Am Fam Physician. 2008 Jul 1;78(1):34-37.
Most primary care physicians know that the rates of childhood obesity in the United States have more than doubled in less than 30 years, with no signs of slowing down. The rates of comorbidities, such as type 2 diabetes, are also increasing.1,2 And yet, there is still a disconnect between this knowledge and delivery of care.3,4
The American Medical Association (AMA) Expert Committee recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity,5 summarized by Rao in this issue of American Family Physician,6 outline a comprehensive role for the primary care physician in managing childhood obesity. The recommendations were based on evidence in the literature and, when evidence was not available, they were based on expert opinion. Physicians should interpret the recommendations in the context of the resources available to them. In particular, screening laboratory tests are recommended in different clinical scenarios, but these tests should be weighed against the recommendations of the American Heart Association7 and the American Diabetes Association8 and whether the screening results will change the management plan for the patient.
The AMA recommendations expand the role of the physician, as previously detailed by Barlow and Dietz in 1998.9 Since the 1998 recommendations were released, multiple publications outlining nutrition and physical fitness guidelines have been written.7,8,10–12 Despite these guidelines, only 39 percent of pediatricians believe they could effectively manage obesity in their patients and, worse, only 12 percent of them report high self-efficacy in this skill set.13 To help boost their confidence in managing childhood obesity and, in turn, to assist in the interpretation and adoption of the AMA recommendations, physicians need access to educational programs, clinical tools, and weight-management and community-based physical activity programs.
Systematic improvements in integrating the promotion of good nutrition and clinical skills are warranted in the education of the primary care physician. Currently, there are opportunities for the already practicing physician to be taught strategies to prevent and manage childhood obesity, and to learn about reimbursement for these office visits.14–17 In addition, a companion guide to help implement the AMA recommendations is available.18 Although nutrition education has been added to the curricula of some residency programs, more comprehensive efforts are needed to consistently teach residents the clinical skills necessary to promote optimal nutrition and physical activity in their patients.19
Optimizing office management through the use of evidence-based tools is essential. Practices need to identify and employ the tools available to easily calculate body mass index (BMI), and to incorporate the Centers for Disease Control and Prevention growth charts that include BMI percentiles. In addition, physicians should have access to tools that support the AMA Expert Committee's tiered approach, assisting them in taking a routine nutrition and physical activity history, and prompting them to provide appropriate counseling focused on lifestyle interventions. The WAVE (weight, activity, variety, and excess) screener and the REAP (Rapid Eating and Activity Assessment for Patients) questionnaire are promising office-based tools.20,21 In this issue of AFP, Rao presents an interesting office-based assessment tool for obesity risk.6 In my practice, at the Venice Family Clinic Simms/Mann Health and Wellness Center in Santa Monica, Calif., we developed and are currently evaluating an innovative tool called the lifestyle log, which standardizes the evidence-based nutrition, physical activity, and inactivity questions and helps initiate counseling.22 Furthermore, the American Academy of Family Physicians has produced a tool called AIM to Change, which focuses on promoting physician-patient dialogue about nutrition and physical activity and creating a supportive office environment.23
Finally, effective evidence-based weight-management programs and models to connect patients to community-based physical activity programs are needed. In a recent meta-analysis of randomized controlled trials, childhood weight-management programs based on lifestyle interventions were determined to produce significant reduction in a child's weight status in the short term and promising changes in the long term.24 The issue of sustaining the weight loss in the long term is complex, however, and requires further study, although a recent report identified families and peers as important mediators in long-term success.25
Because obesity is an epidemic, the definition of community must be broadened to facilitate implementation of the AMA guidelines at all levels of society. The primary care physician is poised to make an impact on the childhood obesity epidemic. Hopefully, one way of doing this is by implementing the Expert Committee's recommendations for assessment of lifestyle habits, family history, physical examination, and consideration of laboratory testing. To practice these recommendations, there needs to be improved residency education, expanded opportunities for continuing education, incentive programs for high-performing practices, evidence-based clinical tools, and increased availability of effective weight-management and community-based physical activity programs. The ultimate solution to the childhood obesity epidemic requires a collaborative effort between the primary care physician and families, policy makers, educators, and community partners.
Address correspondence to Wendelin Slusser, MD, MS, at email@example.com. Reprints are not available from the author.
Author disclosure: Dr. Slusser has provided educational consultation, sits on an obesity advisory board, and has acted as a reviewer of published guidelines for Blue Cross of California/Wellpoint. She also wrote a continuing medical education course on pediatric obesity for and received support for her research on salad bars in schools from Blue Cross of California.
1. Levi J, Segal LM, Gadola E, for the Trust for America's Health. F as in fat: how obesity policies are failing in America. http://healthyamericans.org/reports/obesity2007/. Accessed March 21, 2008.
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3. O'Brien SH, Holubkov R, Reis EC. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):e154–e159.
4. Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 pt 2):210–214.
5. Appendix: Expert Committee recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity. January 25, 2007. http://www.ama-assn.org/ama1/pub/upload/mm/433/ped_obesity_recs.pdf. Accessed March 21, 2008.
6. Rao G. Childhood obesity: highlights of AMA Expert Committee recommendations. Am Fam Physician. 2008;78(1):56–63,65–66.
7. Hayman LL, Meininger JC, Daniels SR, et al., for the American Heart Association. Primary prevention of cardiovascular disease in nursing practice: focus on children and youth. A scientific statement from the American Heart Association Committee on Atherosclerosis, Hypertension, and Obesity in Youth of the Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116(3):344–357.
8. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):381–389.
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10. Daniels SR, Arnett DK, Eckel RH, et al. Overweight in children and adolescents: pathophysiology, consequences, prevention, and treatment. Circulation. 2005;111(15):1999–2012.
11. Krebs NF, Jacobson MS, for the American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112(2):424–430.
12. Gidding SS, Dennison BA, Birch LL, et al., for the American Heart Association. Dietary recommendations for children and adolescents: a guide for practitioners [published correction appears in Pediatrics. 2006;118(3):1323]. Pediatrics. 2006;117(2):544–559.
13. Perrin EM, Flower KB, Garrett J, Ammerman AS. Preventing and treating obesity: pediatricians' self-efficacy, barriers, resources, and advocacy. Ambul Pediatr. 2005;5(3):150–156.
14. Obesity and related co-morbidities coding fact sheet for primary care pediatricians. http://practice.aap.org/content.aspx?aid=1972. Accessed March 21, 2008.
15. Kaiser Permanente. Childhood obesity resources: what families can do together. http://members.kaiserpermanente.org/redirects/childhoodobesity/selectinfo.htm. Accessed March 21, 2008.
16. California Medical Association Foundation, WellPoint. Overweight and obesity in childhood continuing medical education program. http://www.eventstreams.com/wellpoint/010rde/default4.htm. Accessed March 21, 2008.
17. Centers for Disease Control and Prevention. Growth chart training. http://www.cdc.gov/nccdphp/dnpa/growthcharts/training. Accessed March 21, 2008.
18. National Initiative for Children's Healthcare Quality (NICHQ). An implementation guide from the Childhood Obesity Action Network. http://www.nichq.org/NR/rdonlyres/7CF2C1F3-4DA3-4A00-AE15-4E35967F3571/5316/COANImplementationGuide62607FINAL.pdf. Accessed March 21, 2008.
19. Goff SL, Holmboe ES, Curry L. Barriers to obesity training for pediatric residents: a qualitative exploration of residency director perspectives. Teach Learn Med. 2006;18(4):348–355.
20. Soroudi N, Wylie-Rosett J, Mogul D. Quick WAVE Screener: a tool to address weight, activity, variety, and excess. Diabetes Educ. 2004;30(4):616, 618–622, 626–628.
21. Gans KM, Risica PM, Wylie-Rosett J, et al. Development and evaluation of the nutrition component of the Rapid Eating and Activity Assessment for Patients (REAP): a new tool for primary care providers. J Nutr Educ Behav. 2006;38(5):286–292.
22. Venice Family Clinic Simms/Mann Health and Wellness Center: Lifestyle log. http://www.venicefamilyclinic.org/pdf/lifestyle_log_9_13_07.pdf. Accessed March 21, 2008.
23. American Academy of Family Physicians. AIM to Change Toolkit. https://secure.aafp.org/catalog/viewItem.do?itemId=2763. Accessed March 21, 2008.
24. Wilfley DE, Tibbs TL, Van Buren DJ, Reach KP, Walker MS, Epstein LH. Lifestyle interventions in the treatment of childhood overweight: a meta-analytic review of randomized controlled trials. Health Psychol. 2007;26(5):521–532.
25. Wilfley DE, Stein RI, Saelens BE, et al. Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. JAMA. 2007;298(14):1661–1673.
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