Primary care interventions for

overweight and obesity, and

related comorbidities, in the

pediatric population.BRIAN KNOX, MD

ASSOCIATE PROFESSOR

INTERNAL MEDICINE – PEDIATRICS

USF COM

Primary care interventions for

overweight and obesity, and

related comorbidities, in the

pediatric population.AUGUST 22, 2015

Disclosures

I have no disclosures to make

Objectives

Provide effective diet and physical activity counseling to pediatric patients who are overweight and obese.

Identify pediatric patients who would benefit from referral to a tertiary weight disorders clinic.

Provide first line lifestyle interventions for pediatric patients with common weight related comorbidities.

Identify pediatric patients with common weight related comorbidities who would benefit from additional intervention beyond lifestyle counseling.

Prevention

Strategies

All Children

Limit sugar-sweetened beverage consumption

Encourage adequate servings of fruits and

vegetables

No screen time prior to age 2

Less than 2 hours screen time after age 2

Eat breakfast daily

Encourage family meals

Encourage recommended portion sizes

Management

Strategies

Universal assessment of obesity risk and steps to prevention and treatment.

Sarah E. Barlow Pediatrics 2007;120:S164-S192

©2007 by American Academy of Pediatrics

Prevention Plus

What is it?

Office-based interventions setting specific goals for

families

More frequent visits

Mostly performed by scheduled counseling from a

medical provider

Prevention Plus

Specific Behavioral Targets:

Consume at least 5 fruits / vegetables per day

Eliminate sugar-sweetened beverages

<2 hours screen time

Physically active >= 1 hour per day

Breakfast every day

Involve the whole family

Prevention Plus

Implementation:

Stepwise, using realistic and attainable goals

Tailor frequency of visits to individual family

Motivational Interviewing skills recommended

Trial for 3-6 months, and if no improvement,

escalate to next step

Structured Weight

Management

Similar behavioral targets:

Planned meals (3 per day)

Planned Snacks (1-2 per day)

No sugar sweetened beverages

Supervised active play, 60 minutes +

Screen time reduced further to <1 hour

Tracking of behavioral goals

Planned reinforcement for achieved goals

Structured Weight

Management

Implementation:

Need dietician or clinician with additional nutritional

experience to structure meals and snacks

Psychologists / Counselors may be of benefit

Parenting skills

Motivation

Staff with motivational interviewing skills may be

used for follow up

Monthly visits recommended at this stage

Comprehensive Multi-

Disciplinary Weight

Management Team approach should include:

Medical provider (Physician / PA / ARNP)

Behavioral provider (social worker, psychologist,

etc)

Dietician

Exercise specialist

Frequent office visits

Tertiary Care

Failure of improvement in CMI should not

automatically trigger tertiary approach

These can be offered to severely obese adolescents who are carefully selected.

May utilize:

Medications

Very low calorie diet initiation under close

supervision

Bariatric surgery

Medications

Orlistat

Approved for ages 12 +

Phentermine

Approved for ages 16 +

Diethylpropion

Approved for ages 16+

Bariatric Surgery

Candidates should be:

Physically mature

Emotionally mature

BMI >40 with complications, or >50 without

More than 6 months of organized weight loss

attempts

Primary Care

Management

Using Motivational

Interviewing

Assess Patient’s Level of Concern and Attitudes

Concern about weight/nutrition/activity?

Readiness to change?

Past successes and challenges

Is Physician or Provider ready?

Need sufficient time for discussion

Open-minded, POSITIVE attitude

Using Motivational

Interviewing

Empathize/elicit

“Your weight for height, or BMI may put you at increased risk of early diabetes”

“Have you had any concerns about nutrition or weight changes?”

“Would you be interested in talking about ways to reduce risk?”

“Have you thought of or tried making any changes?

“How ready do you or your family feel to make changes?”

Using Motivational

Interviewing

Provide a menu of evidence-based interventions

“Some suggestions on how to reduce your risk are…”

“Are any of these something you and your family would like to work on? Other ideas?”

Elicit patient’s response to the advice provided:

What do you think of these ideas?

What might work for you?

What do you need to be successful?

What challenges do you see?

Using Motivational

Interviewing

Simple messages and plans of action are most

effective

Pick single achievable goal with patient at each visit

Encourage active participation by family

At minimum monthly follow-up on progress with goals

individualize to patient needs

Be Positive

Praise small successes at

EACH visit

Focus on achieving

goals set at each visit,

NOT on weight

Focus is on health

Resources……THAT I FIND HANDY

http://www.obesity.org/resources-

for/clinicians.htm

http://www.letsmove.gov

http://www.choosemyplate.gov

http://www.letsgo.org

https://healthychildren.org/english/health

y-living/pages/default.aspx

Thank You!

I’m happy to answer any questions…