Overview: childhood overweight and obesity diagnosis and treatment

Pediatricians are at the front lines of the pediatric obesity epidemic, charged with helping to get America’s children back to healthy weights, but which tools and programs truly make a difference?

Overview: childhood overweight and obesity

Recent statistics suggest childhood obesity rates may be leveling off.¹ The problems associated with childhood overweight and obesity, however, continue to be a heavy burden on the minds, health, and pocketbooks of society, parents and children, and pediatricians.

Childhood obesity is the number one health concern among parents in the United States, topping drug abuse and smoking²-and with good reason. Excess weight at young ages is associated with higher and earlier death rates in adulthood.

Because of obesity, today’s pediatricians are witness to an onslaught of pediatric patients with adult-like physical and mental health problems. Obesity in children and adolescents is associated with multiple comorbidities, including metabolic, cardiovascular, gastrointestinal, pulmonary, orthopedic, and psychological disorders. In fact, cardiovascular and metabolic impairments in childhood and adolescence constitute major risk factors for developing cardiovascular disease in adulthood.³

And obese children are more likely to become obese adults.^4-6 Also, if children are overweight, obesity in adulthood is likely to be more severe.⁷

Obesity’s financial toll is staggering. Treating obesity and obesity-related conditions costs billions each year. One estimate suggests the United States spent $190 billion on obesity-related health care expenses in 2005, which is twice previous estimates.⁸

Pediatricians who spend their days treating these patients say the old paradigm of dictating to kids and their parents that they need to eat less and exercise more doesn’t work in this new age.

Treatment starts with a conversation

Eliana M. Perrin, MD, MPH, associate professor of pediatrics, University of North Carolina School of Medicine, Chapel Hill, conducts extensive research looking at

Dr Perrinpediatrician-parent communication about weight and body mass index (BMI) screening. Some of the research suggests that parents and pediatricians are not happy with their communication about weight, and there’s reason to believe these conversations often do not take place.

In a study of nearly 5,000 children aged 2 to 15 years with BMIs in the 85th percentile or higher, Perrin and colleagues asked parents if their doctors or health care providers had ever told them their children were overweight. They found that fewer than one-quarter of parents of overweight children said they had been told their children were overweight.⁹

Then, there’s parental perception.

“Many parents of healthy weight children think their children are too skinny, particularly for ages 3 to 8, when that BMI takes a natural dip. And communication of the children’s BMI can help reassure parents and keep them from actively working to fatten them up,” Perrin says.

According to Perrin, parents of overweight children rarely know their children are overweight. This is especially true of younger children, when a healthier dietary pattern and more physical activity could make the most difference, she says.

“I think that’s when parents and pediatricians really need to be having sensitive and careful conversations. Most parents want to know growth chart information and how to keep their children healthy, and I think it’s our responsibility as pediatricians to make those conversations health focused and motivating, and to take the time to have those conversations with families,” Perrin says.

Jamie Jeffrey, MD, medical director, Children’s Medicine Center and HealthyKids Pediatric Weight Management Program at Charleston Area Medical Center, West Virginia, uses the 5210 Let’s Go! toolkit for health care providers (http://www.letsgo.org/programs/healthcare/toolkits/), which includes motivational interviewing techniques aimed at creating more effective conversations between health care providers and families.

“The 5210 motivational interviewing is part of the well-child check. It’s a collaborative approach. It’s staring with, ‘Can I please talk with you about Johnny’s BMI today?’” Jeffrey says.

The take-home for pediatricians, according to Perrin, is effective communication can be pivotal in the care of these children.

“Parents expect us to talk with them, and as long as we do that in a motivating, health-focused, and sensitive manner, those conversations will likely go very well.

We should communicate BMI screening to parents (using color-coded charts) but make the rest of the conversation about health and recommendations about healthy activity and dietary behaviors,” Perrin says. “We shouldn’t talk about diets or dieting, because this is a common pathway into restrictive eating disorders and actually obesity!"

Obesity is a complex problem

Effectively treating obesity requires more than addressing the obvious, some experts say.

The complexities of overweight and obesity include the roles of ethnicity, socioeconomics, and more. Pediatricians should take into consideration families’ cultural and socioeconomic backgrounds and offer families a menu of realistic options so they can choose what works best for them, according to Perrin.

Efforts to provide culturally and linguistically appropriate care, family-based treatment programs, and support services that aim to uncouple socioeconomic factors from adverse health outcomes could improve obesity care for racial/ethnic minority children.¹⁰

The primary things health providers need to look at when treating these children are barriers, according to Lori Fishman, PsyD, an attending psychologist at the Optimal Weight for Life program at Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts.

“What are the barriers or obstacles for these families to be healthy? Sometimes, access is an issue. Is there a financial limitation? Is there a cultural limitation that prevents a good understanding of the nutrition education that we’re trying to provide? Sometimes the barrier is about parenting and parenting style,” says Fishman.

Best practices

In December 2007, Pediatrics published “Expert Committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.¹¹

While those guidelines, as well as others, especially focus on how to screen, today’s guidelines fall short, according to Stephen Pont, MD, MPH, assistant professor of pediatrics at University of Texas Southwestern-Austin and medical director, Texas Center for the Prevention and Treatment of Childhood Obesity. Pont also chairs the American Academy of Pediatrics (AAP) Section on Obesity.

Dr Pont“One thing that is not as well described is what to do with outcomes of the screening tests,” Pont says.

Pont, who is part of the FOCUS on a Fitter Future initiative, says more information is on the way. In 2008, the National Association of Children's Hospitals and Related Institutions (NACHRI) formed FOCUS on a Fitter Future. FOCUS on a Fitter Future’s aim is to articulate the role of children’s hospitals in combating pediatric obesity while building consensus on performance measurement and quality improvement. One of the group’s projects, according to Pont, is a soon-to-be published consensus on treatment algorithms.

However, for most children, it’s not about dieting and losing weight, but rather encouraging the children to “grow into” their weight, Perrin says. “That’s one reason we encourage pediatricians to track BMI and communicate with families so that we can note concerning weight trajectories early on, before unhealthy habits are entrenched and before there is a need to lose weight,” she says. “Involving a nutritionist and other support systems (ie, psychology) can be helpful, as well, if they are available to you in your community.”

The pediatrician is but one part of what it takes to help children with weight issues. Obese children often suffer psychological issues, such as depression, anxiety, low self-esteem, social isolation, teasing, binge-eating disorder, and night-eating syndrome, according to Fishman.

University of California, Los Angeles, researchers analyzed data on more than 43,000 children, aged 10 to 17 years, to study associations between weight status and 21 indicators of general health. They concluded: “Obese children have increased odds of worse reported general health, psychosocial functioning, and specific health disorders. Physicians, parents, and teachers should be informed of the specific comorbidities associated with childhood obesity to target interventions that could enhance well-being.¹²

Fishman says having a behavioral component is crucial when treating obese and overweight patients. “That’s beyond just giving behavioral recommendations, but also thoroughly assessing for mental health concerns,” she says.

There also is the psychosocial component. Overweight and obese children are often teased and ostracized by their peers, so they don’t have as many places to go, socially. They tend not to be as active as other kids their ages, so they end up

Dr Fishmanhome more, with food as their comfort, according to Fishman.

At the Optimal Weight for Life program, the core health care team includes a physician who specializes in obesity, a dietician, and a mental health professional. In short, treatment is a "team sport" requiring involvement of all stakeholders. “What does not work is parents who are not invested and have expectations that children are going to do this on their own,” Fishman says.

Similarly, pediatricians can’t just talk to children about behavior change because parents are responsible for cooking, grocery shopping, getting their kids to activities, and more.

“My goal as a psychologist is to identify barriers and obstacles that are preventing children from being healthy, and implement behavioral strategies for change, Fishman says. “So, one of my biggest recommendations that I want to make sure

pediatricians and families are aware of, is that parents are the role models for their children and they need to provide an environment that is healthful.” She adds, “You don’t want to have a home environment that’s full of junk food, then ask your children not to eat it. We want families to make changes together and not highlight an overweight child in the family as a person that needs to make change.”

Understanding obesity at a deeper level

In 1999, Robert A. Pretlow, MD, a pediatrician in Seattle, Washington, started a Web site called Weigh2Rock.com for obese and overweight teenagers and preteens. At the time, he says, he thought it might provide a safe communication haven for children who are often ostracized, even by their doctors, about their weight.

“. . . [W]ithin a couple of years, I had 100,000 kids a month visiting this site from all over the world. It's still at about that level with about 100,000 kids a month,” Pretlow says.

The next logical step, Pretlow thought, was to use the site to teach those on it conventional wisdom about healthy eating and exercise. The educational component, coupled with the site’s peer support, would surely help them lose weight and maintain healthier weights. Or so he thought.

“That just didn’t happen. . . . Many continued to gain weight, much to their angst. I was dumbfounded as to why,” Pretlow says.

Through subsequent surveys and monitoring the site, Pretlow says he learned the kids didn’t think health-eating education helped. In fact, they felt overdosed on that information, he says.

“What they said they needed help with was cravings. The level of human misery that is expressed in what these kids write in chat rooms is just appalling,” Pretlow says.

In 2009, Pretlow published the book Overweight: What Kids Say (CreateSpace; 2009), based on 134,000 anonymous bulletin board messages posted over 10 years. “What they said was it wasn’t a healthy eating problem. It was something very similar to an addiction. They even called it that: an addiction,” Pretlow says.

Pretlow then published findings in Eating Disorders,¹³ where he wrote about the data he and his colleagues gathered from Weigh2Rock: “Many respondents, ages 8 to 21, exhibited DSM-IV substance dependence (addiction) criteria when describing their relationship with highly pleasurable foods. Further research is needed on possible addiction to highly pleasurable foods in youth. Incorporating substance dependence methods may improve the success rate in combating the childhood obesity epidemic.”

For today’s providers, there is an extensive eCare system contained in the Weigh2Rock.com Web site, where providers may follow and manage their overweight patients remotely. Simultaneously, the children receive peer and educational support from the site.

Dr Pretlow“The children weigh in on their secure individual charts on the site, via the eCare system, and the provider[s] may monitor the weight charts of their patients and post secure supportive and educational messages to the child in each child's individual ‘e-Room,’” says Pretlow.

Jeffrey uses Weigh2Rock.com to keep in touch with children who have completed an intensive 8-week program at her clinic. The children can log in their weights and e-mail providers at the center with questions, problems, and challenges.

“The kids that do Weigh2Rock on a regular basis seem to do better. I don’t have absolute data-I can just tell you that they are more likely to come to their appointments. They are more likely to stay on track with their nutritional and activity goals,” Jeffrey says.

While the provider-patient interaction on social media isn’t reimbursable in West Virginia, Jeffrey says the correspondence is worth her time. “To be honest, corresponding with them between visits and knowing what’s going on makes that in-person visit a lot easier the next time around,” she says.

There is, however, a dilemma with using apps and computer games and gadgets to help kids lose weight. That dilemma: screen time, says Fishman.

“We focus a lot on one particular behavioral strategy for managing weight, which is limiting screen time,” Fishman says. “So, we’re cautionary about using apps or asking people to use screens as part of this because we’re spending so much time encouraging kids to get outside, play sports, and be active.”

Models for change

The care of obese children is evolving, says Jeffrey. “The whole reason I started the HealthyKids Pediatric Weight Management Program was the primary care setting couldn’t adequately take care of these kids. I don’t think my tertiary care setting can take care of them, either. I think we really have to go with the chronic care model and have the village take care of the kids,” she says.

There is hope for better access to obesity-related health care services and better reimbursement. The American Medical Association (AMA) designation of obesity of disease has not impacted reimbursement for childhood obesity and overweight, but it’s a move in the right direction, according to Pont. Health reform could be another positive step in the care of these children, he adds.

“Health reform . . . does recognize that everyone should be able to see their doctor once a year for a health visit, and that would be heavily subsidized or without a copay. Talking about weight could be a part of that visit,” Pont says. “However, for kids, there are so many things we need to cover in that visit . . . that to think there is also going to be time to specifically address all the factors that have led to a child being overweight is unrealistic. We need to have the ability to see them back for future visits.”

In some ways, health care reform is going to prioritize preventive care, which is very important in this discussion, according to Perrin. “For now, we need to make sure we are having efficient, sensitive, motivating conversations with families regarding obesity prevention and treatment,” she says. “I think the provider can be very influential. Parents with an accurate assessment of their children’s weight are more likely to make weight-related behavior changes.”

Reimbursement challenges

As important an issue as childhood obesity is, it isn’t well covered by health insurance plans or the government, some say.

Researchers concluded in 2010 that few states ensured coverage of recommended treatments for adult and pediatric obesity through Medicaid or private insurance. Most states, according to the investigators, allowed obesity to be used to adjust rates in the small-group and individual markets and to deny coverage in the individual market.¹⁴

“Basically, obesity is . . . an automatic rejection by the majority of insurance plans in America,” says Pont. In many cases, a pediatrician cannot follow up with a patient for obesity and overweight and expect to be reimbursed for the visit, unless that child has a medical complication, he says.

“They will attain that medical complication with absolute certainty, but I cannot see them until they attain that additional complication of their weight,” says Pont. “I will say there are a few states that are more proactive and have made changes where you actually can see a doctor for overweight and obesity. I’m hoping other states will follow.”

It’s also encouraging, Pont says, that Medicare has obesity and weight loss coverage because Medicaid and private insurers usually follow Medicare’s lead. However, while adults can lobby for themselves, children cannot, and without more advocacy on behalf of children, reimbursement issues will probably remain, he says.

The reimbursement picture isn’t all dreary and could get better, according to Perrin. “I see predominately children reimbursed by Medicaid, which does reimburse us for counseling related to healthy lifestyles. I actually think we have much better reimbursement than we used to for counseling about this,” she says.

For many pediatricians, however, reimbursement doesn’t come with using obesity codes. Cecelia Nardslico, MBA, practice administrator at Brighton Hill Pediatrics, Syracuse, New York, says payer policies vary on what they will or will not pay for obesity.

“Most currently do not reimburse or cover services that are submitted with only an obesity diagnosis code,” Nardslico says. “However, our children have other comorbidities and/or family risk factors (such as hyperlipidemia, hypertension, acanthosis nigricans, diabetes mellitus) that are directly attributed to their obesity. We find that if we focus our treatment to those specific issues, through our counseling, discussion, education, and treatment options, they are covered services.”

The milieu of health care needs associated with childhood obesity range from physical to mental health issues, but often resources run out before needs do.

"We work in conjunction with specialty services such as registered dieticians, ortho, psych, endocrine, but often these service providers may or may not be covered by various payers," says Nardslico. "When our collaborative efforts do not provide the success we wish for our patients, we have limited resources for further referral, let alone possible insurance reimbursement."

For example, she says, local bariatric programs do not accept pediatric patients. "Perhaps the history of nonreimbursement lies at the root of these limited resources for treating our morbidly obese children. When parents have to decide on how to spend their available resources, if insurance does not cover a service, what choices do they have? After all, it costs less to buy a kid a burger and fries than go to a nutritionist that the insurance company won't reimburse."

According to Nardslico, the 7-physician, 4 midlevel pediatric practice bills an appropriate level evaluation and management code (example, a 99213, 99214, or 99215 for an established patient-time based) and uses the specific comorbidity diagnoses.

“So, historically, we do not bill just the V codes and thus our reimbursements have been consistent,” Nardslico says. “With the recent recognition of obesity as a disease by the AMA (June 2013), we are hopeful that the carriers who do not currently cover an obesity diagnosis will be changing their policies.”

REFERENCES

1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):483-490.

2. American Heart Association (AMA). Overweight in children. AMA Web site. http://www.heart.org/HEARTORG/GettingHealthy/Overweight-in-Children_UCM_304054_Article.jsp. Updated June 26, 2013. Accessed August 17, 2013.

3. Neef M, Weise S, Adler M, et al. Health impact in children and adolescents. Best Pract Res Clin Endocrinol Metab. 2013;27(2):229-238.

4. Biro FM, Wien M. Childhood obesity and adult morbidities. Am J Clin Nutr. 2010;91(5):1499S-1505S.

5. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869-873.

6. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22(2):167-177.

7. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. Relationship of childhood overweight to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics. 2001;108(3):712-718.

8. Cawley J, Meyerhoefer C. The medical care costs of obesity: an instrumental variables approach. J Health Econ. 2012;31(1):219-230.

9. Perrin, EM, Skinner AC, Steiner MJ. Parental recall of doctor communication of weight status: national trends from 1999 through 2008. Arch Pediatr Adolesc Med. 2012;166(4):317-322.

10. Peña MM, Dixon B, Taveras EM. Are you talking to ME? The importance of ethnicity and culture in childhood obesity prevention and management. Child Obes. 2012;8(1):23-27.

11. Barlow SE. Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4):S164-S192.

12. Halfon N, Larson K, Slusser W. Associations between obesity and comorbid mental health, developmental, and physical health conditions in a nationally representative sample of US children aged 10 to 17. Acad Pediatr. 2013;13(1):6-13.

13. Pretlow RA. Addiction to highly pleasurable food as a cause of the childhood obesity epidemic: a qualitative internet study. Eating Disord. 2011;19(4):295-307.

14. Lee JS, Sheer JL, Lopez N, Rosenbaum S. Coverage of obesity treatment: a state-by-state analysis of Medicaid and state insurance laws. Public Health Rep. 2010;125(4):596–604.

MS HILTON is a medical writer in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organization that may have an interest in any part of this article.

Subscribe to Contemporary Pediatrics to get monthly clinical advice for today's pediatrician.