Pediatricians face obstacles in treating adolescent obesity

April 2003

MIAMI BEACH, Fla. — Calling obesity the No. 1 health problem facing children and adolescents today, Vaughn I. Rickert, PsyD, encouraged pediatricians to recognize obesity and treat their patients despite significant obstacles.

“There are significant medical and psychological morbidities such as type 2 diabetes, depression, and emotional distress,” Rickert said here at the Miami Children’s Hospital’s 38th Annual Pediatric Postgraduate Course, “Perspectives in Pediatrics,” sponsored by Miami Children’s Hospital. “As with most diseases that face the public health in the national community, there are significant racial/ethnic disparities related to the co-morbidity of obesity.”

Rickert, president-elect of the Society of Adolescent Medicine and director for research and evaluation for the Center for Community Health and Education at the Mailman School of Public Health, Columbia University, New York, cited the National Health Assessment for Nutrition and Education Survey, which calculates that 22% to 23% of children and adolescents are overweight and 10.5% of children and adolescents are obese.

Pediatricians who treat obesity face considerable barriers including motivating the patient and involving the parents, insufficient support services and inadequate reimbursement for providing a diagnosis and managing the disorder. In addition, there is a lack of research and data on effective treatment approaches for adolescents.

Approaching the diagnosis

While Rickert encourages pediatricians to diagnose and treat obesity, at the same time he cautions them to be “honest and realistic.”

“It’s very, very important for pediatricians to provide a diagnosis early and then to develop a plan of action. Unfortunately, this is not going to be the same kind of plan of action as when someone presents for otitis media or for an acute disease,” Rickert explained.

Measuring the body mass index (BMI=weight [kg]/height [m]²) of the child or adolescent is an easy way to screen patients for obesity. Charts that depict BMI for age percentile for boys and girls 2 to 20 years of age are available from the CDC and can help physicians quickly assess their patients’ status.

The child or adolescent is overweight if his or her BMI is 85th percentile. Obesity is defined as BMI >95th percentile. If the child is found to be at risk of being overweight, Rickert recommends a second-level screen. For children at risk of being overweight, the second-level screen includes family history, blood pressure, total cholesterol, whether there has been a large change in BMI during the patient’s lifespan, as well as whether the child is concerned about his or her weight. If the results of these tests are positive, Rickert encourages physicians to conduct an in-depth medical assessment. If most of the factors are negative, then a note on the chart is usually adequate and therapeutic action is not usually required.

If the child or adolescent is found to be overweight, an in-depth medical assessment is required. Rickert recommends that the medical evaluation include the patient’s history, a physical exam and further evaluation for insulin insensitivity and polycystic ovarian syndrome as per CDC guidelines. Few patients may require genetic testing, karotyping or metabolic testing is a syndrome is suspected.

Two common conditions associated with obesity are type-2 diabetes and ovarian hyperandrogenism/polycystic ovarian syndrome. Rickert noted that type-2 diabetes is increasingly prevalent among the obese. “One in four children and one in five adolescents who are overweight or obese have type-2 diabetes,” he said. “It’s heavily concentrated among the urban population and ethnic minorities such as African-American and Native-American youth.”

The key feature in diagnosing diabetes is insulin resistance, Rickert said. Although metformin (Glucophage, Glucovance, Bristol-Myers Squibb) has been used to treat children and adolescents, the drug is not indicated for children younger than 16 years.

Ovarian hyperandrogenism may present with hirsutism and can be seen in both slim and obese patients. Low-dose androgen oral contraceptives and antiandrogen (spironolactone) are the treatments of choice, Rickert said.

Treating obesity

The physician who wishes to treat a child or adolescent for obesity must first assess how ready both the family and the patient are to make changes. Helpful questions to ask: What is the diet history? What are the eating habits? Do they skip meals? Do they eat at fast food restaurants?

In addition to assessing their current intake, it’s important to look at their physical activity history. “Look at the levels at which they are involved in any kind of activities, gym class, sports clubs and the like, as well as what they do in their daily lives,” Rickert said.

He advises making gradual changes that can facilitate lifestyle changes. “This is not an easy condition to manage,” he said. “It didn’t just happen, and it’s not going to get better quickly.”

Although the debate between high fat and low fat and high carbohydrate and low carbohydrate diets has not been resolved, he does believes that substituting for higher fat and highly refined sugar foods does have important benefits.

“Teach teenagers to read labels and look at what they are drinking and eating. Teach them how to eat out, to not binge eat and to downsize. Pay attention particularly to the fluid intake of your teenagers because they do drink a lot of soft drinks. There are substitutes,” he said.

In evaluating physical activity, Rickert finds it can be helpful to assess their ability to walk a mile a day. Rather than setting up a distance marker, he advises patients to start by substituting higher energy consumption activities for lower energy consumption activities such as simply walking downstairs instead of taking the elevator or escalator. “Rather than watching television for two hours I will ask, ‘Can you watch television for just two shows and then get out for a few minutes?’”

Intervention needs to begin early, he said, and when the family is involved success is more likely. That includes educating the families about the medical as well as psychological complications and co-morbidities of obesity.

“Treatment programs should institute permanent changes, not short-term diet or exercise programs aimed at rapid weight loss. Treatment should also help families and mothers and fathers to monitor their own eating and activity as well as that of their children,” Rickert said.

“Encourage and emphasize, don’t criticize,” he advised. “Expect relapses, but you can move forward.”

Weight management goals

For overweight or obese children, growing into one’s weight may be a useful weight management strategy, according to Rickert. For example, for a child younger than 7 years whose BMI is 95th percentile, prolonged weight maintenance is the ideal goal. However, children younger than 7 years with BMI 95th percentile would benefit from weight loss.

For children older than 7 years with no medical complications, prolonged weight maintenance is appropriate if the BMI is between the 85th and 95th percentiles. When BMI is between the 85th and 95th percentiles and there is a nonacute secondary complication, weight loss has been recommended. If the BMI is >95th percentile, weight loss is recommended.

“The primary goal of any weight program to manage uncomplicated obesity is healthy eating and activity, not achievement of an ideal body weight,” Rickert said. “This is something that needs to be stipulated to your parents. If they’re coming to you for just simply weight loss, you’ve got to reframe the goal of your treatment for this child to healthy eating and activity.”

Behavioral goals

Behavioral goals include developing an awareness of current eating habits, activity and parenting behaviors. Rickert suggests identifying problem behaviors such as specific high calorie foods, eating patterns and obstacles to activity.

“Look at particular problem behaviors, don’t tackle everything at once,” he said. “Modify current behaviors in a few small incremental changes one at a time and have a continual vigilance about problems that arise as the teen becomes more independent, their schedule changes or as demands on the family occur.”

“The improvement or resolution of the complication is an important medical goal that can contribute and reinforce behavioral and psychological changes. As the child or adolescent makes very small changes it can have a rather profound effect both in terms of motivation and in terms of his life and how he approaches his fears,” Rickert continued.

Skills for a lifetime

For a weight management program to be successful, Rickert stressed the need to address both diet and physical activity. “Regardless of type, diets offer a structure that is helpful to some adolescents, although not all,” he said.

According to Rickert, protein-sparing modified fast diets are reasonably safe when carried out under supervision. But while they offer significant weight loss in the short term, they have been found to provide no significant improvement in the long term.

Instead, he recommends the Stoplight Diet, in which the physician identifies “red light foods” that the patient cannot eat, “yellow light foods” that can be eaten in moderation and “green light foods” that can be eaten in unlimited quantities.

“While this may seem simplistic to the 18-year-old if they are sophisticated or even the 14-year-old who eschews this kind of approach, it is very helpful,” Rickert said.

“Essentially, what you want to do is try to teach a patient to obtain skills for a lifetime of weight management,” Rickert said.

For Your Information:

• Rickert VI. Adolescents and obesity. Presented at Miami Children’s Hospital’s 38th Annual Pediatric Postgraduate Course, “Perspectives in Pediatrics.” Jan. 24-30, 2003. Miami Beach, Fla.
• Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert committee recommendations. Pediatrics. 1998;102:e29. www.pediatrics.org/cgi/content/full/102/3/e29.
• Barlow SE, Dietz WH. Management of child and adolescent obesity: summary and recommendations based on reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics. 2002;110:236-238.
• Editorial. Dietary fat is a major player in obesity – but not the only one. Obesity Review. 2002;3:57-58.
• Harvey EL, Glenny AM, Kirk SFL, et al. An updated systematic review of interventions to improve health professionals’ management of obesity. Obesity Review. 2002;3:45-55.
• Jonides L, Buschbacher V, Barlow SE. Management of child and adolescent obesity: Psychological, emotional, and behavioral assessment. Pediatrics. 2002;110:215-221.