New Expert Recommendations for Prevention and

Treatment of Childhood Obesity in Primary Care

Policy Paper #2 • 2008 Planting the seeds for better health

SUMMARY epidemic has worsened and in 2005, About Nemours Health and
the American Medical Association, in Prevention Services
This issue brief describes recommend- collaboration with the U.S. Department
ations on prevention, evaluation, of Human Services’ Health Resources Nemours Health and Prevention
and treatment of childhood obesity Services Administration and the Services (NHPS) is a division of
recently released by a national Expert Centers for Disease Control, convened Nemours, one of the nation’s
Committee made up of representatives an Expert Committee to produce largest pediatric health systems,
from fifteen professional organizations. updated recommendations. The
operating the Alfred I. duPont
It also outlines action steps for Delaware Hospital for Children and
Committee members were drawn from
stakeholders in pediatric health. outpatient facilities throughout
15 professional organizations with
the Delaware Valley and northern
expertise in obesity-related conditions and central Florida. The Nemours
Introduction and included physicians, dietitians and A.I. duPont Hospital for Children
Childhood obesity is one of the most epidemiologists.9 treats children of all ages suffering
serious public health crises facing the This Committee established from mild to severe obesity
nation. Over the last 40 years childhood recommendations for all aspects of through multi-disciplinary and
obesity has more than quadrupled in the child and adolescent obesity care based family based methods.
6–11 year-old population, rising from 4 on scientific evidence and clinical The goal of NHPS is to drive
to 19 percent, and more than tripled in experience. Because the evidence base long-term improvements in policies
the 12–19 year-old population, from 5 to for prevention and treatment of obesity and practices that promote child
17 percent. Nearly one third of children is still emerging, some recommendations health, and to leverage community
aged 6 through 19 years are overweight represent a consensus based on the best strengths and resources to help
or obese.4 The health and economic available information.3 children grow up healthy. One
consequences of obesity could be of our initial areas of emphasis
unprecedented if the epidemic continues. Recommendations on Prevention is the prevention of childhood
obesity through promotion of
The childhood overweight and obesity The Expert Committee recommends healthy lifestyles, the centerpiece
epidemic will increase the prevalence universal prevention, universal screening, of which is the 5-2-1-Almost None
of associated conditions, such as heart and early intervention for childhood prescription for a healthy lifestyle
disease and type-2 diabetes, and further overweight and obesity. All children, (see inside for details).
contribute to the rising cost of health starting at birth (and prenatally), should
care. Eighty percent of obese adolescents be targeted for obesity prevention efforts
will remain obese throughout adulthood, by health care providers. Pediatric
resulting in an increased risk for diseases providers are trusted resources for
including cardiovascular disease and families and can provide information
diabetes.5 Obesity’s rising prevalence and support so that children develop
is responsible for an almost 30 percent healthy habits that will lead to a healthy
increase in medical expenditures weight.
nationally.6 At least $207 million is
spent each year to treat obesity-related The Expert Committee recommends
medical problems in Delaware.7 that clinicians provide anticipatory
guidance to all families on adopting and
maintaining specific target behaviors,
Expert Committee Recommendations
including:
The first national recommendations
• Encouraging diets with US Department
on the evaluation and treatment of
of Agriculture (USDA) recommended
childhood obesity were published
quantities of fruits and vegetables;
in 1998.8 Since then, the obesity

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Nemours Health & Prevention Services page 1

 New Expert Recommend
Treatment of Childhood
(continued from page 1)

Our Formula for a • Limiting television and other screen “obese” (>/=95th percentile for age and
Healthy Lifestyle: time according to American Academy gender).
of Pediatrics Guidelines;10
5–2–1–Almost None No child wants to be called obese.
NHPS is taking a leading role to
• Promoting moderate to vigorous Yet it is essential that pediatric providers
help people understand the causes physical activity for at least 60 minutes discuss a child’s weight status given
and health implications of obesity a day;11 and that research indicates that parents
and the best ways to promote of overweight and obese children are
• Limiting consumption of sugar
healthier lifestyles among children often unaware of their child’s weight
sweetened beverages.
and families. status.12 Providers need to maintain a
This guidance is consistent with non-judgmental attitude and can refer
5-2-1-Almost Nemours’ 5-2-1-Almost None formula to the full recommendations for advice
None is our for a healthy lifestyle (see left panel). on sensitive ways of discussing weight
formula for a
In addition, the Committee also management issues with families.3
healthy lifestyle.
recommends:
The Committee recommends assessing
• Eat five or more servings of fruits
and vegetables per day.
• Eating breakfast daily; all pediatric patients’ physical activity
levels and sedentary behaviors at each
• Spend no more than two hours • Limiting eating out at restaurants,
well-child visit at a minimum. The
per day in front of a screen especially fast-food;
assessment should include self-efficacy
(TV, video games, recreational • Encouraging family meals; and and readiness to change, environment
computer time).
• Limiting portion sizes according to and social support, and barriers to
• Get at least one hour of physical activity.
physical activity per day.
USDA recommendations.
Because it is difficult to change behavior, Other criteria involve whether the child
• Drink almost no sugary is meeting daily recommendations of 60
beverages like soda and the Expert Committee encourages
physicians and other health care minutes of at least moderate physical
sports drinks.
professionals to take a comprehensive activity and a comparison of the child’s
For more information about
approach, by functioning as counselors screen time to a standard of less than
our work to make Delaware’s
and using motivational interviewing two hours per day. Screen time includes
Children the Healthiest in watching television, playing video games,
techniques; documenting BMI on
the Nation, visit: and using the computer.
a routine basis; and establishing
www.growuphealthy.org
procedures to deliver obesity prevention Providers should also assess all pediatric
messages to all children. patients’ dietary patterns at each well-
child visit, at a minimum. The assessment
Recommendations on Assessment should include excessive consumption of
sweetened beverages, frequency of eating
The Expert Committee recommends
outside the home at restaurants or fast
plotting weight, height, and Body Mass
food establishments, and consumption of
Index (BMI) on the appropriate growth
excessive portion sizes.
chart to obtain percentiles for the child’s
age and gender at least once a year.
The Committee also reclassified BMI Recommendations on Treatment
percentile categories. Those previously Treating childhood overweight and
considered “at-risk for overweight” obesity can help reduce future risk of
are now categorized as “overweight” chronic disease. Interventions at the early
(85th up to 95th percentile for age and stages of disease and with young children
By Pat Redmond, Judith Feinson gender) and those previously considered are more sustainable than interventions
and Grace Anglin, Nemours Health “overweight” are now categorized as at more advanced stages.
and Prevention Services

page 2 Nemours Health & Prevention Services

 ations for Prevention and
d Obesity in Primary Care
The Expert Committee recommends The Delaware Primary
a four stage approach to customize RECOMMENDED ACTION STEPS Care Initiative on Childhood
weight management for individual
children. Current BMI, past attempts at
weight loss, motivation, and maturity
1 Key Delaware stakeholder
organizations should endorse the
recommendations by signing the
Overweight
Led by NHPS, the initiative seeks
are used to determine the appropriate to equip health care providers with
Delaware Obesity Prevention and knowledge and skills to implement
intervention. Each stage builds upon the
Treatment Commitment document. the new recommendations with
previous one.

2 The Expert Committee all patients. The aim is to better

The following is the staged approach prevent, identify and manage
recommendations should be widely
for children between the ages of 2 and childhood overweight and promote
circulated among professionals and
19 years whose BMI is at or above the healthy eating and physical activity.
shared, as appropriate, with parents
85th percentile and is consistent with the
and the media. The long-term goal of the initiative
NHPS 5-2-1-Almost None formula for a

3
is to contribute to a statewide
healthy lifestyle. Delaware pediatric providers should
effort aimed at reducing the
adapt their clinical practice to the
Stage 1. Prevention Plus protocol: prevalence of overweight among
new recommendations.
Delaware children.
At this stage, a primary care physician
or allied healthcare provider with some
training in pediatric weight management
4 Quality improvement opportunities
and/or training on the new
recommendations should be made
For more information, visit:
www.growuphealthy.org
and behavioral counseling should work
available to Delaware practitioners.
with the family and child. Dietary and Changes to HEDIS 2009
physical activity recommendations Health care providers should
include: note that there is now a greater
highly trained in weight management, emphasis on measuring quality
• Five or more servings of fruits and
as well as a dietitian, a counselor, or a of care by focusing on obesity
vegetables per day;
physical therapist can implement Stage 2 prevention and treatment. The
• No more than two hours of screen recommendations; which include: National Committee for Quality
time per day, and no television in the Assurance has added two new
• I ncreased structured daily meals and
child’s bedroom; measures focused on obesity to the
snacks;
Healthcare Effectiveness and Data
• One hour or more of daily physical
• S upervised active play of at least one Information Set (HEDIS).
activity; and
hour per day;
The HEDIS is the most widely used
• Restriction of sugar-sweetened
• Screen time of one hour or less per day; performance measurement system
beverages.
in health care. The new measures
• I ncreased monitoring (e.g, logs for
The goal should be weight maintenance will assess how consistently
screen time, physical activity, dietary physicians perform BMI
with growth that results in a decreasing
intake) by provider, patient and family. measurements among adults and
BMI as age increases. If no improvement
is noted after 3 to 6 months, the provider The goal should be weight maintenance children and will also, for children,
should assess patient/family readiness to with growth that results in decreasing track physician counseling for
change and may advance the patient to BMI as age increases. If no improvement nutrition and physical activity. The
Stage 2. is noted after 3 to 6 months, the patient final measures were released in
2008; data for the new measures
should be advanced to Stage 3.
Stage 2. Structured Weight will be collected in 2009 and made
Management protocol: Stage 3. Comprehensive publicly available in 2010.13
Multidisciplinary protocol:
At this stage, a multidisciplinary
team that may include a primary care At this stage, the patient should
physician or allied health care provider optimally be referred to a
(continued on page 4)

Planting the seeds for better health page 3

 (continued from page 3)

multidisciplinary obesity care Implementation of Recommendations

team. Dietary and physical activity
recommendations include: The full report by the Expert Committee
provides a detailed description of the
252 Chapman Road, • Implementing a structured behavioral goals and methods used in childhood
Christiana Building Suite 200 modification program, including obesity prevention, assessment and
food and activity monitoring and treatment. Additional tools, including
Newark, Delaware 19702 development of short-term diet and the Primary Care Provider Toolkit
302.444.9100 • 888.494.5252 physical activity goals; and produced by NHPS, are available
• Involving primary caregivers/families to assist with incorporating the
email: [email protected] recommendations into clinical practice.
in behavioral modification for children
www.growuphealthy.org under age 12 and training for all The full report is available at http://
primary caregivers/families. pediatrics.aappublications.org/cgi/
The goal should be weight maintenance reprint/120/Supplement_4/S164
or gradual weight loss until BMI is less The Toolkit is available at www.
than 85th percentile. Weight loss should nemours.org/department/nhps/
not exceed 1 lb. per month in children five-two-one/pcp.html
aged 2-5 years or 2 lbs. per week in older
obese children and adolescents.14

Notes
1. Institute of Medicine. (2005). Committee on Prevention of Obesity in Children and Youth. Preventing Childhood Obesity: Health in
the Balance. Washington, D.C.: National Academies Press.
2. Epstein LH, Wing RR, Penner BC, Kress MJ. (1985). Effect of diet and controlled exercise on weight loss in obese children. Journal of
Pediatrics, 107: 358-361.
3. Barlow SE & the Expert Committee. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment
of child and adolescent overweight and obesity: Summary report. Pediatrics, 120, S164-S194.
4. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CH, Flegal KM. Prevalence of overweight and obesity in the United
States, 1999-2004. Journal of the American Medical Association, 295: 1549-1555. At the time these data were published, the old
classification for overweight was still used—individuals with a BMI equal to or greater than 85% and less than 95% were classified as
“at risk for overweight” and individuals with a BMI equal to or greater than 95% were classified as “overweight.” Based on the 2007
Expert Committee Recommendations, the authors described the previous category of “at risk of overweight” as “overweight” and
those previously referred to as “overweight” are described as “obese.”
5. Guo SS, Wu W, Chumlea WC, Roche AF. (2002). Predicting overweight and obesity in adulthood from body mass index values in
childhood and adolescence. American Journal of Clinical Nutrition, 76: 653-658.
6. Thorpe KE, Florence CS, Howard DH, Joski P. (2004). The impact of obesity on rising medical spending. Health Affairs, 4:
W480-W484.
7. Finkelstein EA, Fiebelkorn IA, Wang G. (2004). State-level estimates of annual medical expenditures attributable to obesity. Obesity
Research, 12: 18-24.
8. The Department of Health and Human Services Health Resources and Service Administration convened an expert committee in 1997
tasked with developing recommendations on the assessment and treatment of childhood obesity.
9. Expert committee members were selected to represent the views of diverse cultural groups.
10. The American Academy of Pediatrics recommends no television watching for children under the age of two and no more than two
hours of television watching for children older than two.
11. The Expert Committee recommends other healthy behaviors including eating a diet rich in calcium, high in fiber, with limited energy-
dense foods and balanced micronutrients. The Expert Committee also recommends exclusive breastfeeding to 6 months of age and
continued breastfeeding until 12 months of age.
12. Rhee KE, De Lago CW, Arscott-Mills T, Mehta SD, Davis RK. (2005). Factors associated with parental readiness to make changes for
overweight children. Pediatrics, 116, e94-e101.
13. National Committee for Quality Assurance. (2008). Obesity screening measures highlight additions to HEDIS 2009. Retrieved July 2,
2008 from http://www.ncqa.org/tabid/662/Default.aspx.
14. The Expert Committee also provides recommendations regarding tertiary care interventions including medications, very low-calorie
diets, and weight control surgeries.

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Planting the seeds for better health