Evaluation and Treatment of Children and Adolescents With Obesity

Publication Date: January 8, 2023
Last Updated: May 12, 2023

Assessment and Evaluation

Key Action Statements

Pediatricians and other PHCPs should measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific CDC growth charts or growth charts for children with severe obesity at least annually for all children 2 to 18 y of age to screen for overweight (BMI ≥ 85th percentile to <95th percentile), obesity (BMI ≥ 95th percentile), and severe obesity (BMI ≥ 120% of the 95th percentile for age and sex). (B, R)
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In children 10 y and older, pediatricians and other PHCPs should evaluate for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function in children and adolescents with obesity (BMI ≥ 95th percentile) and for lipid abnormalities in children and adolescents with overweight (BMI ≥ 85th percentile to < 95th percentile). (B, S)
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In children 10 y and older with overweight (BMI ≥ 85th percentile to < 95th percentile), pediatricians and other PHCPs may evaluate for abnormal glucose metabolism and liver function in the presence of risk factors for T2DM or NAFLD. In children 2 to 9 y of age with obesity (BMI ≥ 95th percentile), pediatricians and other PHCPs may evaluate for lipid abnormalities. (C, R)
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Pediatricians and other PHCPs should treat children and adolescents for overweight (BMI ≥ 85th percentile to < 95th percentile) or obesity (BMI ≥ 95th percentile) and comorbidities concurrently. (A, S)
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Pediatricians and other PHCPs should evaluate for dyslipidemia by obtaining a fasting lipid panel in children 10 y and older with overweight (BMI ≥ 85th percentile to < 95th percentile) and obesity (BMI ≥ 95th percentile). (B, S)
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Pediatricians and other PHCPs should evaluate for dyslipidemia by obtaining a fasting lipid panel in children 2 through 9 y of age with obesity (BMI ≥ 95th percentile) and may evaluate for dyslipidemia. (C, R)
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Pediatricians and other PHCPs should evaluate for prediabetes and/or diabetes mellitus with fasting plasma glucose, 2-h plasma glucose after 75-g oral glucose tolerance test (OGTT), or glycosylated hemoglobin (HbA1c). (B, R)
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Pediatricians and other PHCPs should evaluate for NAFLD by obtaining an alanine transaminase (ALT) test. (A, S)
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Pediatricians and other PHCPs should evaluate for hypertension by measuring blood pressure at every visit starting at 3 y of age in children and adolescents with overweight (BMI ≥ 85 percentile to < 95th percentile) and obesity (BMI ≥ 95th percentile). (C, R)
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Consensus Recommendations

The CPG authors recommend pediatricians and other PHCPs:
  • Perform initial and longitudinal assessment of individual, structural, and contextual risk factors to provide individualized and tailored treatment of the child or adolescent with overweight or obesity.
  • Obtain a sleep history, including symptoms of snoring, daytime somnolence, nocturnal enuresis, morning headaches, and inattention, among children and adolescents with obesity to evaluate for OSA.
  • Obtain a polysomnogram for children and adolescents with obesity and at least 1 symptom of disordered breathing.
  • Evaluate for menstrual irregularities and signs of hyperandrogenism (ie, hirsutism, acne) among female adolescents with obesity to assess risk for PCOS.
  • Monitor for symptoms of depression in children and adolescents with obesity and conduct annual evaluation for depression for adolescents 12 years and older with a formal self-report tool.
  • Perform a musculoskeletal review of systems and physical examination (eg, internal hip rotation in growing child, gait) as part of their evaluation for obesity.
  • Recommend immediate and complete activity restriction, nonweight-bearing with use of crutches, and refer to an orthopedic surgeon for emergent evaluation, if SCFE is suspected. PHCPs may consider sending the child to an emergency department if an orthopedic surgeon is not available.
  • Maintain a high index of suspicion for IIH with new- onset or progressive headaches in the context of significant weight gain, especially for females.

Treatment

Key Action Statements

Pediatricians and other PHCPs should treat overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile) in children and adolescents, following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers. (B, S)
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Pediatricians and other PHCPs should use motivational interviewing (MI) to engage patients and families in treating overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile). (B, R)
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Pediatricians and other PHCPs should provide or refer children 6 y and older with overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile) to intensive health behavior and lifestyle treatment. Health behavior and lifestyle treatment is more effective with greater contact hours; the most effective treatment includes 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-mo period. (B, R)
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Pediatricians and other PHCPs should provide or refer children 2 through 5 y of age with overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile) to intensive health behavior and lifestyle treatment. Health behavior and lifestyle treatment is more effective with greater contact hours; the most effective treatment includes 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-mo period. (C, R)
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Pediatricians and other PHCPs should offer adolescents 12 y and older with obesity (BMI ≥ 95th percentile) weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment. (B, R)
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Pediatricians and other PHCPs should offer referral for adolescents 13 y and older with severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) for evaluation for metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers. (C, R)
This KAS was given a Grade C recommendation, as available evidence is from observational and case-controlled studies. As described in the methods section for the evidence review, only randomized and comparative effectiveness studies were included for the CPG. The Evidence Review Panel made the decision to include observational and case-control studies specifically for surgical interventions only, because of ethical considerations and practical challenges to randomization.
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Consensus Recommendations

The CPG authors recommend that pediatricians and other PHCPs:
  • Deliver the best available intensive treatment to all children with overweight and obesity.
  • Build collaborations with other specialists and programs in their communities.
  • May offer children ages 8 through 11 years of age with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.

Additional Information

Implementation Consensus Recommendations

  • The subcommittee recommends that the AAP and its membership strongly promote supportive payment and public health policies that cover comprehensive obesity prevention, evaluation, and treatment. The medical costs of untreated childhood obesity are well-documented and add urgency to provide payment for treatment.122 There is a role for AAP policy and advocacy, in partnership with other organizations, to demand more of our government to accelerate progress in prevention and treatment of obesity for all children through policy change within and beyond the health care sector to improve the health and well-being of children. Furthermore, targeted policies are needed to purposefully address the structural racism in our society that drives the alarming and persistent disparities in childhood obesity and obesity-related comorbidities.
  • The subcommittee recommends that public health agencies, community organizations, health care systems, health care providers, and community members partner with each other to expand access to evidence-based pediatric obesity treatment programs and to increase community resources that address social determinants of health in promoting healthy, active lifestyles.
  • The subcommittee recommends that EHR vendors, health systems, and practices implement CDS systems broadly in EHRs to provide prompts and facilitate best practices for managing children and adolescents with obesity.
  • The subcommittee recommends that medical and other health professions schools, training programs, boards, and professional societies improve education and training opportunities related to obesity for both practicing providers and in preprofessional schools and residency and fellowship programs. Such training includes the underlying physiologic basis for weight dysregulation, MI, weight bias, the social and emotional impact of obesity on patients, the need to tailor management to SDoHs that impact weight, and weight-related outcomes and other emerging science.

Table 22. Role of the Pediatrician or PCHP

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Focus Role of the Pediatrician or PHCP
Diagnosis and measurement Measure height and weight
Calculate BMI and assess BMI Percentile
Communicate BMI and weight status to patient and family
Risk factors Assess individual, structural, and contextual risk factors
Evaluation Perform comprehensive patient history
Conduct physical exam
Evaluate for comorbidities0
Order relevant diagnostic studies and laboratories
Assess readiness to change
Treat comorbidities Treat obesity and comorbidities concurrently
Treat obesity Manage children with overweight & obesity following principles of chronic care model and medical home
Deliver nonstigmatizing care
Use MI to engage patient and families in addressing overweight and obesity, set goals and promote participation or utilization of local resources or programs
Promptly engage and refer children to intensive HBL T treatment, if available. If intensive HBL T treatment is not available in your area, deliver highest intensity HBL T treatment possible.
Foster self-management strategies
Refer to subspecialists if needed
Serve as medical home, coordinate care, advocate for family, and support transition to adult care.
Offer weight loss pharmacotherapy, to eligible patients, according to medication indications, risks, and benefits, as an adjunct to HBL T.
For eligible patients with severe obesity, offer referral to a local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery center for surgical evaluation.

Table 1. Selected Examples of Multilevel Influencers and Contributors to Obesity

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Policy factors
  • Marketing of unhealthy foods
  • Underresourced communities
  • Food insecurity

Neighborhood and community factors
  • School environment
  • Lack of fresh food access
  • Fast food proximity
  • Access to safe physical activity
  • Environmental health

Family and home environment factors
  • Parenting feeding style
  • Sugar-sweetened beverages
  • Portion sizes
  • Snacking behavior
  • Dining out and family meals
  • Screen time
  • Sedentary behavior
  • Sleep duration
  • Environmental smoke exposure
  • Psychosocial stress
  • Adverse childhood experiences

Individual Factors

Genetic factors
  • Monogenetic syndromes and polygenetic effects
  • Epigenetic effects

Prenatal risk
  • Parental obesity
  • Maternal weight gain
  • Gestational diabetes
  • Maternal smoking

Postnatal risk
  • Birth weight
  • Early breastfeeding cessation and formula feeding
  • Rapid weight gain during infancy and early childhood
  • Early use of antibiotics

Childhood risk
  • Endocrine disorders
  • Children and youth with special health care needs
  • Children with autism spectrum disorder
  • Children with developmental and physical disabilities
  • Children with myelomeningocele
  • Attention-deficit/hyperactivity disorder
  • Weight-promoting appetitive traits
  • Medication use (weight-promoting medications)
  • Depression

Table 2. Genetic Syndromes Associated With Obesity

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Table 4. Special Considerations in the Review of Systems for the Patient With Overweight or Obesity

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Table 5. Assessment Components

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Table 8. NHLBI Criteria for Lipid Testing Results

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Table 10. Criteria for Diagnosing Prediabetes and T2DM

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Table 12. BP Categories by Age and Number of Visits Needed for Diagnosis

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Table 18. Behavior Strategies

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Recommendation Grading

Overview

Title

Evaluation and Treatment of Children and Adolescents With Obesity

Authoring Organization

American Academy of Pediatrics

Publication Month/Year

January 8, 2023

Last Updated Month/Year

August 29, 2024

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Child

Health Care Settings

Ambulatory

Intended Users

Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D009765 - Obesity, D063766 - Pediatric Obesity

Keywords

obesity, pediatric obesity, childhood obesity

Source Citation

Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics 2023; e2022060640. 10.1542/peds.2022-060640