Evidence-based obesity management for primary care

Introduction

As attested to by popular media and epidemiological surveys alike, pediatric obesity and overweight have reached epidemic levels in the United States and much of the developed world. The most recent National Health and Nutrition Evaluation Survey indicates that approximately 17 percent of children and adolescents in the United States are obese and about 32 percent are overweight (Ogden, Carroll, Kit & Flegal, 2012) — a three-fold increase over rates estimated in 1980.

In addition to increased risk of persistent obesity through adulthood, children and adolescents who are overweight or obese are at increased risk for a number of physical and mental health conditions, including insulin resistance, hypertension, abnormal glucose intolerance, sleep apnea, peer victimization, decreased health-related quality of life and increased risk for internalizing problems (for reviews, see Jelalian & Hart, 2009, Vivier & Tomkins, 2008 and Zeller & Modi, 2008). Some of these conditions (e.g., decreased subjective quality of life, internalizing problems) have been associated with further decreases in positive health behaviors (e.g., moderate/vigorous physical activity), thereby resulting in a feedback loop of decreasing health quality, increasing distress and increasing risk for obesity (see Luppino et al., 2010 for a review).

The epidemiological patterns suggest that risk for overweight in the U.S. varies across social, economic, and racial/ethnic groups. Specifically, individuals with lower household incomes, those from rural communities and those who are African-American or Latino/a are at increased risk for obesity and overweight (e.g., Lutfiyya, Lipsky, Wisdom-Behounek, & Inpanbutr-Martinkus, 2007; Singh, Siahpush, Kogan, 2010; Voss, Masuoka, Webber, Scher & Atkinson, 2013).

Although there are likely genetic vulnerabilities for the development of obesity, environmental, economic, cultural and behavioral factors are also important contributors to the risk. For example, foods high in caloric density (e.g., fast food) are frequently less expensive than those of higher nutritional value, increasing risk in low-income families. Similarly, the risk of obesity is increased for children who live in poorly resourced communities and therefore have fewer opportunities for safe physical activity. Regardless of economic or environmental conditions, children who receive modeling of unhealthy diets or patterns of physical activity are at increased risk.

In 2007, the Expert Committee on Pediatric Obesity (Barlow et al., 2007) recommended a sequence of graded stages of obesity care, with more intensive treatment components for children and adolescents with higher degrees of obesity, or those for whom other treatments did not produce adequate results. At each recommended stage of care, the committee noted specific treatment components with consistent evidence supporting their efficacy in structured and comprehensive care. These treatment components included dietary and physical activity changes, a program of behavior modification to support these changes, involvement of the whole family in lifestyle changes and frequent contact with the treatment team.

Given their central role in managing children's health, primary care clinicians (including primary care pediatric psychologists; PCPPs ) are vital contributors to the multifaceted solutions necessary to curb pediatric obesity. PCPPs benefit from: 1) an established and trusting relationship with families that extends beyond a focus on health behavior, 2) a large number of reimbursable opportunities for follow-up, 3) decreased stigma for receiving treatment (as opposed to treatment in a mental health setting) and 4) opportunities for multidisciplinary collaboration and medical monitoring. Below we highlight some of the specific tasks that comprise competent evidence-based management of pediatric obesity.

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