PACE-PC: Primary Care Management of Adolescent Obesity

Obesity in adolescence is becoming increasingly prevalent. Thirty years ago the prevalence of obesity among adolescents aged 12-19 years was approximately 6%. Between 1980 and 1994, the number of children and adolescents meeting criteria for overweight/obese, as defined by a body mass index (BMI) > 95% for children of the same age and gender, increased by 100% in the United States (Ogden, Flegal, Carroll et al., 2002). The increased prevalence of childhood obesity has been universal in all age, gender, and ethnicity classification. As of the year 2002, over 16% of adolescents are obese in the United States (Ogden et al., 2002) and this problem is even more important in selected regions of the country. For example, the California Center for Public Health Advocacy, (2002), reported that the percentage of 5th, 7th, and 9th graders (ages 10 and 15 years) who had a body mass index (BMI) greater than the 95th percentile ranged from 17.3% - 36% depending upon school attended. Overall childhood obesity is increasingly recognized as one of the nation's most important health issues (IOM, 2004).

Obesity affects all parts of the body including the brain, lungs, heart, liver, pancreas, intestines, kidneys, and skeleton. Consequently, children who meet the criteria for obesity are at risk for serious health problems. A lower quality of life has also been shown among children who are overweight (Schwimmer et al., 2003). Adolescent obesity is also a significant predictor of adult obesity (Clark & Lauer, 1993; Mossberg, 1989). Approximately 1/3 of overweight adults are overweight before 20 years of age. An even larger percentage of morbidly obese adults became obese as children (Rimm & Rimm, 1976). Overweight adolescents are the pediatric group carrying the highest risk for childhood obesity persistence into adulthood (Whitaker et al., 1997).

There is strong evidence of the health benefits of physical activity (USDHHS, 1996; Biddle et al., 2004) including improvements in risk of cancer, longevity, cardiovascular diseases, (CVD), CVD risk factors, diabetes, obesity, osteoporosis, immune functioning, and mental health. More recent guidelines from the Dietary Guidelines for Americans (USDHHS, 2005) and the United Kingdom Health Education Authority recommend 60 minutes of daily PA for youth (Biddle et al., 1998; Cavill et al., 2001). Although national survey data in the U.S. indicate that about two-thirds of adolescent boys and about one-half of adolescent girls are meeting an adult-oriented recommendation for vigorous activity (Pate et al., 1994), objective measures suggest less than 40% of teens are meeting the 60 minute guideline (Pate et al., 2002). Females, older adolescents, minorities and disadvantaged youth are even less likely to be meeting this recommendation (USDHHS, 1998).

Poor dietary behaviors are a known risk factor for the development of obesity, as well as for the nation's three leading causes of death: CHD, cancer and stroke. Research supports that a diet rich in fruits and vegetables and low in fat is important in preventing these chronic diseases, and is recommended by the USDA, USDHHS, Surgeon General, NRC, NHLBI, NCI, ACS, and AHA (USDA, 1991; USDA, 1992; National Research Council, 1989; NHLBI, 1990; NHLBI, 1991; NCI, 1991; Weinhouse et al., 1991; AHA, 1988). Although national surveys indicate a decline in the average proportion of calories from total and saturated fat over the past several decades, the CDC estimated in 2000 that only 38% of individuals 2 years and older met the recommendation for total fat intake and 41% of these individuals met the recommendation for saturated fat intake. Simple dietary restriction has not been associated with successful weight control (NAS, 1991) and may even result in a nutritionally inadequate diet. Thus, rather than focusing only on limiting total energy intake, it is important to promote a diet that is nutrient dense: high in vegetables, fruits, grains, and other fiber-rich plant foods, yet low in fat, at a given level of energy intake.

Obesity is a chronic health condition (WHO, 1998). As such, long-term medical management is appropriate, with particular attention to comorbidity development and identification. According to the Institute of Medicine (IOM), primary care is "the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients and practicing within the context of family and community" (IOM, 1996)." Various studies have evaluated primary healthcare and found that primary care provides accessible, comprehensive, coordinated, adequately communicated, longitudinal healthcare (Flocke, 1997; Safran et al., 1998; Starfield, 1998). Primary healthcare has been called the "medical home;" and the American Academy of Pediatrics (AAP) (1992, p. 251) describes the "medical home" (with respect to care for infants, children, and adolescents) as: "accessible, continuous, comprehensive, family centered, coordinated, and compassionate"; "delivered or directed by physicians who are able to manage or facilitate essentially all aspects of pediatric care"; and involving physicians who "should be known to the child and family and able to develop a relationship of mutual responsibility and trust." Thus, pediatricians, family physicians and others in primary care have many opportunities to assist with obesity treatment in children.