and physical exercise trainer (if
    needed).

-   Refer for sleep study, cardiology, neurologist, orthopedist,
    geneticist, gynecologist, endocrinologist, urologist, and
    pulmonologist, if concomitant disease processes are present or are
    suspected in relationship to child´s overweight status.

-   Refer to specialty weight reduction clinics including consideration
    of medication and/or bariatric surgery (needed in less than 1% of
    children and adolescents identified as obese).

-   Schedule patient for regular return visits for follow-up.

***Monitoring of Treatment***

-   CDC Fit 4 Life Program - Introduce nutritional meals and treats,
    review activity calendar, and discuss the importance of having a
    variety of activities and foods.

-   Monitor improvement and/or plateau or regression as per the Weight
    Management Program.

-   Adjust intensity of therapy and/or modality dependent on patient\'s
    enthusiasm or resistance (treatment will be individualized for each
    patient in order to provide the best opportunity for success).

***Continuation of Follow-up Visits***

-   Take vital signs including blood pressure; calculate BMI and compare
    to prior visits.

-   Evaluate patient\'s (family) compliance with diet.

-   Evaluate patient\'s (family) compliance with exercise.

-   Evaluate patient\'s (family) sedentary time activities.

-   Evaluate side effects of current regimen if any; avoid consequences
    of intense scrutiny of one\'s body size -- body dysmorphia,
    anorexia, bulimia, and/or depression.

-   Support improvements other than scale weight loss:

    -   Body fat per caliper measurement

    -   Engagement in physical activity

    -   Improved self-esteem and confidence

    -   Improved family functioning

    -   Engagement in self-regulating behaviors

-   Identify triggers and roadblocks that might hinder short- and
    long-term success.

-   Repeat follow-up steps above as appropriate.

**Intervention**

***Visit 1***

[Subjective Assessment]{.underline}

-   History

-   Symptoms

-   Past medical history

-   Medication history

-   Family history

-   Psychosocial history

-   Substance abuse history

-   Dietary history

-   Reproductive history (menses history for females and secondary
    sexual characteristics for boys and girls). Document according to
    Tanner Stages

[Objective Assessment]{.underline}

-   Physical exam

    -   Blood pressure (mmHg)

    -   Height (meters)

    -   Height percentile

    -   Weight

    -   Weight percentile

    -   BMI (weight in kg/height in meters squared)

    -   BMI percentile by age and gender

    -   Assess for facial dysmorphia (genetic syndrome)

    -   Funduscopic exam (papilledema)

    -   Tonsils (hypertrophy)

    -   Thyroid (goiter)

    -   Assess for acanthosis nigricans (glucose intolerance)

    -   Assess for hirsutism (PCOS)

    -   Assess for violaceous striae (Cushing\'s disease)

    -   Assess for upper abdominal tenderness (gallbladder disease)

    -   Assess for undescended testicle (Prader Willi Syndrome)

    -   Assess for small hands and feet (Prader Willi Syndrome)

    -   Assess for limited hip range of motion (SCFE)

    -   Assess for lower-leg bowing (Blount´s disease)

Source: Eissa M, Gunner K. Evaluation and management of obesity in
children and adolescents. Journal of Pediatric Health Care 2004 Jan;
18(1): 35-38.

[Assessment/Plan]{.underline}

-   Perform diagnostic procedures including measurements of blood
    pressure, hemoglobin A1C, BMI, thyroid-stimulating hormone (TSH),
    lipid panel, and complete metabolic panel.

-   Perform additional testing as warranted (e.g. 12-lead
    electrocardiogram and/or echocardiogram, urinalysis, complete blood
    count \[CBC\], urine microalbumin, pulmonary function test, chest
    x-ray, skin fold measurements, and sleep studies).

-   Categorization of weight according to BMI as optimal, at-risk for
    overweight, and/or overweight as defined by greater than or equal to
    85^th^ percentile and 95^th^ percentile, respectively, according to
    growth charts for age, sex, and ethnicity.

-   Provide follow-up recommendations based on screening measurement.

-   Perform other tests based on positive findings in history and
    physical examination (e.g., PCOS, genetic screening for disease
    processes such as Prader-Willi Syndrome, Blount\'s disease,
    pseudotumor cerebri, gallbladder disease, metabolic syndrome, fatty
    liver, SCFE).

***Visit II***

-   Provider will initiate \"Weight Management Plan: A Guide for General
    Practitioners\"
    <http://www.obesityguidelines.gov.au/pdf/children_gp.pdf>.

-   Provider will introduce patient and family to CDC \"Fit 4 Life\"
    recommendations at <http://www.bam.gov/fit4life/fitt.htm> (for ages
    9 to 13).

-   Conduct assessment and determine patient and/or family readiness to
    engage in therapeutic lifestyle change. Primary care physician (PCP)
    will assess and determine motivation and stages to change
    (precontemplation, contemplation, preparation, action, maintenance
    and relapse-prevention).

-   Administer Brief Quality of Life Tool to patient and parent(s) to
    establish baseline of self-esteem (Example: PedsQL Pediatric Quality
    of Life Inventory, version 4.0 for ages 8 to 12).

-   Advanced practice nurse/primary care physician will monitor vital
    signs including blood pressure and BMI and review abnormal labs.

-   If referrals were made at initial visit, determine if family
    complied with those initial recommendations.

***Visit III***

-   Briefly review the Weight Management Plan, specifically psychosocial
    distress, labs as necessary, and risk factors.

-   Monitor level of intervention based on patient and family response
    to weight management plan.

-   Advanced practice nurse/primary care physician will monitor vital
    signs including blood pressure, BMI, and labs.

-   Discuss compliance to diet, physical activity, and stages of change
    and results of self-esteem tool.

-   Implement motivation tactics and strategies based on child and
    family´s values and reward system.

-   Refer as necessary.

***Visit IV***

-   Advanced practice nurse/primary care physician will monitor vital
    signs including blood pressure, BMI, and labs.

-   Discuss obstacles, triggers, and roadblocks to success.

-   Assess stages of change.

-   Assess family\'s adherence to the Fit 4 Life Module, giving praise
    for even the smallest effort to a therapeutic lifestyle change.

-   Review Weight Management Plan including level of psychosocial
    distress.

-   Administer Patient Quality of Life Tool to patient and parent(s) to
    compare with baseline.

***Subsequent visits***

-   Repeat above efforts, modify plans according to outcomes.

-   Continue to monitor changes in comparison to baseline (BMI, blood
    pressure, quality of life, psychosocial distress, labs).

**[Definitions]{.underline}**

**Strength of Recommendations**

**Level I**: Usually indicated, always acceptable, and considered useful
and effective.

**Level IIa**: Acceptable, of uncertain efficacy, and may be
controversial. Weight of evidence in favor of usefulness/efficacy.

**Level IIb**: Acceptable, of uncertain efficacy, and may be
controversial. May be helpful, not likely to be harmful.

**Levels of Evidence**

**Grade A**: Randomized clinical trials\
**Grade B**: Well-designed clinical trials\
**Grade C**: Panel consensus

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for
screening and follow-up management of childhood obesity.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated. The guideline draws heavily from the Expert Committee
Recommendations for Obesity Evaluation and Treatment and the American
Heart Association Guidelines for Primary Prevention of Atherosclerotic
Cardiovascular Disease Beginning in Childhood.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Prompt and appropriate interventions for at-risk or overweight
    children

-   Prevention and/or treatment of hypertension (HTN), adult obesity,
    dyslipidemia, musculoskeletal problems, diabetes and psychosocial
    problems

-   Improved body image and confidence

-   Improved physical health

#### POTENTIAL HARMS

-   Over/under monitoring before initiating treatment

-   Body dysmorphia

-   Affective reaction

-   Disruption or challenging family dynamics

-   Cultural dissonance regarding body image

-   The inherent inconsistencies of office measurement may lead to
    non-adherence to treatment program and potential long-term negative
    psychological effects.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline is not intended to direct the treatment of patients
younger than 2 years of age, or children or adolescents who become
pregnant. Patients experiencing severe complications related to obesity
or those showing continued weight gain despite intervention should be
referred to a specialized obesity management program.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

University of Texas at Austin, School of Nursing, Family Nurse
Practitioner Program. Evaluation and treatment of childhood obesity.
Austin (TX): University of Texas at Austin, School of Nursing; 2004 May.
30 p.

#### ADAPTATION

The guideline draws heavily from the Expert Committee Recommendations
for Obesity Evaluation and Treatment and the American Heart Association
Guidelines for Primary Prevention of Atherosclerotic Cardiovascular
Disease Beginning in Childhood.

#### DATE RELEASED

2004 May

#### GUIDELINE DEVELOPER(S)

University of Texas at Austin School of Nursing, Family Nurse
Practitioner Program - Academic Institution

#### SOURCE(S) OF FUNDING

University of Texas at Austin, School of Nursing, Family Nurse
Practitioner Program

#### GUIDELINE COMMITTEE

Practice Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Diana M. Arteaga, RN, BSN, MSN; Vashti Jude Forbes, RNC, MSN;
Anna Regina Loomis-Jessup, RN, BSN, MSN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from the University of Texas at Austin, School
of Nursing. 1700 Red River, Austin, Texas, 78701-1499

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 26, 2004. The
information was verified by the guideline developer on November 12,
2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
subject to the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008