Evaluation and Management of Childhood and Teen Obesity

Why should we treat childhood and adolescent obesity?

The notion that obese children and adolescents will “grow out of it” is waning. About 50% of obese school-age children and 75 % of obese teenagers go on to become obese adults. In adulthood, obesity is a chronic disease with health consequences that account for almost as many deaths as smoking. Obesity is responsible for the explosion of Type 2 diabetes, which is now seen in children and adolescents at an average age of 13. Children and adolescents need the resources and support to deal with their weight before it becomes a life-long problem.

What should I do if my child has a weight problem?

If you are a parent and believe that your child has a weight problem, first make an appointment with your primary care doctor. Your doctor will follow the steps below, to evaluate and address the problem with you and your child.

Step 1: Evaluate the problem

The current tool for clinical assessment of obesity is the Body Mass index (BMI). Calculate BMI by dividing weight in kilograms by height in meters squared (kg/m²) and plot it on a BMI curve.

• Children who fall over the 95^th percentile are overweight or obese. Those who are not done growing may not have to lose weight, they might be better off maintaining their weight so that they can indeed “grow into it”. Weight loss is appropriate for those who have already gone through puberty and are at their tallest. Those who fall between the 85^th and 95^th percentile are considered at risk and should be treated depending upon cardiovascular risk.
• The most recent CDC growth charts include BMI curves for boys and girls ages 2 to 20 years and can be found at: http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/charts.htm

Step 2: Address the problem

Try not to place blame or guilt on children and teenagers by saying “you’re too heavy.” Negative comments are not helpful and may make the problem worse. Focus on health (eating and activity habits, see below), not weight. It is crucial to begin by asking “how do you feel about your weight or body size?” Let the child or teenager provide a self-evaluation. Most obese teens have already struggled with their weight and attempted to diet in the past.

Step 3: Gather the pertinent information

A nutritionist or doctor will do a quick 24-hour food recall with you and your child. This is a way to gather information about meal patterns, sugared-beverages, and snacking. Teenagers can answer the question, “tell me everything you ate since yesterday.” Children and young adolescents need pointed questions, such as “what do you usually have to eat when you come home from school?” Finally, physical activity level should be assessed. Most children and parents only count sports and physical education class as “exercise.” However, time spent playing with friends, walking to school and dancing to music counts as exercise. On the other hand, sedentary time spent watching television and playing computer games promotes weight gain.

Step 4: Contract for change

First, the doctor will make suggestions based on the information gathered. Allow the child to choose which suggestions to take and agree on three positive changes to make. For example, stop drinking soda and juice, or walk for 15 minutes three times per week. Second, set goals that do not focus on weight. An example of a concrete, short-term goal is to “pack a healthy lunch for school three times per week” (not “getting down to 145 pounds”). Third, identify barriers by asking, “what could get in your way of your effort get healthier?” Use the answer to problem-solve. Fourth, motivate by helping to establish a non-food reward system. Buying a new pair of jeans is a good example. Finally, encourage self-monitoring: keeping a notebook with a food and activity record. This is a valuable tool for everyone.

Step 5: Do your homework

Any treatment decisions that you make with your teenager or child’s doctor have to be supported at home. It’s impossible for children to control their weight without family support. Set a good example by doing healthy activities and eating healthy foods yourself. Even if your weight is fine and other kids in the family are fine too, everyone has to make the same healthy changes together. Singling out the one kid in the family because they are heavy has been shown to fail. Here are the top 6 strategies that you can start with:

1. Cut out all sugared drinks: this includes soda, lemonade, sports drinks, juice (even all natural juice) horchata and liquidos.

   Why? Did you know that one cup of juice per day adds up to 15 pounds of fat per year? One bottle of soda (22 ounce) adds up to 25 pounds per year.

   Tips: Instead, drink water and low fat milk. Get a water filter pitcher for your refrigerator so that water is nice and cold. Buy zero-calorie sparking or flavored water. Eat a piece of fruit instead of drinking juice. If you absolutely must have a sweet drink, choose one that is diet or sugar-free.

2. Eat more vegetable: at lunch and dinner, half of your plate should be made up of vegetables.

   Why? Vegetables are packed with vitamins, minerals and fiber. They are super-nutritious, taste great, and make you feel full. All for very few calories.

   Tips: Keep veggies cut up and ready to go in a container in the fridge, to make them just as easy as opening a bag of chips. Serve salad at meals. Don’t worry about the dressing, it’s Ok to serve regular dressing as long as it’s made with olive or canola oil.

3. Switch to whole grains: get away from white bread, white pasta, white rice, potatoes and refined snacks like pretzels, crackers and cookies.

   Why? White or refined flour contains no fiber. Therefore, the carbohydrate is quickly absorbed into your bloodstream as sugar. The result is that you feel hungrier sooner and are more likely to store these calories as fat.

   Tips:Check labels for “dietary fiber”. A good while grain bread will have 3 grams of dietary fiber per serving; a good cereal will have 5 grams.

4. Decrease fast food, try to limit it to no more than once a week.

   Why? Studies in young adults have identified eating fast food as a risk factor for obesity. It’s probably because fast food is so high in fat, sugar and calories.

   Tips: Carry a cooler in the car with ready to go snacks, like string cheese, apple slices, peanut butter on celery, and yogurt with strawberries. If these are on-hand for carpooling and trips to and from school, you’ll be less likely to go through the drive through. If teenagers are going to fast food with their friends, counsel them on how to make healthier choices. This is called damage control. The top two healthy choices are: 1.) no soda, and 2.) smaller portions (for example, regular burger and small fries instead of Quarter Pounder with large fries).

5. Join a team or exercise as a family

   Why? Children and adolescents are more likely to stick with group activities that are fun. Unlike adults, they are not willing to commit to exercise just for the benefits to their health or appearance. Many kids have a treadmill or stationary bike in the basement that they do not use. Enlist community resources and encourage your child to get involved. Organizations, teams, sports, and clubs provide opportunities to increase physical activity, self-esteem, peer involvement and acceptance, and decrease opportunities to eat out of boredom and anxiety.

   Tips: Take an evening walk with the dog or plan a family hike on the weekends. Encourage your child or adolescent to join a team or any activity that is led by an adult. This does not have to be a competitive sport, it could be a dance class at the local YMCA.

6. Decrease screen time

   Why? Studies show that watching less TV decreases weight gain in young people. This is probably because kids are more active when they don’t have TV, video games and computer access. Also, we know that children and adolescents are more likely to snack on junk food when sitting in front of the screen.

   Tips: Get the TV out of the bedroom. Set limits on TV and electronics. Get a monitor that connects to the electrical cord and shuts off the screen when time is up.

Step 6: follow-up with your doctor

Follow-up with your doctor in 2 to 4 weeks to reinforce positive changes, address new barriers and revise the former contract as needed. The doctor may send you to a nutritionist for in-depth nutrition counseling, advice on cooking, shopping, and eating out.

Shapedown is an excellent lifestyle modification program for children and families: Phone (650) 858-1167 http://www.shapedown.com/(self-pay)

Weight Watchers might be appropriate for older adolescents with a parent or adult relative: Phone 1-800-651-6000 http://www.weightwatchers.com/(self-pay)

The WATCH clinic at the University of California San Francisco

If your doctor thinks that your child’s weight is a problem, s/he can refer your child to UCSF pediatric obesity program, WATCH (Weight Assessment for Teen and Child Health). WATCH is a team of care providers from several disciplines, including, pediatrics, adolescent medicine, nutrition, psychology, endocrinology, surgery, orthopedics, and pulmonary. After you have seen your primary care doctor to get a referral, you can make an appointment by calling: 415-353-2813. Please note that appointments can only be made if the clinic has received the referral papers from your doctor.