Prevention and management of obesity for children and adolescents. This is the current release of the guideline. Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI) : The recommendations for
prevention and management of obesity for children and adolescents are presented in the form of a table with a list of evidence-based recommendations and an algorithm with 12 components, accompanied by detailed annotations. An algorithm is provided in the original guideline document for Prevention and Management of Obesity for Children and Adolescents (see the “Guideline Availability” field); clinical highlights and selected annotations (numbered to correspond with the algorithms) follow. Quality
of evidence (Low Quality, Moderate Quality, and High Quality) and strength of recommendation (Weak or Strong) definitions are repeated at the end of the “Major Recommendations” field. Recommendations : (Strong Recommendation, High Quality Evidence) (Barlow & Expert Committee, 2007)The following counseling messages should be directed to all parents, regardless of the weight status of their child.Healthy DietBreastfeeding: Studies suggest that exclusive breastfeeding to six months of age is associated with decreased rates of obesity later in childhood [High Quality Evidence]. See ICSI guideline Preventive services for children and adolescents for further information.Milk : The American Academy of Pediatrics recommends that children be started on cow’s milk at 1 year of age. Whole milk is recommended for most children ages 12 months to two years. However, if the child is at risk for overweight or if there is a family history of obesity or cardiovascular disease, 2% milk is recommended. For children ages two years and up, a low-fat (skim or 1%) milk should be used. Sugar-sweetened beverages : Families should limit their child’s consumption of sugar-sweetened beverages [High Quality Evidence] . Current evidence indicates a strong association between sugar-sweetened beverage consumption and total daily energy intake. Decreasing consumption of sugar-sweetened beverages is one strategy to decrease total daily energy intake [Reference] . Refer to the original guideline document for information regarding fruit juice and fruits and vegetables. Meal Structure
Eating out : Eating out at restaurants, especially fast food restaurants, should be limited. Restaurants, especially fast food restaurants, serve energy-dense food that can contribute significantly to a child’s daily energy intake [High Quality Evidence] . The frequency of eating out is associated with body fatness in children and adults [Reference] . Refer to the original guideline document for information about portion sizes, child self-regulation, physical exercise, sleep, television, and the importance of the community in promoting a healthy lifestyle. For a detailed review of age appropriate “well care,” including screening, assessment and anticipatory guidance, the work group recommends http://www.brightfutures.org.
Recommendations :
DefinitionsBody mass index (BMI) is a useful tool to assess body fat. It is defined as weight (in kilograms) divided by the square of height (in meters). BMI levels correlate with body fat and with concurrent health risks [High Quality Evidence].In children, an absolute scale for BMI is not used. Instead, a percentile scale is used, based on the child’s age and sex. Waist circumference measurements are a measure visceral adiposity. In children, they are not currently recommended for clinical use. Reference values that identify risk beyond that already identified by BMI are not available for children [High Quality Evidence] , [Reference] . TerminologyIt is recommended that appropriate terminology be used when evaluating children’s BMI. The appropriate terminology for children ages 2 to 18 is as follows:
Other Medical ScreeningRecommendations :
Refer to the original guideline document for additional information on blood pressure, cholesterol, and health risk assessment.
Recommendations :
Refer to the original guideline for information about major and minor comorbid conditions associated with obesity and review of systems for weight-related problems. Physical Examination in Primary Care Settings
[Reference]Laboratory Workup
ALT, alanine transaminase; AST, aspartate transaminase; BMI, body mass index *Per Krebs, to be performed every two years starting at age 10 years. #Per American Academy of Pediatrics (AAP), a non-fasting non-HDL cholesterol may be used for screening in this age group, to be followed-up with a fasting lipid panel if the screen is abnormal. [Reference]See Appendix D in the original guideline document for acceptable, borderline-high, and high plasma lipid, lipoprotein and apolipoprotein concentrations (mg/dL) for children and adolescents. Evidence-Based Recommendations for Dietary Management of Elevated Low-density Lipoprotein Cholesterol (LDL-C), non-HDL-C and Triglycerides (TG)Grades reflect the findings of the evidence review. Recommendation levels reflect the consensus opinion of the National Heart, Lung and Blood Institute (NHLBI) Expert Panel. Supportive actions represent expert consensus suggestions from the Expert Panel provided to support implementation of the recommendations; they are not graded. NOTE : Values given are in mg/dL. To convert to SI units, divide the results for total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL–C), and non-HDL-C by 38.6; for triglycerides (TG), divide by 88.6.
[Reference]Refer to the original guideline document for information on blood pressure (BP) measurement, categorization, and management; type 2 diabetes mellitus; nonalcoholic fatty liver disease; and eating disorder.
Recommendation :
Introduction to Weight Management/Lifestyle ChangeWeight management is a skill. Patients need to set realistic, achievable goals and to be held accountable to practicing the new behaviors that produce and maintain weight loss. Record keeping or self-monitoring (either by the patient or their family) of progress on specific behaviors is key to successful weight management. The ICSI Patient Advisory Council reviewed the latest revision of the Prevention and Management of Obesity for Adults guideline and supports the value of the physician initiating the conversation and suggested that patients were more likely to act on the recommendations of his/her clinician. Because obesity can be an overwhelming condition for the patient and family, creating small achievable goals and celebrating those achievements are important for continued success and healthy choices. The Working Group recommends that clinicians guide goals using the acronym “SMART” (specific, measurable, action based, realistic, and time-based). Refer to the original guideline document for information about stages of change model, overview of motivational interviewing, and 5210 toolkit for Healthy Habit Action Plans.
BMI is the initial screen for all children coming in for a well child visit. BMI should be calculated and plotted on a growth chart. Once calculated:
There are three assessments to be reviewed – medical risk, behavior risk and attitudes for change:
Once the BMI is calculated and assessment is reviewed with parent and child, it is important to acknowledge and praise good behaviors if the child is in a healthy weight category. If the child is overweight, the clinician should identify and target specific behaviors to prevent obesity. If there is a health risk such as family history of obesity, then prevention and intervention for treatment should be initiated. If the child’s BMI indicates obesity, it is important to target family and child’s concerns and motivation for change, and proceed to intervention and treatment stages. Stages of Obesity Treatment
[High Quality Evidence]Clinic-based weight management centers may not have the availability or capacity to meet the existing demand to treat all obese patients who require stage three treatment. Further, there are other barriers to families utilizing specialized weight management centers, including the variability of insurance coverage for weight management services [High Quality Evidence] , [Reference] , physical barriers (scheduling, parking, location), organizational barriers (clinical environment) and participant satisfaction with the type of educational content [Reference] . Health care clinicians should be encouraged to utilize alternative pediatric weight management resources when appropriate (such as community-based interventions), as long as those resources employ key evidence-based elements of successful obesity interventions. These core evidence-based elements are cited in these ICSI guidelines and include combining dietary, physical activity, and behavioral components, a focus on key, evidence-based behavioral changes [High Quality Evidence] , family-targeted interventions [Reference] , and interventions that achieve a certain threshold of intensity [Reference] . Community-based childhood obesity interventions founded on the above principles and other existing evidence represent a promising option for many families and afford unique benefits such as removing transportation as a barrier and scalability.
Recommendations :
Dietary interventions should be tailored to each individual child. Fat-free milk is commonly recommended after age 2 years for the benefit of essential nutrients and avoidance of excess saturated fat and calories. The clinician may consider recommending fat-free milk earlier than age 2 years, taking into consideration the child’s overall health (i.e., child’s growth, risk for obesity, overall nutritional intake, appetite), as long as the child’s diet supplies 30% of calories from fat. Children who increase their healthy eating showed greater reduction in BMI compared to children who decreased their consumption of high energy-dense food [Reference]. Thus, it may be useful for clinicians to teach children and families to focus on adding healthy foods versus telling them to decrease or completely eliminate foods low in nutritional value. The USDA has an online program called Supertracker that can assist children and families increase their health eating habits per USDA guidelines (see https://www.supertracker.usda.gov/default.aspx).Refer to the original guideline document for more information on dietary interventions.
Recommendations :
The work group recognizes the limitations of influence on children’s activities outside of the clinical setting and encourages clinicians to advocate for the following:
Children who suffer from severe obesity/deconditioning should be advised to begin an exercise program slowly and increase expenditure 10% per week so as to prevent injury. Those individuals with a history of prior injury or predisposing conditions such as generalized laxity, torsional abnormalities or flat feet, may benefit from an evaluation by a sports medicine physician, physical therapist, certified athletic trainer or other knowledgeable clinician. Infants and ToddlersThere is insufficient evidence to recommend exercise programs or classes for infants and toddlers as a means of promoting increased physical activity or preventing obesity in later years. The AAP recommends that children younger than 2 years not watch any television. Supervised, unstructured free play and activities such as neighborhood walks and other outdoor activities are encouraged. Preschool Aged Children 4 to 6Very young children (toddlers to 5 years of age) should have up to 120 minutes of moderate-to-vigorous physical activity (MVPA) per day, with 60 minutes of it as structured activity and 60 minutes as unstructured or free play. AAP recommends supervised free play with emphasis on fun, playfulness, exploration and experimentation. Appropriate activities include running, swimming, tumbling, throwing and catching. Preschoolers can begin to walk tolerable distances and reduce sedentary transportation by car and stroller. Limit screen time to fewer than two hours per day. Elementary School-age Children 6 to 9Older children should perform 60 minutes or more of physical activity each day, and MVPA that is aerobic in nature should make up most of the 60 or more minutes of physical activity. Muscle and bone strengthening activities such as gymnastics, calisthenics (e.g., push-ups, jumping jacks), jumping rope and running should be included at least three days per week as part of the 60 minutes. Continued free play with more sophisticated movement patterns and fundamental skill acquisition should be encouraged. Organized sports may be initiated but should have flexible rules and short instruction time, with emphasis on enjoyment rather than competition. Co-ed participation is not contraindicated. Middle School-aged Children 10 to 12Older children should perform 60 minutes or more of physical activity each day, and MVPA that is aerobic in nature should make up most of the 60 or more minutes of physical activity. Muscle and bone strengthening activities such as gymnastics, calisthenics (e.g., push-ups, jumping jacks), jumping rope and running should be included at least three days per week as part of the 60 minutes. Focus on enjoyment with family members and friends. Sports employing more complex coordination and strategy such as football, basketball and hockey are more feasible. Weight training may be initiated if supervised, using small free weights with high repetitions. AdolescentsOlder children should perform 60 minutes or more of physical activity each day, and MVPA that is aerobic in nature should make up most of the 60 or more minutes of physical activity. Activities that are of interest, fun and include friends are more likely to engage the adolescent. In addition to competitive sports, encourage personal fitness activities such as dance, yoga, running and weight training to include heavier weights once the individual reaches physical maturity. Household chores may also count for physical activity. The origins of childhood and adolescent obesity are multifactorial and complex. No less so are the possible solutions including the role of physical activity. Numerous studies demonstrate a positive effect of physical activity on general fitness, academic achievement and general well-being. Children exposed to enjoyable physical activity in life tend to be more active as adults. However, while physical activity contributes to a positive energy balance, it alone does not provide a solution to the childhood obesity problem. The answer will likely incorporate increased physical activity with a program employing behavior modification/counseling for the child and family.
Recommendations :
Lifestyle interventions should be provided for overweight and obese youth. Lifestyle interventions (including behavior therapy, diet and physical activity) have been shown to be effective with youth and have minimal to no adverse side effects (e.g., possible injuries related to exercise) [High Quality Evidence].Clinicians should help establish target behaviors [Moderate Quality Evidence]. Children and families benefit from determining specific target behaviors on which to focus, rather than global aspirations. Target behaviors may be developed with the child or PAC or in collaboration.Clinicians should encourage self-monitoring [Moderate Quality Evidence]. Self-monitoring for children might include the child, PAC or both recording behavior. The information recoded may vary but will likely include information regarding food and beverage consumption and/or physical activity.Clinicians should work with the child and/or PAC to set goals [Moderate Quality Evidence]. Clinicians should work with youth and families to set realistic, achievable goals. Rather than discussing global aspirations (e.g., lose 20 pounds), the goals should state the specific behaviors that will be targeted, by whom, and when the changes should occur (e.g., the youth will replace one soda with water at least five days this week [parents will have bottled water available at home]). It is important to consider the developmental stage of the youth when setting goals and determining how much PAC support is required.One model of goal setting is SMART goals. SMART stands for specific, measurable, assignable, realistic and time-based. By setting a SMART goal, the goal will be detailed (specific) and able to be evaluated (measurable). It will be provided to those involved in the behavior change (assignable) and it will be attainable (realistic). It is important to consider the developmental stage of the child when determining if the goal is attainable. There will also be a timeline in which the goal is completed (time-based). Another option for a goal-setting framework is provided with the “My Action Plan” handout; see Appendix F, “Pediatric Weight Management Program – My Action Plan,” in the original guideline document. Clinicians should teach children and PACs about stimulus control [Moderate Quality Evidence] . Stimulus control occurs when particular stimuli cue specific behaviors. To use this principle to promote a healthy lifestyle, individuals are often encouraged to eat only at the table; limit the amount of unhealthy food in the home; remove televisions from bedrooms, kitchens and other eating areas; and use smaller dishes. The environment can also be altered to increase the availability of healthy food options and access to activities that involve movement [Moderate Quality Evidence] . For children, PACs will likely need to be involved in making these environmental modifications. PACs should participate in the treatment process [High Quality Evidence] . Many intervention approaches use some combination of family and individual therapy. Regardless of the level of involvement, PACs should be part of the process and educated about the intervention strategies. Specific age-based recommendations from the National Heart, Lung, and Blood Institute (NHLBI [High Quality Evidence] ) include the following [High Quality Evidence] :
Refer to the original guideline document for additional information on behavior management.
The Work Group suggests weighing the relative risk of adverse events due to medications in children against the long-term potential for obesity-related morbidity and mortality. The long-term effects of these medications on growth and development have not been studied. Medications may be considered in obese children with comorbidities or those with severe obesity (BMI >99th percentile) in addition to a lifestyle modification program that includes diet, exercise and behavior modification. The Work Group emphasizes that pharmacotherapy should be offered only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions. Presently, orlistat is the only medication approved by the U.S. Food and Drug Administration (FDA) for treatment of childhood obesity [Reference]. This drug is approved for children ≥12 years of age. No weight-loss medications are approved for use in children <12 years old.Side effects of orlistat include abdominal cramping, flatus, oily bowel movements, and oily spotting on underwear caused by unabsorbed fat in the feces. Patients taking orlistat must take a daily multivitamin supplement as it can interfere with the absorption of fat-soluble vitamins. Orlistat has undergone two label changes because of reports of liver injury, cholelithiasis and pancreatitis; however, a cause-and-effect relationship of severe liver injury with orlistat use has not been established. Orlistat has been available for over-the-counter use since 2006. Metformin may be useful in combating the weight gain observed in children taking atypical antipsychotic medications and other psychotropic medications (e.g., clozapine, olanzapine, risperidone, quetiapine, aripiprazole and valproate) [High Quality Evidence] , [Reference] . The main adverse effects of metformin are diarrhea, nausea, vomiting and flatulence, which are usually transient and mild to moderate. Octreotide may be of potential benefit in children with hypothalamic obesity who demonstrate insulin hyper secretion [Reference]. However, it should be used in tertiary care centers with adequate expertise in care of severely obese children.Leptin therapy in patients with mutations of the leptin gene results in extraordinary loss of weight and fat mass along with reduction in hyperphagia, resolution of obesity and induction of puberty. This condition is, however, very rare and is unlikely to be encountered by majority of care clinicians. Use of phentermine, a stimulant medication and an appetite suppressant, has been FDA approved for adolescents older than 16 years and for adults only for short-term (usually interpreted as “up to 12 weeks”) use, while following non-pharmacological approaches to weight loss such as healthy eating and exercise.
There is limited information on the long-term efficacy and safety of bariatric surgery in children and adolescents. Consideration for bariatric surgery should be given only under the following conditions [Reference]:
Bariatric surgery should not be performed for preadolescent children, for any patient who has not mastered the principles of healthy dietary and activity habits, and for those with unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome. Pregnant, breastfeeding adolescents and those planning to become pregnant within two years of surgery should not be considered candidates for bariatric surgery. Bariatric surgery in adolescents should be performed in regional bariatric centers of excellence with programs equipped to handle the data acquisition, long-term follow-up, and multidisciplinary issues of these difficult patients [High Quality Evidence]. A multidisciplinary team with medical (including endocrine, gastrointestinal, cardiovascular, pulmonary and otolaryngological expertise), surgical, nutritional and psychological expertise should carefully select adolescents who are well informed and motivated as potential candidates for bariatric surgery and should provide preoperative care and counseling. Patients and families must be well informed as to the risks and complications of bariatric surgery.Roux-en-Y gastric bypass (RYGB) is the most common type of procedure performed in adolescents, and it involves stapling and excluding almost all of the stomach. RYGB is both a restrictive procedure, since a small proximal stomach pouch is created, and a minimal malabsorptive procedure, as the duodenum and a portion of the jejunum are bypassed. RYGB is the well-studied procedure in adolescents with the best outcomes regarding weight loss and resolution of comorbidities. Adolescents lose approximately 50% to 85% of their excess body weight with nearly complete resolution of comorbidities. Risks specific to RYBG include anastomotic leak, small bowel obstruction, dumping syndrome (symptoms that may include nausea, bloating, vomiting, cramps, diarrhea and/or other symptoms), protein-calorie malnutrition, and micronutrient deficiency related to malabsorption [Reference]. Many of these risks are minimized by close follow-up and providing a vitamin supplement regimen (iron, folate, calcium, vitamin B12 and thiamine) to help prevent nutritional deficiencies.Laparoscopic adjustable-gastric band (LAGB) procedure is a purely restrictive bariatric procedure that has the added advantages of being reversible and having the least potential for adverse nutritional consequences. However, the LAGB has not been approved by the FDA for use in people <18 years of age, because of a lack of both short-term and long-term safety and efficacy data for adolescent patients. Sleeve gastrectomy (SG), a purely restrictive procedure, is emerging as a potential alternative bariatric procedure in well-selected adolescents. While short-term outcomes look promising, long-term data in adolescents is lacking [Reference]. Possible long-term nutritional risks, sustained weight-loss effectiveness, and durability of resolution of comorbidities in growing children have not been adequately evaluated.
Follow-up and long-term management strategy:
Epigenetic and Genetic Considerations for Obese ChildrenEpigenetic issues are those that relate to cellular changes during intrauterine development that lead to risk factors for the development of obesity. These factors do not directly cause obesity but rather lead to an increased risk when combined with other environmental and other genetic factors. Infants of diabetic mothers, especially type 2 and gestational diabetes, are at increased risk for obesity. More and more women are diagnosed with type 2 diabetes at a younger age, leading to an increase in the number of infants born to diabetic mothers. Infants with intrauterine growth restriction (IUGR) are also at increased risk of developing obesity. The mechanism for this is related to insulin resistance created by the IUGR state that continues throughout life. Infants born to obese mothers are also at increased risk of developing obesity, as well as are those infants born large for gestational age (LGA). Maternal smoking has also been shown as a risk factor for obesity. There are several genetic syndromes that are associated with obesity in childhood that need to be considered when evaluating the obese child (see the Table on page 44 in the original guideline document). Genetic testing should be considered in severely obese children, especially at a young age, who are also developmentally delayed as developmental delay goes along with many of these syndromes. There are also single gene defects that can lead to obesity in childhood referred to as monogenic human obesity syndromes. These are listed in the table on page 45 of the original guideline document. They are not associated with other syndromic characteristics and for the most part do not change management for the patient as they are not currently treatable in a unique fashion. The one exception is severe leptin deficiency. This is treatable with replacement of leptin by injection, with excellent results in weight loss. It is, however, quite rare as a cause for obesity. Many genes have been identified as playing a role in the development of obesity. The FTO or fat mass and obesity-associated gene has been studied and associated with obesity. Currently there is little clinical application for these genetic associations, but over time this is likely to improve as more and more is understood about the role genes play in relationship to the environment and the development of the obese state. Obesity is a complex chronic disease without one cause or treatment. To be knowledgeable of these genetic issues may someday help to better identify those patients at risk and who might benefit from more intense counseling, as well as develop new and novel treatment strategies. Definitions:Quality of Evidence and Strength of Recommendations
Supporting LiteratureIn addition to evidence that is graded and used to formulate recommendations, additional pieces of literature are used to direct the reader to other topics of interest (see the original guideline document). This literature is not given an evidence grade and is instead used as a reference for its associated topic. These citations are noted by (author, year) and are found in the references section of the original guideline document.Clinical Algorithm(s)A detailed and annotated clinical algorithm titled “Prevention and Management of Obesity for Children and Adolescents” is provided in the original guideline document. In addition, the following four algorithms from the National Heart, Lung and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents are provided in the original guideline document:
Another algorithm from the 2007 report “Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of Child and Adolescent Overweight and Obesity,” titled “Universal Assessment of Obesity Risk and Steps to Prevention and Treatment” is also provided in the original guideline document (see the “Guideline Availability” field). ScopeDisease/Condition(s)
Guideline Category
Clinical Specialty
Intended Users
Guideline Objective(s)
Target PopulationChildren from birth through 17 years of age Interventions and Practices ConsideredPrevention
Diagnosis/Screening
Management
Major Outcomes Considered
MethodologyMethods Used to Collect/Select the Evidence
Description of Methods Used to Collect/Select the EvidenceA consistent and defined process is used for literature search and review for the development and revision of Institute for Clinical Systems Improvement (ICSI) guidelines. Literature search terms for the current version of this document included pediatrics, children, childhood obesity published between November 2005 and March 29, 2013, systematic reviews, randomized control trials, meta-analyses, restricted to human studies, limited to pediatrics in the following topic areas: prevention, screening, treatments/drug studies, medications, gastric bypass and/or bariatric surgery, lipid and cholesterol screening, activity recommendations, screen time (TV, computer, video gaming), genetic studies, family-based therapy, readiness for change, motivational interviewing, goal setting, managing chronic conditions, binge eating disorders, binge eating disorder assessment and scale. Number of Source DocumentsNot stated Methods Used to Assess the Quality and Strength of the Evidence
Rating Scheme for the Strength of the EvidenceQuality of Evidence and Strength of Recommendations
Supporting Literature In addition to evidence that is graded and used to formulate recommendations, additional pieces of literature are used to direct the reader to other topics of interest (see the original guideline document). This literature is not given an evidence grade and is instead used as a reference for its associated topic. These citations are noted by (author, year) and are found in the references section of the original guideline document. Methods Used to Analyze the Evidence
Description of the Methods Used to Analyze the EvidenceNot stated Methods Used to Formulate the Recommendations
Description of Methods Used to Formulate the RecommendationsNew Guideline Development Process A work group consisting of 6 to 12 members that includes physicians, nurses, pharmacists, other healthcare professionals relevant to the topic, and an Institute for Clinical Systems Improvement (ICSI) staff facilitator develops each document. Ordinarily, one of the physicians will be the leader. Most work group members are recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, 1 or 2 members may be recruited from medical groups, hospitals, or other organizations that are not members of ICSI. Patients on occasion are invited to serve on work groups. The work group will meet for 7 to 8 three-hour meetings to develop the guideline. A literature search and review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the algorithm and write the annotations and footnotes and literature citations. Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review. Revision Process of Existing Guidelines ICSI scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature. For documents that are revised on a 24-month schedule, ICSI checks with the work group on an annual basis to determine if there have been changes in the literature significant enough to cause the document to be revised earlier or later than scheduled. For yearly reviewed documents, ICSI checks with every work group 6 months before the scheduled revision to determine if there have been changes in the literature significant enough to cause the document to be revised earlier than scheduled. Literature Search ICSI staff, working with the work group to identify any new pertinent clinical trials, systematic reviews, or regulatory statements and other professional guidelines, conduct a literature search. Revision The work group will meet for 1 to 2 three-hour meetings to review the literature, respond to member organization comments, and revise the document as appropriate. A second review by members is indicated if there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations. If a review by members is not needed, the document goes to the appropriate steering committee for approval according to the criteria outlined in the “Description of Method of Guideline Validation” field. Rating Scheme for the Strength of the RecommendationsSee the “Rating Scheme for the Strength of the Evidence” field. Cost AnalysisThe guideline developers reviewed published cost analyses. Method of Guideline Validation
Description of Method of Guideline ValidationCritical Review Process The purpose of critical review is to provide an opportunity for the clinicians in the member groups to review the science behind the recommendations and focus on the content of the guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give the work group and to consider changes necessary across systems in their organization to implement the guideline. All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a criterion for continued membership within the Institute for Clinical Systems Improvement (ICSI). After the critical review period, the guideline work group reconvenes to review the comments and make changes, as appropriate. The work group prepares a written response to all comments. Document Approval Each document is approved by the Committee for Evidence-Based Practice (CEBP). The committee will review and approve each guideline/protocol, based on the following criteria:
Once the document has been approved, it is posted on the ICSI Web site and released to members for use. Evidence Supporting the RecommendationsReferences Supporting the Recommendations
Type of Evidence Supporting the RecommendationsThe type of supporting evidence is classified for selected recommendations (see the “Major Recommendations” field). Benefits/Harms of Implementing the Guideline RecommendationsPotential BenefitsEffective prevention and appropriate management of obesity in children and adolescents Potential HarmsPhysical Activity Possible injuries related to exercise Weight Loss Medications
Bariatric Surgery Risks specific to Roux-en-Y gastric bypass (RYBG) include anastomotic leak, small bowel obstruction, dumping syndrome (symptoms that may include nausea, bloating, vomiting, cramps, diarrhea and/or other symptoms), protein-calorie malnutrition, and micronutrient deficiency related to malabsorption. ContraindicationsContraindicationsPregnant, breastfeeding adolescents and those planning to become pregnant within two years of surgery should not be considered candidates for bariatric surgery. Qualifying StatementsQualifying Statements
Implementation of the GuidelineDescription of Implementation StrategyOnce a guideline is approved for general implementation, a medical group can choose to concentrate on the implementation of that guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others, they may form an action group. In the action group each medical group sets specific goals they plan to achieve in improving patient care based on the particular guideline(s). Each medical group shares its experience and supporting measurement results within the action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented and shared with interested medical groups within the collaborative. Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and tobacco cessation. Implementation Recommendations Prior to implementation, it is important to consider current organizational infrastructure that address the following:
The following system changes were identified by the guideline work group as key strategies for health care systems to incorporate in support of the implementation of this guideline:
Institute of Medicine (IOM) National Healthcare Quality Report CategoriesIOM Care Need
IOM Domain
Identifying Information and AvailabilityBibliographic Source(s)
AdaptationNot applicable: The guideline was not adapted from another source. Date Released2013 Jul Guideline Developer(s)
The Institute for Clinical Systems Improvement (ICSI) is comprised of 50+ medical group and hospital members representing 9,000 physicians in Minnesota and surrounding areas, and is sponsored by five nonprofit health plans. For a list of sponsors and participating organizations, see the ICSI Web site. Source(s) of Funding
Guideline CommitteeCommittee on Evidence-based Practice Work Group Members : Angela Fitch, MD ( Work Group Leader ) (Park Nicollet Medical Group) (Bariatrician); Claudia K. Fox, MD, MPH ( Work Group Leader ) (University of Minnesota Physicians) (Director of Pediatric Weight Management Program); Nancy K. Monaghan-Beery, DO, (Essentia Health Children’s Services) (Pediatrician); Jessica N. Larson, MD (Fairview Health Services) (Pediatrician); Tracy Newell, RD, LD, CNSD (HealthPartners Medical Group and Regions Hospital) (Registered Dietician); Patrick J. O’Connor, MD, MA, MPH (HealthPartners Medical Group and Regions Hospital) (Family Medicine and Geriatrics); Andrew J. Thomas, MD (HealthPartners Medical Group and Regions Hospital) (Pediatric Sports Medicine); Tara Kaufman, MD (Mayo Clinic) (Family Medicine); Esther Krych, MD (Mayo Clinic) (Community Pediatrics and Adolescent Medicine); Seema Kumar, MD, PdE (Mayo Clinic) (Endocrinology, Pediatric & Adolescent Medicine); Jo Anne Judge-Dietz, PHN, MA (Olmsted County Public Health Services); Amber Spaniol, RN, LSN, PHN (Robbinsdale School District #281) (Health Services Program Director); Nicole Martens, CNP (South Lake Pediatrics) (Pediatrics); Kathleen Bauerly, BSN, RN, LSN (St. Cloud Community Schools); Amy C. Gross, PhD, LP, BCBA (University of Minnesota) (Assistant Professor of Pediatrics); Dan Leslie, MD (University of Minnesota Physicians) (GI and Bariatric Surgery); Deborah F. Landin, RN (Warroad Public Schools) (School Nurse); Carla Heim (Institute for Clinical Systems Improvement [ICSI]) (Clinical Systems Improvement Coordinator); Beth Webb, RN, BA (ICSI) (Project Manager) Financial Disclosures/Conflicts of InterestThe Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols. In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011). Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group. The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site. **Disclosure of Potential Conflicts of Interest** Kathleen Bauerly, BSN, RN, LSN (Work Group Member) Angela
Fitch, MD (Work Group Leader) Claudia Fox, MD, MPH (Work Group Leader) Amy Gross, PhD, LP, BCBA (Work Group Member) Jo Anne Judge-Dietz, PHN, MA (Work
Group Member) Tara Kaufman, MD (Work Group Member) Esther H. Krych, MD (Work Group Member) Seema Kumar, MD, PdE (Work Group Member) Deborah Landin, RN (Work Group Member) Jessica Larson, MD (Work Group Member) Daniel Leslie, MD (Work Group Member) Nicole Martens, CNP (Work Group Member) Nancy K. Monaghan-Beery, DO (Work Group Member) Tracy L. Newell, RD, LD, CNSD (Work Group Member) Patrick O’Connor, MD, MA, MPH (Work Group Member) Amber Spaniol, RN, LSN, PHN (Work Group Member) Andrew Thomas, MD (Work Group Member) Guideline StatusThis is the current release of the guideline. Guideline AvailabilityAvailable for purchase from the Institute for Clinical Systems Improvement (ICSI) Web site. Also available to ICSI members for free at the ICSI Web site and to Minnesota health care organizations free by request at the ICSI Web site. Availability of Companion DocumentsThe following companions are provided to those who access the guideline (see the “Guideline Availability” field):
Additionally, the following are available in the appendices of the original guideline document:
Patient ResourcesA patient action plan is available in Appendix F of the original guideline document (see the “Guideline Availability” field). Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content. NGC StatusThis NGC summary was completed by ECRI Institute on November 21, 2013. This summary was updated by ECRI Institute on April 15, 2016 following the U.S. Food and Drug Administration advisory on Metformin-containing Drugs. Copyright StatementThis NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original guideline, which is subject to the guideline developer’s copyright restrictions. The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties. If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization’s employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Guidelines. DisclaimerNGC DisclaimerThe National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site. All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities. Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria. NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes. Readers with questions regarding guideline content are directed to contact the guideline developer. Which of the following is a guideline for preventing childhood obesity?The most important strategies for preventing obesity are healthy eating behaviors, regular physical activity, and reduced sedentary activity (such as watching television and videotapes, and playing computer games).
What is pediatric anticipatory guidance?Anticipatory guidance, specific to the age of the patient, includes information about the benefits of healthy lifestyles and practices that promote injury and disease prevention. Common examples of anticipatory guidance include reminding parents to have their children use bicycle helmets and to use sunscreen.
What topics are commonly included in anticipatory guidance quizlet?What topics are included in anticipatory guidance? safety, nutrition, sleep, play exercise, development and discipline.
Why is it important to measure the growth weight and height or length of the child during each office visit?Body measurements of infants and children help to identify significant conditions, including growth retardation, malnutrition, obesity, and developmental abnormalities. Plot all measurements of head circumference, length/height, and weight on age- and gender-specific CDC Growth Charts.
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