Preventing Childhood Obesity - Evidence Policy and Practice.pdf

Working in primary care
Adolescence
Assessment and m onitoring
Assessment of the adolescent should include weight
and height (BMI) and in those at risk such as those
over the 95th percentile of BMI or with a family
history of co - morbidity, waist circumference, blood
pressure, serum fasting glucose, insulin and lipid
levels, and liver function tests. Co - morbidities include
psycho - social dysfunction or depression, bulimia or
other eating disorder, obstructive sleep apnea, asthma,
raised blood pressure, dyslipidemia, metabolic syndrome,
insulin resistance or Type 2 diabetes, gall
bladder disease, steatohepatitis, polycystic ovarian
syndrome and orthopedic complications such as
slipped capital femoral epiphyses.
Whether or not to involve the parents in consultations
with older children about weight issues should
be considered in light of the older child ’ s maturity and
competence to make decisions. 15 It is helpful to assess
the adolescents ’ view about their weight, eating and
physical activity patterns, as well as their social, cultural
and ethnic context, previous attempts to change,
readiness to change and confidence in their ability to
make change. 15 There are also other issues of significance
in this age group, such as peer pressures, issues
of alcohol, drugs and sexuality. It is also a time of
increased prevalence of eating disorders such as
bulimia and anorexia. The HEEADSSS mnemonic
(Table 31.2 ) may be useful to investigate the context
of any potential weight issues. Questions to ask about
eating could include: “ What do you like or not like
about your body? ” and “ Have there been any changes
in your weight over the last year? ” 25
Management
The same principles of advice around diet, physical
activity and sedentary behaviors would apply to this
Table 31.2 The HEEADSS mnemonic.
H
E
E
A
D
S
S
S
Home environment
Education/employment
Eating
Peer - related Activities
Drugs
Sexuality
Suicide & depression
Safety from injury and violence
group but the issues and barriers are different from
younger children and more research is needed which
addresses this group.
Little evidence exists around primary care interventions
for dietary change in overweight or obese adolescents.
There has been some evidence of improvement
in fruit and vegetable consumption over two years
among adolescents using a primary care intervention
in the US, but this involved a group of underweight
adolescent girls who are likely to have very different
population characteristics and responses. 26 Also, the
intervention was intensive (bi - monthly meetings, self -
monitoring and quarterly telephone calls).
There is a small amount of evidence for physical
activity counseling in primary care among adolescents.
In a Spanish trial, which assessed effectiveness
of 5 – 10 minutes of physical activity counseling versus
no counseling, significantly more adolescents were
active in the intervention group compared with the
control at 6 and 12 months. 27 The addition of more
intensive follow - up did not improve increases in
physical activity among adolescents in a US trial over
7 months. 28
In the adolescent, there is some evidence for short -
to medium - term effectiveness in weight loss for pharmaceutical
treatments, such as phentermine, although
this also causes severe insomnia. 14 Metformin may be
useful in the obese adolescent with hyperinsulinemia.
14 A 6 – 12 month trial of orlistat or sibutramine,
or bariatric surgery, such as lap banding, may be
appropriate after specialist assessment, particularly in
morbid obesity (e.g. BMI ≥ 40) or when co-morbidities
exist, although evidence for long - term effectiveness
in this age - group is lacking. 15,29 Management of
co-morbidities identified is also required. Other
minor medical sequelae of obesity may also require
management such as musculoskeletal discomfort,
heat intolerance or shortness of breath. 14
Incorporating the e vidence
Primary care initiatives need to work within the
context of wider organizational and policy changes
that support the advice given. At a practice level, the
impact of simple advice should not be underestimated,
even in light of limited evidence for specific
primary care intervention. Partnership and goal -
setting with parents, children and adolescents around
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