Screening and Evaluation

Evaluation and Treatment Guidelines

Any child between the ages of 2 and 19 with a BMI of >95th percentile for age can be referred to our program. Children who are overwwight with a BMI > 85th percentile for age can be referred if there are associated medical risks such as a strong family history of heart disease or diabetes. A child with dyslilidemia or hypertension or increased truncal obesity can be referred to our program with a lower BMI. If you would like to refer one of your patients to our program, please contact our offices at (718) 240-5857 or (718) 240-8125 or (718) 221-0333.

Screening by BMI

Screening consists of height and weight measurement and calculation of Body Mass Index (Wt/Ht2):

BMI Diagnosis Treatment Guidelines
BMI >95 percentile OVERWEIGHT In depth medical Assessment & treatment
BMI 85-95th percentile At Risk of Overweight Start dietary & activity intervention
BMI < 85th percentile Normal Continue preventive strategies

Preventive strategies

Monitor BMI at all visits

Medical Assessment

Medical History

  • Severe Headache
  • Blurring of Vision
  • Snoring During Sleep
  • Oligomenorrehea/amenorrehea
  • Hip or Knee Pain
  • Chest Pain, Exertional Dyspnea
  • Syncope

Family History (age < 55 years)

  • Diabetes
  • Obesity
  • Hypertension
  • Heart Attack
  • Stroke
  • Dyslipidemias

Dietary History

  • Intake of liquid calories, juice, soda, sweetened beverages
  • Examples of breakfast, lunch, dinner and snacks (daily eating habits and dietary details)

Activity History

  • Sedentary activity time, time for TV, computer/video games, homework
  • Physical activity, gym, outdoor activity, special activities

Examination

  • Height(cm), Weight(kg), BMI, B.P.(Average of 3 B.P.)
  • Waist circumference(cm)
  • Hip circumference(cm)
  • Cardiac examination
  • Fundus examination (if headaches)
  • Acanthosis nigricans
  • Hirsuitism
  • Enlarged tonsils, adenoids
  • General physical examination

Known Complications of Obesity

Acute Complications

  • Obstructive sleep apnea
  • Psuedotumor cereberi
  • Slipped Capital Femoral Epiphysis

Chronic Complications

  • Dyslipedemia: (look for age related values)
    • increased triglycerides
    • inecreased LDL
    • decreased HDL
  • Hyperinsulinemia >15miu/ml
  • Hypertension (systolic or diastolic BP>90th percentile for age)
  • Glucose intolerance or Type 2 diabetes
  • Poly Cystic Ovarian Syndrome
  • Metabolic Syndrome

The Metabolic Syndrome

3 or more of the following:

  • Fasting plasma glucose >100mg/dl
  • Hypertriglyceridemia: >90th percentile for age
  • Low HDL cholesterol
  • Hypertension: BP >90th percentile for age
  • Central adiposity: waist circumference >90th percentile for age sex and race

Management of Metabolic Syndrome

  • Low carbohydrate diet – Limit consumption of sweetened beverages
  • Glucose Intolerance or Type 2 – Consider OGT & Metform in therapy after consultation with obesity experts
  • Daily physical activity with target weight loss of 5-10 % in 6 months to 1 year period
  • Persistent lifestyle changes

Management

Anthropometric & Metabolic Assessment

  • BMI, BMI Z scores, waist & hip circumference, BP (average of 3 readings)
  • Fasting lipid profile, fasting glucose and insulin, LFT’s, CRP, HbA1C, Urine for microalbuminurea
  • PFTs if indicated or symptoms
  • Evaluation for sleep apnea if symptoms with lateral neck X-ray and sleep studies
  • Evaluation for pseudotumor cerebri if associated with headaches
  • Baseline EKG; Echo if morbidly obese, abnormal EKG or associated risk factors such as hypertension, strong (+) family history, symptoms, etc.

Identification of Complications

  • Treat urgent/care complication if any
  • Identify chronic complications
  • Assess for the presence of Metabolic Syndrome – 3 or more of the following risk factors:
    • Elevated BP>90th Percentile for age
    • TG>90th percentile for age
    • HDL< 40mg/dl
    • Waist circumference >90th percentile for age & race specific

Interventions

  • Start early interventions
  • Promote breast feeding
  • No fruit juice till 6 mths of age
  • Stop all sweetened bevarges
  • Based on new food pyramid and low glycemic index foods, limit starch to whole grain products, only 1 per meal
  • No white bread, ready to eat cereals, potatoes, cakes and cookies
  • Low fat milk products 2-4 servings/day
  • 3-5 servings of fruits and vegetables
  • Olive oil/canola oil and handful or nuts
  • Drink 6-8 glasses of water daily

Activity

  • Limit TV watching time to less than 2 hours per day
  • Prescription for regular physical activity at home – stationary bike, Jump rope, exercise video tape
  • Join a recreation center or gym

Behavior Therapy

  • Family involvement and understanding
  • Desire to make a change
  • Small permanent changes at a time
  • Continued reinforcement – not limited to few weeks

Weight Goals

BMI: 85th – 95th Percentile

  • Weight Maintenance
  • Change of lifestyle

BMI > 95th Percentile

No Complications
  • Weight Maintenance
  • Long term to achieve Weight loss
Complications
  • Weight Loss of half a pound per week

Prevention Strategies

  • Promote breast feeding
  • No fruit juice until 6 months of age
  • Not more than 1 cup of juice in daily diet
  • Avoid sweetened beverages at all times
  • Cut down refined starch, baked products, breads
  • Limit TV watching/computer games etc. to less than 2 hrs/daily
  • 1 hour of daily physical exercise or activity
  • Never use food as reward
  • Parental involvement, and to be role models
  • Offer only healthy options
  • Constant reinforcement of these behaviors at school and home

Lifestyle guidelines

  • Eat 3 meals a day, if desired 2 snacks & 6-8 glasses of water
  • Limit fruit juice to no more than 1 cup per day. Limit caffeine containing beverages
  • Eliminate sugar laden beverages
  • Limit starch to 1 serving per meal, limit starch that converts to sugar easily
  • Select 2-4 servings of fresh fruits a day, limit dried fruit
  • Select 3-5 servings of vegetables a day
  • Select lean sources of proteins, 2-3 servings per day.include more fish and tuna
  • Select skim or 1% low fat milk, 2-3 cups a day. Lite or non fat yogurt. Low fat hard cheese
  • Select olive or canola oil, eliminate saturated, hydrogenated or partially hydrogenated oils
  • Limit fast food to once a week, skip the fries, coke, shakes etc.
  • Do 1 hour of physical activity a day
  • Get a scale and check your weight once every other week

References

  • August, G. P., Caprio, S., Fennoy, I. L., Freemark, M. B., Kaufman, F. R., Lustig, R. H., et al. (2008). Prevention and treatment of pediatric obesity: an Endocrine Society clinical practice guideline based on expert opinion. J. Clin. Endocrinol. Metab., 93, 4576-4599.
  • Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report Barlow S E Pediatrics 2007; 120:S164-S192