Stages of Obesity Treatment: Guidance From the American Academy of Pediatrics

In 2015, the American Academy of Pediatrics (AAP) compiled a clinical algorithm for the assessment and management of childhood obesity in patients 2 years and older (https://ihcw.aap.org/resources/Pages/default.aspx). This childhood obesity algorithm is based on the 2007 Expert Committee Recommendations and new evidence in obesity medicine (Barlow & Expert Committee, 2007). The algorithm is written as a two-page guide to which practitioners can refer for ease in management and/or referral of children affected by obesity. The four stages of obesity management were refined from the 2007 original guidelines and included in the algorithm. This column reviews the AAP Childhood Obesity algorithm and the four stages of obesity care as outlined by the AAP's Institute for Healthy Childhood Weight—the algorithm authors. After this review, implications for clinical practice are discussed. The childhood obesity algorithm is intended as a guide to assess behavioral and environmental factors to ascertain strengths and areas of improvement within the family setting, provide counseling on healthy lifestyle, determine weight classification, and determine health risk factors. Assessing behavioral and environmental factors in detail is not addressed in-depth in the algorithm. The reader is referred to the Barlow and Expert Committee (2007) guidelines for specific obesity assessment. The algorithm briefly discusses healthy lifestyle counseling (5-2-1-0: 5 fruits and vegetables, 2 hours or less of screen time, 1 hour or more of physical activity, and 0 sugary drink every day), which is also covered in more depth in the Barlow and Expert Committee guidelines and on the AAP Institute for Healthy Living Web site (https://ihcw.aap.org/). On the algorithm, the three classifications of healthy weight, overweight, and obesity are combined with assessment and physical examination to identify clinical pathways that determine possible obesity-related risk factors and clinical management. An emerging fourth category (severe obesity: >99th percentile for age and gender) is described in the literature as the fastest growing obesity group (Kelly et al., 2013; Skinner, Perrin, & Skelton, 2016). There is a high level of concern for obesity-related comorbidities in this weight group; cardiometabolic risk factors are reported to be as high as 50% in severe obesity (Li et al., 2016; Weiss et al., 2004). The childhood obesity algorithm also includes the AAP's recommended stages of obesity care for children and adolescents. Stages 1 and 2 occur in the primary care office by appropriately trained obesity care providers. Using positive communication skills such as motivational interviewing, the provider uses themed visits, each discussing different aspects of healthy living, family support, and environmental challenges. Stage 1 (prevention plus) recommends at least monthly visits, whereas Stage 2 adds intensity with visits every 2–4 weeks. Use of a registered dietitian or activity specialist is recommended. Advancement to the next stage is recommended if improvement is not achieved after 3–6 months. Stage 3 increases the intensity and support offered to the family and child. This stage utilizes a multidisciplinary team, including a pediatric provider (physician, nurse practitioner, or physician assistant), nurse, dietitian, activity professional, and counseling by a psychologist or a social worker. Although not a requirement, most children in Stage 3 programs are over the 85th percentile for weight. Stage 4 has the same components of Stage 3 but adds the advanced therapeutic modalities of medications, devices, and surgery as recommended. CLINICAL IMPLICATIONS With approximately 17% of children and adolescents in the overweight and obese categories (and 6% of these in the severely obese category), clinicians treat children with increased weight almost daily in their practice, no matter what the clinician's specialty. Depending on the context, the clinician's encounter with the child and family may be an opportunity to determine any concerns about the child's weight and health. Knowing the categories of weight, what potential obesity-related comorbidities might be present, their risks, how they are assessed, and potential treatment options allows the clinician to address concerns as they present. Knowing community resources encourages early referral for appropriate intensity obesity treatment.