The Stages of Obesity Treatment are defined based on the AAP Expert Committee recommendations and are summarized below:
Stage 1: Prevention Plus
is defined as a first step, in which overweight and obese patients and their families focus on basic healthy lifestyle eating and activity habits (e.g., 60 min of physical activity per day; 5 or more fruit and vegetables, etc.) that form the obesity prevention strategies. The Prevention Plus stage of obesity treatment can take place in the office setting by physicians, advanced practice nurses, physician assistants, and office nurses, with appropriate training.
Stage 2: Structured Weight Management
is distinguished from Stage 1 Prevention Plus by the support and structure
provided to the child to achieve healthy lifestyle behaviors. Specific eating and activity goals such as a planned diet or daily eating plan, planned, supervised physical activity or active play for 60 minutes per day and monitoring of these behaviors through use of logs. For implementation of structured weight management, the following points should be noted.
Stage 3: Comprehensive Multidisciplinary Intervention
- the eating plan requires a dietitian or a clinician who has received additional training in creating this kind of eating plan for children
- office staff members who have some training in motivational interviewing and in teaching of monitoring and reinforcement techniques can establish initial goals with families and see them for follow-up care
- a counselor is available for some families who need help with parenting skills, resolution of family conflict, or motivation
- depending on the child and family, referral to a physical therapist or exercise therapist can help the child and family develop physical activity habits
- monthly office visits are probably most appropriate at this level
- a provider's office staff can provide much of this treatment, with some additional training
- group sessions may be included
increases the intensity of behavior changes
, the frequency of visits
, and the specialists
involved, to maximize support for behavior changes. Generally, this type of program would exceed the capacity of a primary care office to offer within the typical visit structure. However, an office or several offices could organize specialists to offer this kind of a program. For implementation of comprehensive multidisciplinary intervention, the following points should be noted.
Stage 4: Tertiary Care Intervention
- the structured program in behavior modification should include, at a minimum, food monitoring, short-term diet and physical activity goal setting, and contingency management
- negative energy balance resulting from structured dietary and physical activity changes is planned
- parental participation in behavior modification techniques is needed for children <12 years of age. Parental involvement would be progressively less with older youths
- parents should be trained regarding improvement of the home environment
- systematic evaluation of body measurements, diet, and physical activity should be performed at baseline and at specified intervals throughout the program (suggest)
- a multidisciplinary team with experience in childhood obesity, including a behavioral counselor (for example, social worker, psychologist, other mental health care provider, or trained nurse practitioner), registered dietitian, exercise specialist (physical therapist or other team member with training or a community program prepared to assist obese children), and primary care provider who continues to monitor medical issues and maintains a supportive alliance with the families, should be involved
- frequent office visits should be scheduled; weekly visits for a minimum of 8 to 12 weeks seem to be most efficacious. Subsequently, monthly visits can help maintain new behaviors
- group visits may be more cost-effective and have therapeutic benefit
- an established pediatric weight management program may be best suited to provide this type of intervention, although such programs are sparse and often are not covered by insurance plans
- commercial weight management programs can be considered, but the primary care provider's office needs to screen the programs to ensure that the approach is healthy and appropriate for the age of the child. Information to guide this evaluation is included in the treatment report
The intensive interventions in this category may be offered to some severely obese youths. These interventions (medications, very low-calorie diets, surgery) move beyond the goal of balanced healthy eating and activity habits that are the core of the other stages.