AMA Recommends 4-Stage Approach to Treatment of Childhood Obesity


July 17, 2008 — A 4-stage approach to treatment of childhood obesity is recommended by the American Medical Association (AMA), according to a review for primary care clinicians in the July 1 issue of the American Family Physician. The study authors note that many of these recommendations for treatment and prevention can be carried out by family clinicians.

«Childhood obesity has become so severe that diseases that once affected only adults are now appearing in children,» writes Goutham Rao, MD, from Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania. «The long-term implications of this epidemic are extremely serious. Obese children are much more likely than children of healthy weight to become obese adults.»

The statistics are alarming, with «overweight» youth (those with age-adjusted and sex-adjusted body mass index [BMI] above the 95th percentile, which is equivalent to the «obese» classification for adults) consisting of 13.9% of children 2 to 5 years old, 18.8% of children 6 to 11 years old, and 17.4% of adolescents and teenagers 12 to 19 years old.

Although type 2 diabetes in children was rare 2 decades ago, it now accounts for nearly one half of all new cases of diabetes among children in some settings. In adults, correlates of obesity include not only type 2 diabetes but also hypertension, osteoarthritis, gout, dyslipidemia, cardiovascular disease, and biliary tract disease as well as cancers of the colon, breast (in postmenopausal women), endometrium, and esophagus.

Recognizing the scarcity of practical strategies available to primary care clinicians to combat the problem of childhood obesity, the AMA recently convened an expert panel to review evidence about how best to manage and prevent obesity and to write a series of reports.

Specific recommendations of The Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity, and their accompanying level of evidence, are as follows:

  • At least once a year, measure height and weight and calculate BMI plus BMI percentile for all children (level of evidence, C).
  • To achieve or maintain a healthy weight, encourage all children to participate in at least 60 minutes of moderate to vigorous physical activity on most, and preferably all, days of the week (level of evidence, A).
  • Advise children not to drink more than 1 serving per day of sweetened beverages, such as fruit juice, fruit drinks, regular-calorie soft drinks, sports drinks, energy drinks, sweetened or flavored milk, or sweetened iced tea (level of evidence, B).
  • Advise families to limit their children’s television viewing and other screen time to 2 hours per day or less (level of evidence, B).
  • Recommend that children’s fast-food consumption be limited to no more than once per week (level of evidence, C).
  • Advise families with children to eat meals together as often as possible, on most, and preferably all, days of the week (level of evidence, C).


During the annual visit, family clinicians should evaluate key dietary and lifestyle habits, including consumption of sweetened beverages and physical activity; willingness to improve dietary and lifestyle habits; and family history of obesity and related illnesses.

Dietary habits that contribute to obesity include frequent consumption of fast food and large volumes of sweetened beverages, eating large portions, skipping breakfast, eating high-fat snacks or other foods high in energy density, low intake of fruits and vegetables, and irregular meal frequency and snacking patterns.

Physical examination should include measurement of pulse, blood pressure, and evaluation for signs often associated with obesity, such as hepatomegaly from fatty liver disease and acanthosis nigricans, which is associated with insulin resistance. The examination may detect signs of possible reversible causes of obesity, such as deep purple striae and the «buffalo hump» of Cushing’s syndrome.

The degree of obesity and presence of comorbid conditions should determine laboratory testing. A fasting lipid profile is recommended for children with BMI between the 85th and 94th percentiles but with no obesity-related illnesses, Children with BMI between the 85th and 94th percentiles and with obesity-related illnesses should also be tested for alanine transaminase, aspartate transaminase, and fasting blood glucose levels, and children with BMI higher than the 95th percentile should also undergo measurement of serum urea nitrogen and creatinine levels.

Depending on progress, the committee recommends a staged approach of increasing intensity to manage overweight and obese children and adolescents 2 to 19 years old:

  • Stage I (Prevention-Plus Protocol): Make specific dietary and physical activity recommendations, with monthly follow-up. If BMI does not improve in 3 to 6 months, consider stage II.
  • Stage II (Structured Weight Management Protocol). This more structured plan includes a low–energy-dense, balanced diet; structured meals; supervised physical activity of at least 60 minutes daily; limiting television-watching and other screen time to 1 hour per day or less; and use of logs to self-monitor these behaviors. Family clinicians may require assistance from allied care professionals to implement this step, and children should be followed up as often as needed. If BMI does not improve in 3 to 6 months, stage III is appropriate.
  • Stage III (Comprehensive, Multidisciplinary Intervention) and Stage IV (Tertiary-Care Intervention) are more intensive interventions administered by highly trained teams expert in obesity management. Specialized centers can provide effective, intensive counseling programs that promote behavior modification for obese children. Referral is especially indicated for severely obese children and for those with obesity-related comorbidities.
  • «A four-stage approach to treatment of childhood obesity is recommended,» Dr. Rao writes. «Many of these recommendations can be carried out by family physicians for treatment and prevention. These include advising families to limit consumption of sweetened beverages and fast food, limit screen time, engage in physical activity for at least 60 minutes per day, and encourage family meals on most, and preferably all, days of the week.


Dr. Rao has disclosed no relevant financial relationships.

Am Fam Physician. 2008;78:56-63.

Clinical Context

According to the Centers for Disease Control and Prevention, children with age-adjusted and sex-adjusted BMI from the 85th to 94th percentiles are considered «at risk for overweight» and those with BMI at the 95th percentile or greater are considered «overweight.» The prevalence of overweight children is 13.9% for ages 2 to 5 years, 18.8% for ages 6 to 11 years, and 17.4% for ages 12 to 19 years. In the May-June 2005 issue of Ambulatory Pediatrics, Perrin and colleagues found that only 12% of pediatricians self-reported high efficacy in the management of obesity.

This study summarizes the recommendations for the assessment and management of childhood overweight and obesity from the AMA Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity.

Study Highlights

  • Recommendations were based on literature review and expert opinion.
  • The AMA recommends consistent terminology for children and adults: «overweight» (BMI from 85th to 94th percentile), «obese» (BMI at or above 95th percentile), and «severely obese» (BMI above 99th percentile).
  • Assessment includes dietary and lifestyle habits, family history, physical examination, readiness to change, and laboratory tests.
  • Dietary habits linked to obesity are frequent fast-food intake, large volumes of sweetened drinks, large portions, skipping breakfast, high-energy dense foods, few fruits and vegetables, and irregular meals and snacking.
  • Lifestyle habits include environment, social support, barriers to activity, sedentary behavior, and physical activity.
  • Pertinent family history includes obesity, type 2 diabetes, and cardiovascular disease.
  • Physical examination should include height, weight, BMI, pulse, and blood pressure.
  • Physical examination findings associated with obesity are hepatomegaly from fatty liver disease, acanthosis nigricans linked to insulin resistance, and striae and buffalo hump from Cushing’s syndrome.
  • Stages of readiness to change are precontemplation, contemplation, preparation, action, and maintenance.
  • Laboratory testing is guided by BMI and personal or family history of risk factors:
    • BMI from 85th to 94th percentiles and no risk factors: fasting lipid profile
    • BMI from 85th to 94th percentiles and risk factors: add alanine transaminase and aspartate transaminase and fasting blood glucose
    • BMI above 95th percentile: add serum urea nitrogen and creatinine levels
  • Address weight and lifestyle habits once a year with all patients.
  • Treatment for overweight and obese children aged 2 to 19 years includes 4 stages.
  • Stage I consists of specific recommendations, monthly follow-up, and advancement to stage II if BMI does not improve in 3 to 6 months: 5 or more daily servings of fruits and vegetables, television and computer use of no more than 2 hours daily, no television in child’s room, at least 60 minutes of daily moderate to vigorous physical activity, no sugar-sweetened drinks, breakfast daily, meals outside the home limited, family meals at least 5 times a week, and self-regulation of food.
  • Stage II consists of more structured and supervised stage I recommendations, limiting television and computer use to less than 1 hour daily, follow-up as often as needed, help from allied health professionals, and advancement to stage III if BMI does not improve in 3 to 6 months.
  • Stage III involves multidisciplinary intervention.
  • Stage IV involves tertiary care intervention.
  • Referrals are important for children with severe obesity or obesity-related morbidities.
  • Goal is to maintain lifetime healthy behaviors, but guidelines depend on age and obesity level:
    • BMI 85th to 94th percentiles: maintain weight until BMI below 85th percentile or BMI curve decreases
    • BMI at 95th percentile or greater: maintain weight until BMI below 85th percentile or weight loss up to 1 pound per month until BMI below 85th percentile
    • BMI more than 21 or 22 kg/m2 in children aged 2 to 5 years or at 99th percentile or greater: weight loss of 1 to 2 pounds per month until BMI below 85th percentile
  • Obesity prevention for children with BMI between 5th and 84th percentiles should address dietary habits, sedentary behaviors, physical activity, authoritative parenting, family involvement, and school and community support.
  • The National Initiative for Children’s Healthcare Quality published a guide to facilitate implementation.

Pearls for Practice

  • The recommended assessment of childhood obesity includes evaluation of dietary and activity habits, family history of obesity-related illnesses, readiness to change habits, and related physical examination findings. Depending on the severity of obesity and related conditions, laboratory testing might include fasting lipid profile, alanine transaminase, aspartate transaminase, fasting blood glucose, serum urea nitrogen, and creatinine.
  • The recommended 4-stage approach to treatment of childhood obesity includes limiting intake of sweetened drinks and fast food; limiting television and computer use; physical activity for at least 60 minutes daily; family meals; close follow-up; and, if needed, assistance from allied health professionals or weight management center.
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