Initially, physicians are the best source for the diagnosis of pediatric obesity, according to the U.S.
Surgeon General. Doctors and other health care professionals are the best source in determining
whether a child or adolescent’s weight is healthy, and they can help rule out rare medical problems
as the cause of unhealthy weight. A body mass index (BMI) can be calculated from measurements
of height and weight. Health professionals often use a BMI “growth chart” to help them assess
whether a child or adolescent is overweight. A physician will also consider a child or adolescent’s
age and growth patterns to determine whether his or her weight is healthy. Only providers trained
in pediatric medicine possess the level of expertise required to provide an accurate assessment of
pediatric obesity. Regardless, studies indicate that pediatric health care providers diagnosed overweight
in only one half (53%) of overweight children [17]. We found similar poor rates of diagnosis
and referral in a study of Louisiana youth seen in three separate physician’s offices [18]. Physicians
diagnosed obesity in very few of their patients who were classified as greater than 95th percentile
BMI (Table 4.1).
Physicians also provide guidance to parents so that they may best understand the definition of
overweight or at risk for overweight in children. The physicians can then, with the parents’ input,
decide on the best plan of action for the overweight child. Recent studies indicate that at this point,
about 75% of physicians will refer patients initially to registered dieticians [14], and only about
20% of patients will be referred to weight management programs. In another study, in those children
diagnosed as overweight by their physicians, comprehensive treatment programs were not generally
prescribed [17]. In our study, we observed similar low referral rates [18] (Table 4.1). Of more
concern is that between 27% and 42% of pediatricians or pediatric health providers report that
weight management programs are not available in their area [14].
Several clinical observations [19–26] have detailed an interdisciplinary pediatric weight management
intervention in which the physician or pediatric health care provider has an integral role
in treatment. He or she is responsible for the overall medical supervision of the program and
oversees the diagnosis, evaluation, and dietary and physical activity plan of action. In this chapter,
step-by-step details are provided of the medical oversight provided in this approach. Further details
may be found in Chapter 2 by Sothern, Chapter 12 by Schumacher et al., Chapter 14 by Sothern,
Chapter 19 by Carlisle and Gordon, and Chapter 20 by von Almen and Sothern, and in Appendices
A1, A2, and A3.
PERFORMING THE INITIAL MEDICAL EVALUATION (TABLE 4.2)
An initial medical history and a physical examination are performed before enrollment into the
treatment program. This medical information is reviewed with the parents and child before entry
into the program. Assessment and discussion of the child’s growth chart and current weight status
occurs at this time. To determine the child’s goal weight, the physician observes on the BMI growth
chart what weight would match the child’s height percentile (Appendix A1.10). This is the child’s
ideal body weight. The child’s goal weight is this weight plus an additional 20%.
ORDERING AND INTERPRETING LABORATORY BLOOD WORK (TABLE 4.2)
The pediatrician orders an initial battery of blood work that includes a complete blood count, metabolic
panel, and lipid profile (Appendix A2.2). These laboratory tests are repeated 3 months into the program
and at the end of the program. Other tests may be ordered after the initial medical evaluation as needed.
PRESCRIBING AN APPROPRIATE DIET IN COORDINATION WITH THE PROGRAM DIETICIAN
The diet will be for either weight loss or weight maintenance. The child’s medical history, family
health history, age, gender, and current weight status will be considered before prescribing an
appropriate diet. In children at risk for overweight, moderate approaches are best. However, in
children with clinically significant overweight conditions (BMI > 99th percentile), more aggressive
approaches may be necessary. Although the research is limited with respect to such approaches,
several clinical observations and a few randomized controlled trials indicate that the use of very
low calorie diets, low-carbohydrate diets, and low-glycemic diets may result in short-term weight
loss in very overweight youth. In Chapter 11, Sothern and others survey the literature and provide
specific guidelines for low glycemic diets. Sample diets are located in Appendix 3.
PROVIDE ONGOING MEDICAL SUPERVISION (TABLE 4.3)
In group interventions, the pediatrician may choose to attend most of the intervention sessions,
especially during the first 3 months of the program. He may elect to weigh the children and check
vital signs while discussing their progress and answering questions. This helps to ensure medical
safety throughout the course of the program. Whether the physician attends the sessions routinely
or not, he or she should be available by phone to address questions or problems that arise between
weekly sessions. In overweight and normal-weight children with parental obesity frequent monitoring,
reduced television viewing, and increased opportunities for unstructured active play are
typically recommended by the physician (Table 4.4).
FOLLOW-UP (TABLE 4.5)
At the beginning of treatment for pediatric obesity, and every 3 months afterward, patients undergo
a comprehensive evaluation. The results of the evaluations are distributed to the children and parents
and are discussed with the family as necessary. In some cases, the physician may choose to refer
the family to a staff psychologist, if available, or other appropriate mental health professional. A
registered dietician or exercise professional should also be available to assist with interpretation
and to answer questions as well. These evaluations consist of the following 10 items. Appendix 2
contains detailed measurement protocols.
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