Antecipatory Guidance

THE BRIGHT FUTURES CLINIC AL GUIDE TO PERFORMING PRE VENTIVE SERVICES

ANTICIPATORY GUIDANCE

T
he anticipatory guidance component of every Bright Futures visit
gives the health care professional, parents, and the child or adolescent
a chance to ask questions and discuss issues of concern. This guidance
is organized around 5 priority areas, and specific questions and discussion
points are provided for the health care professional. Health care professionals
are encouraged to adapt and enhance these questions and discussion points
to meet the specific needs of their families and communities.
The chapters in this section of the book focus on topics of public health
importance, in which active discussion and guidance can make a positive
impact in the lives of families. For example, the Motivational Interviewing
chapter provides a framework to help health care professionals talk to
patients and families about behavior change, a subject that is central
to all the topics in this section of the book.

Bicycle Helmets
Joel Bass, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Children, Adolescents, and Media
Victor C. Strasburger, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Cardio-metabolic Risk of Obesity
Stephen Cook, MD COMING SOON

Motivational Interviewing
Robert Schwartz, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Secondhand Smoke Exposure
and Tobacco Cessation
Dana Best, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Weight Maintenance and Weight Loss
Sandra G. Hassink, MD and Mary Lou Pulcino, NP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 ANTICIPATORY GUIDANCE

1


JOEL BASS, md

BICYCLE HELMETS

Why Is It Important to Include Bicycle Effective programs directed specifically at increasing the
Helmets in Anticipatory Guidance? use of bicycle helmets in children have leveraged the
synergy of legislation, community-based initiatives, and
Many children and youth love to bicycle but they economic incentives.4 One report, which also included
don’t always wear a helmet. Bicycling is a popular reinforcing community initiatives with advice from
recreational activity in the United States, particularly pediatric practices, resulted in a significant increase in
among children. It is estimated that 33 million children helmet use.5
ride bicycles for nearly 10 billion hours each year.

Unfortunately, only 15% of children use helmets all or
How Should You Provide Anticipatory
most of the time while cycling.1 Guidance About Bicycle Helmets?
Bicycle-related injuries are common. Every year, about Urge parents to
450,000 children are treated in emergency departments
for bicycle-related injuries. Of the injuries, 153,000 are for ••Check that the helmet meets the bicycle safety
standards of the Consumer Product Safety
head injuries. These head injuries are often very serious
Commission.
and account for most bicycle-related deaths.

Many of the nonfatal injuries also are of great ••Fit the helmet squarely on top of the child’s head,
covering the forehead. Be certain that it does not move
consequence, often producing lifelong disability
around on the head or slide down. Adjust the chin
associated with brain damage.2
strap to a snug fit.
Bicycle helmets protect children. It is well established
that bicycle helmets are effective in preventing head ••Be certain that the child wears the helmet every time
he or she rides the bike.
injuries associated with bicycling. Overall, helmets
decrease the risk of head and brain injury by about 80%.
The risk of facial injuries to the upper and mid face is
••Serve as a model for the child. Parents also should
always wear a helmet when bicycle riding.
reduced by 65%.
Use materials from the American Academy of Pediatrics
Counseling and safety programs can increase helmet (AAP) Injury Prevention Program (TIPP) to enhance your
use. Although not specific to bicycle helmet counseling, counseling. The TIPP sheets “About Bicycle Helmets” and
injury prevention counseling of parents of young children “Tips for Getting Your Children to Wear Bicycle Helmets”
in the primary care setting has been shown to result in have additional educational points.

enhanced educational and behavioral outcomes. In some
cases, it has resulted in decreased injuries.3 Consider performing an actual assessment of the helmet
in your office. It can provide further reinforcement and
education about bicycle helmets.6

2

B I C YC L E H E L M E T S

What Anticipatory Guidance Should You survey is completed by the child. Each survey includes
Provide if You Encounter Resistance to a physician copy in which at-risk responses are easily
identified.7 This provides a useful, interactive method
Helmet Use?
to counsel parents and children and also provides
Give parents who do not require their children to use a documentation of the counseling process.
helmet extensive information about the risks of bicycle-
Web Sites
related head injuries, including the TIPP sheets and details
of state or local legislation or regulations. American Academy of Pediatrics: http://www.aap.org/
Whenever available, provide discount coupons for Bicycle Helmet Safety Institute http://www.bhsi.org/
approved helmets. If your community has an active index.htm
helmet program, they may provide access to free helmets
under certain circumstances. Centers for Disease Control and Prevention: http://www.
cdc.gov/
Children who answer that they do not use a bicycle
helmet should be given information appropriate to their Harborview Injury Prevention and Research Center: http://
age and cognitive level on the need for helmets. Materials depts.washington.edu/hiprc/
for children from ongoing state or local community
programs also may be available. References
1. Bicycle injury interventions: bicycle helmet effectiveness.
What Results Should You document? Harborview Injury Prevention & Research Center Web Site. 2001.
http://depts.washington.edu/hiprc/practices/topic/bicycles/
Documentation of counseling efforts is always helmeteffect.html
recommended. The physician copies of the Framingham 2. Injury-Control Recommendations: Bicycle Helmets. MMWR,
Safety Surveys also are useful for documentation and to 44(16), 325 (1995). available at: cdc.gov/.mmwr/preview/
identify patients who would benefit from reviewing the mmwrhtml/00036941.htm
issue of helmet use at subsequent visits. 3. Bass JL, Christoffel KK, Widome MW, et al. Childhood injury
prevention counseling in primary care settings: a critical review of
the literature. Pediatrics. 1993;92:544–550
CPT and ICD-9-CM Codes 4. Bicycle injury interventions: programs to increase helmet use.
99401 Preventive medicine counseling or risk Harborview Injury Prevention & Research Center Web Site. 2001.
http://depts.washington.edu/hiprc/practices/topic/bicycles/
factor reduction intervention(s) provided helmeteduc.html
to an individual; approximately 15
5. Abularrage JJ, DeLuca AJ, Abularrage CJ. Effect of education and
minutes.
legislation on bicycle helmet use in a multiracial population. Arch
The American Academy of Pediatrics publishes a complete line of coding publications Pediatr Adolesc Med. 1997;151:41–44
including an annual edition of Coding for Pediatrics. For more information on these
excellent resources, visit the American Academy of Pediatrics online bookstore at
www.aap.org/bookstore/.
6. Parkinson GW, Hike KE. Bicycle helmet assessment during well
visits reveals severe shortcomings in condition and fit. Pediatrics.
2003;112:320–323
Resources
7. American Academy of Pediatrics Committee and Section on Injury,
Violence and Poison Prevention. TIPP: A Guide to Safety Counseling
Tools
in Office Practice. Elk Grove Village, IL: American Academy of
Pediatrics; 1994
The AAP TIPP Program has injury prevention counseling
questionnaires, including the Framingham Safety Survey:
From 5 to 9 Years and from 10 to 12 Years. This survey
covers the issue of bicycle helmet use. The 5 to 9 Years
survey is completed by the parent and the 10 to 12 Years

3 PRE VENTIVE SER VICES MANUAL


VICTOR C. STRASBURGER, md

CHILDREN, ADOLESCENTS,
AND MEDIA

Why Is It Important to Include media positive reinforcer for producing aggression. Bullying
Usage in Anticipatory Guidance? online and via text messaging is also an increasing
concern.
Children and teenagers spend more than 7 hours
Sex. Television shows for teenagers actually contain
a day with a variety of different media.1 Television
more sexual content than adults’ shows, yet less than
predominates, with more than 4 hours a day of screen
10% of that content involves the discussion of risks or
time, although viewing may now be via a computer
responsibilities involved in sexual relationships. In the
or a cell phone screen instead of a TV set. Media use
absence of effective sex education at home or in schools,
represents the leading leisure time activity for young
the media have arguably become the leading sex
people—they spend more time with media than they
educator in the United States. Several longitudinal studies
do in any other activity except sleeping. Increasingly,
now link exposure to sexual content at a young age to
preteens and teens are using new technologies (social
earlier onset of sexual intercourse. In addition, up to 20%
networking sites, cell phones) to communicate with each
of teens have engaged in “sexting.” 6
other; but there are documented risks to this as well,
including bullying and displays of risky behaviors online Drugs. More than $20 billion a year is spent advertising
and in text messages.2–4 legal drugs in the United States—$13 billion on cigarettes,
$5 billion on alcohol, and $4 billion on prescription
Thousands of studies now attest to the power of
drugs. Numerous studies have found that advertising can
the media to influence virtually every concern that
be a potent influence on whether teenagers will start
pediatricians and parents have about the health and
using cigarettes or alcohol. New research has found that
development of children and adolescents—sex, drugs,
witnessing smoking or drinking alcohol in movies may
obesity, school achievement, bullying, eating disorders,
be the leading factor associated with adolescent onset of
and even attention-deficit disorder (ADD) and attention-
substance use.
deficit/hyperactivity disorder (ADHD).5 The research has
been well documented and summarized in a number of Obesity. Dozens of studies have implicated media in the
American Academy of Pediatrics (AAP) policy statements current worldwide epidemic of obesity; however, the
and in recent books. mechanism is unclear. Young people see an estimated
10,000 food ads per year on TV, most of them for junk
Media violence. The impact of television in particular
food or fast food. Screen time increases unhealthy
on aggressive behavior in young people has been
snacking, may displace more active pursuits, and may
documented since the early 1950s in more than 2,000
interfere with healthy sleep habits.
published studies. While media violence is not the

leading cause of violence in society, it can be a significant Eating disorders. The impact of media on unhealthy
factor. In addition, virtually everyone is desensitized by body self-image, especially in young girls, has been well
the violence they see on TV, movie, and video screens. documented, especially in advertising and mainstream
American media specialize in portraying the notion of media. Two studies have linked media use with eating
justifiable violence (eg, “good” guys versus “bad” guys). In disorders.
the research literature, this is the single most powerful

4

CHILDREN, ADOLESCENTS, AND MEDIA

Other health concerns. Several studies have linked Because of the research findings, children or teens who
media use with ADD, ADHD, and poorer school are overweight or obese, have school problems, exhibit
performance. In addition, half a dozen studies have found aggressive behavior, display sexual precociousness, or are
potential language delays in infants younger than 2 years depressed or suicidal should be asked specifically about
exposed to TV or videos. how much screen time they spend and what programs,
specifically, they are watching.
Prosocial media. While all of these potential health
problems exist, clinicians also need to recognize the
extraordinary power of the media to teach prosocial What Anticipatory Guidance Should You
attitudes and behaviors like empathy, cooperation, Provide Regarding media Usage?
tolerance, and even school readiness skills. Media have an
The AAP makes the following recommendations for
amazing ability to teach—the only question is, what are
advising parents:
children and teenagers learning from them?
••Limit total entertainment screen time to fewer than 2
Should You Screen for media Usage? hours per day.

Since they potentially influence numerous aspects of ••Avoid screen time for babies younger than 2 years.
child and adolescent health, the media may represent the
most important area of anticipatory guidance in well-
••Encourage a careful selection of programs to view.
child visits. One study has shown that a minute or two of ••Coview and discuss content with children and
office counseling about media violence and guns could adolescents.
reduce violence exposure for nearly 1 million children
per year.7 Given the sheer number of hours that children
••Teach critical viewing skills.
and teens spend with media, as well as the convincing ••Limit and focus time spent with media. In particular,
research on health effects of the media, counseling is parents of young children and preteens should avoid
imperative. Parents are also looking for help, especially exposing them to PG-13 and R-rated movies.
understanding and supervising computer use and social
networking sites. ••Be good media role models—children often develop
their media habits based on their parents’ media
behavior.
How Should You Screen for media Usage?
••Emphasize alternative activities.
••Create an “electronic media–free” environment in
To screen for media usage, clinicians should ask 2
questions about media use at health supervision visits:
children’s rooms.
(1) How much screen time per day does the child
spend? and ••Avoid use of media as an electronic babysitter.
(2) Is there a TV set or Internet connection in the child’s ••Avoid watching TV during family meals.
bedroom?
What Results Should You document?
The AAP Media Matters campaign developed a media
history form for parents that can be filled out while Total amount of screen time per day and presence of a TV
waiting to see a clinician. set or an Internet connection in the bedroom should be
documented.


Resources Council on Communications and Media blog: http://cocm.
blogspot.com/
AAP Policy Statements
Kaiser Family Foundation: http://www.kff.org
American Academy of Pediatrics Committee on Many content analyses and review articles on children
Communications. Children, adolescents, and advertising. and media.
Pediatrics. 2006;118:2563–2569 Media history form: http://www.aap.org/advocacy/
American Academy of Pediatrics Committee on Public Media%20History%20Form.pdf
Education. Sexuality, contraception, and the media.
Advice for Parents
Pediatrics. 2001;107:191–194

American Academy of Pediatrics Council on AAP: SafetyNet: Keep Your Children Safe Online: http://
Communications and Media. Policy statement: media safetynet.aap.org/
violence. Pediatrics. 2009;124:1495–1503
References
Books
1. Rideout V. Generation M2: Media in the Lives of 8- to 18-Year-Olds.
Christakis DA, Zimmerman FJ. The Elephant in the Living Menlo Park, CA: Kaiser Family Foundation; 2010

Room: Make Television Work for Your Kids. New York, NY: 2. Moreno M. Update on social networking sites. Pediatr Ann. In press
Rodale Press; 2006
3. Moreno MA, Parks MR, Zimmerman FJ, Brito TE, Christakis DA.
Display of health risk behaviors on MySpace by adolescents:
Strasburger VC, Wilson BJ, Jordan AB. Children,
prevalence and associations. Arch Pediatr Adolesc Med.
Adolescents, and the Media. 2nd ed. Thousand Oaks, CA: 2009;163:27–34
Sage; 2009
4. Ybarra ML, Espelage DL, Mitchell KJ. The co-occurrence of Internet
harassment and unwanted sexual solicitation victimization and
Web Sites
perpetration: associations with psychosocial indicators. J Adolesc
Health. 2007;41:S31–S41
American Academy of Pediatrics: www.aap.org
5. Strasburger VC, Jordan AB, Donnerstein E. Health effects of media
Center on Media and Child Health: http://www.cmch.tv/ on children and adolescents. Pediatrics. 2010;125(4):756–767
Online library of research articles. 6. National Campaign to Prevent Teen and Unplanned Pregnancy.
Sex and Tech. Washington, DC: National Campaign to Prevent Teen
Children’s Health Topics: Internet & Media Use: http:// and Unplanned Pregnancy; 2008
www.aap.org/healthtopics/mediause.cfm
7. Barkin SL, Finch SA, Ip EH, et al. Is office-based counseling about
Common Sense Media: http://www.commonsensemedia. media use, timeouts, and firearm storage effective? Results from
org/ a cluster-randomized, controlled trial. Pediatrics. 2008;122(1):e15–
e25
Ratings and advice for parents on a variety of different
media.


6


ROBERT SCHWARTZ, md

MOTIVATIONAL
INTERVIEWING
Motivational interviewing (MI) is a shared decision-making strategy for enhancing a
patient’s motivation to make a behavior change—for example, in weight, tobacco,
or safety counseling. It is a particularly helpful method in addressing resistance to
change because it helps you create an alliance with the patient irrespective of his or
her willingness to make a change. Although MI is not specifically described in Bright
Futures, these methods are quite effective in providing many types of anticipatory
guidance where a change is needed.

What Is motivational Interviewing? improve your self-confidence in counseling skills and your
efficacy in helping patients change behavior.
Motivational interviewing is a patient-centered
guiding method for enhancing motivation to Motivational interviewing works. Randomized
change.1,2 Ambivalence is a stage in the normal process controlled trials have demonstrated the efficacy of MI in
of change, and must be resolved for change to occur.1 treating alcohol and substance abuse problems.4–8
Motivational interviewing can be effective for those who Motivational interviewing also is being used to address
are initially ambivalent about making behavior changes other health behaviors, such as eating, smoking, physical
because it allows the person to explore and resolve their activity, and adherence with treatment regimens.3–5,7,9,10, 11
ambivalence.1,2
Motivational interviewing may be useful with
Motivational interviewing is a collaborative process of adolescents. Because of its lack of authoritarian style
decision-making. Its style is empathetic, nonjudgmental, and avoidance of confrontation, MI may be effective in
supportive, and nonconfrontational.1,3 It acknowledges counseling adolescents.5,6
that behavior change is driven by motivation, not
information. Motivation to change occurs when a person
How do You do motivational
perceives a discrepancy or conflict between current
behavior and important life goals, such as being healthy.1,3
Interviewing?
The reasons for behavior change arise from the patient’s The acronym OARES summarizes the key components of
own goals or values, and it is up to the patient to find MI.1

solutions to the problem.1
••Ask Open-ended questions.
Why Is It Important to Use motivational `• This type of question uses the patient’s own
Interviewing in Anticipatory Guidance? words, is not biased or judgmental, and cannot be
answered by a simple “yes” or “no.” For example,
Physicians have been trained to provide information, instead of asking, “Are you feeling OK?” you might
but not how to help patients change their behavior. restate the question as, “Help me understand how
Pediatricians often lack confidence in their motivational you feel.”
and behavioral counseling skills. Training in MI may
7

M O T I VAT I O N A L I N T E R V I E W I N G

••Affirm what your patient says. ••Summarize.
`• Affirmations are statements that recognize your `• At the end, summarize your conversation and
patient’s strengths and efforts. Example: “You are decisions. This links together and reinforces what
really connected to your family and friends.” your patient has stated.

••Use Reflective listening. The acronym FRAMES is a brief adaptation of MI.5,6
`• This type of listening allows you to clarify the ••Provide Feedback on the risks and consequences of the
meaning and feeling of what your patient says. behavior.
Examples: “It sounds like you are not happy in the
relationship with your boyfriend.” “You feel like
••Emphasize the patient’s personal Responsibility to
change or not to change. “It’s up to you.”
nobody understands you.”

••Elicit self-motivational statements or “change talk.” ••Provide Advice—your professional opinion and
recommendation.
`• A person’s belief in his or her ability to change
is a good predictor of success. The first step in
••Offer Menus. You provide a menu of strategies, not a
single solution. The patient selects the approach that
affirming this belief and to elicit “change talk” is to seems best for him or her.
ask the patient about their level of “importance and
confidence” in making a behavior change using the ••Show Empathy. A positive, caring manner will foster
following scale.1,3 rapport.

••Encourage Self-efficacy. Encourage positive “change
talk” and support your patient in believing that he or
Importance and Confidence Scale she can change the behavior.

IMPORTANCE Continued resistance may indicate that you misjudged
On a scale of 0 to 10, with 10 being very important, your patient’s readiness or motivation to change.12
how important is it for you to change? Be empathetic and use reflective listening. You could
respond by saying, “It sounds like this may not be the
0 1 2 3 4 5 6 7 8 9 10
right time for you to make a change. Perhaps you are
Not at all Somewhat Very
concerned about something else.”
CONFIDENCE
On a scale of 0 to 10, with 10 being very interested,
What Results Should You document?
how interested are you in changing? Document topics (behaviors) discussed, the patient’s level
0 1 2 3 4 5 6 7 8 9 10 of importance and confidence in making change, plans
Not at all Somewhat Very for follow-up, and time spent counseling.

Follow this “importance and confidence” questions
scale with 2 probes: “You chose (STATE NUMBER).
Why didn’t you choose a lower number?” This
question elicits arguments for change by the patient.
Then ask, “What would it take to get you to a higher
number?” This identifies barriers.3


Counseling and/or Risk-Factor Reduction References
Intervention Codes 1. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for
Change. 2nd ed. New York, NY: Guilford Press; 2002

CPT Codes 2. Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for
Practitioners. London, UK: Churchill Livingstone; 1999
Individual Counseling
3. Resnicow K, DiIorio C, Soet JE, Ernst D, Borrelli B, Hecht J.
99401 15 minutes Motivational interviewing in health promotion: it sounds like
99402 30 minutes something is changing. Health Psychol. 2002;21:444–451

99403 45 minutes 4. Erickson S, Gerstle M, Feldstein SW. Brief interventions and
motivational interviewing with children, adolescents, and their
99404 60 minutes parents in pediatric healthcare settings. Arch Pediatr Adolesc Med.
2005;159:1173–1180
Group Couseling
5. Sindelar HA, Abrantes AM, Hart C, Lewander W, Spirito A.
99411 30 minutes
Motivational interviewing in pediatric practice. Curr Probl Pediatr
99412 60 minutes Adolesc Health Care. 2004;34:322–339
The American Academy of Pediatrics publishes a complete line of coding publications 6. Tevyaw TO, Monti PM. Motivational enhancement and other
excellent resources, visit the American Academy of Pediatrics online bookstore at brief interventions for adolescent substance abuse: foundations,
www.aap.org/bookstore/. applications and evaluations. Addiction. 2004;99(suppl 2):63–75

7. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational
Do not use these codes to report counseling for patients interviewing: a meta analysis of controlled clinical trials. J Consult
with symptoms or established illness. Clin Psychol. 2003;71:843–861

If counseling by the physician makes up more than 50% 8. Spirito A, Monti PM, Barnett NP, et al. A randomized clinical trial of
a brief motivational intervention for alcohol positive adolescents
of the face-to-face time with the patient/family, then time
treated in an emergency department. J Pediatr. 2004;145:396–402
may be considered the controlling factor to qualify for a
particular level of evaluation and management services. 9. Berg-Smith SM, Stevens VJ, Brown KM, et al. A brief motivational
intervention to improve dietary adherence in adolescents. Health
Code 99078 is for a physician providing counseling/ Ed Res. 1999;14 (3):399–410
educational services in a group setting for patients with 10. Resnicow K, Dilorio C, Soet JE. Motivational interviewing in
an illness. medical and public health settings. In: Miller WR, Rollnick S, eds.
Motivational Interviewing: Preparing People for Change. 2nd ed.
New York, NY: Guilford Press; 2002:251–269
Resources
11. Schwartz, RP, Hamre R, Dietz WH, et al. Office-based motivational
interviewing to prevent childhood obesity. Arch Pediatr Adolesc
Articles and Books Med. 2007;161:495–501

American Academy of Pediatrics. PREP Audio Pediatrics 12. DiClemente CC, Velasquez MM. Motivational interviewing and
the stages of change. In: Miller WR, Rollnick S, eds. Motivational
Review Education Program. Vol 1. No 9. 2006. http://www.
Interviewing: Preparing People for Change. 2nd ed. New York, NY:
prepaudio.org Guilford Press; 2002:201–216

Rollnick S, Miller WR, Butler CC. Motivational Interviewing
in Health Care: Helping Patients Change Behavior. New York,
NY: Guilford Press; 2007

Schwartz RP. Motivational interviewing (patient-centered
counseling) to address childhood obesity. Pediatr Ann.
2010;39:154–158.

Web Sites

Motivational Interviewing Training Workshops: http://
www.motivationalinterview.org/

9


dANA BEST, md

SECONDHAND SMOKE
EXPOSURE AND TOBACCO
CESSATION
Bright Futures recommends that health care professionals screen for tobacco use
and secondhand tobacco smoke exposure, encourage tobacco cessation, and
provide smoking cessation strategies and resources at most visits.

Why Is It Important to Include Secondhand Smoke
Secondhand Smoke Exposure and Secondhand smoke can have harmful effects on the
Tobacco Cessation in Anticipatory fetus. Prenatal exposure to tobacco is associated with
Guidance? low birth weight, intrauterine growth restriction (small for
dates), placental abruption, premature delivery, sudden
Considerable evidence demonstrates the harms of both
infant death syndrome, and neurocognitive harms.1
tobacco use and secondhand smoke exposure, with the
2006 Surgeon General’s report indicating that there is no It can have harmful effects on infants and children.
safe level of secondhand smoke exposure. 1 Given that Exposure to secondhand tobacco smoke is associated
the only way to completely protect against secondhand with increased risk of upper and lower respiratory
smoke exposure is for all smokers to quit, it is imperative infections, increased incidence and exacerbation of
that all families are screened for smoking at each medical reactive airway disease, and permanent decrease in lung
visit, advised to quit, and offered assistance to quit. The function. It also increases the chance that a child will
literature shows that counseling and nicotine replacement initiate smoking and potentially become addicted, with all
each double the likelihood that a smoker will quit.2 of its associated harms. It is not safe to “try” smoking, as
about half of youth who try a few puffs will progress, and
As shown here, smoking can have harmful effects
about a quarter will become established smokers.
throughout the life cycle.
Tobacco Cessation

Tobacco use addiction is a preventable disease. Risk
factors for initiating tobacco use include

••Parent, sibling, and/or friends use tobacco (source of

first cigarettes, modeling of behavior, normalization of
behavior)

••Media exposure, including smoking in movies
••Depression, anxiety, psychiatric disorders (major and
minor)
Aligne CA, Stodal JJ. Tobacco and children: An economic evaluation
of the medical effect of parental smoking. Arch Pediatr Adolesc Med.
1997;151:662
10

S E C O N D H A N D S M O K E E X P O S U R E A N D T O B A C C O C E S S AT I O N

See the Tobacco Dependence chapter for more details nicotine replacement therapies (NRTs). (see Table 1)
on assessing tobacco use and dependence among Patients younger than 18 need a prescription, even for
adolescents. over-the-counter (OTC) products, because use among this
age group is off-label.
Many smokers and other tobacco users want to quit.
Most adult tobacco users want to quit and have already Some insurance plans cover OTC products.
made one or more quit attempts. They are receptive to Pharmacotherapies include
cessation advice from their child’s pediatrician.
••Over-the-counter products, including nicotine gum,
Pharmacotherapies increase the chance of successful patch, lozenge. Be sure to read the directions for use.
quitting.2 Pharmacotherapies include a variety of Using combinations of NRTs is recommended by the

Table 1. Nicotine Replacement Options
NICOTINE REPLACEMENT OPTIONS
PATCHES (OTC)
Nicotine Patch Initial: 1 patch/16-24hrs Treatment Duration:
21 mg 14 mg 7 mg MAX: Same as above 8 wks
(pack +/day) 10-15 cig/day) (<cig/day)
GUM (OTC)
Nicotine Gum Initial: 1 piece every 1-2 hrs Treatment Duration:
4 mg 2 mg MAX: 24 pieces/24hrs 8-12 wks
(>20 cig/day) (<20 cig/day)
NASAL SPRAY
Nicotrol NS Initial: 1-2 doses/hr Treatment Duration:
10 mg/ml MAX: 5 doses/hr or 40 doses/day 3-6 mos
INHALER
Nicotine Inhaler Initial: 6-16 cartridges/day Treatment Duration:
10 mg/cartridge MAX: 16 cartridges/day 3-6 mos
LOZENGE (OTC)
Commit 1 loz/1-2 hrs(wks 1-6) Treatment Duration:
2 mg 1 loz/2-4 hrs(wks 7-9) 12 wks
4 mg 1 loz/4-8 hrs(wks 10-12)
NON-NICOTINE MEDICATION
BUPROPION HCL SR
Zyban Initial: 150 mg/day (days 1-3) Treatment Duration:
150 mg tablets 300 mg/day (day 4+) 7-12 wks
MAX: 300 mg/day
VARENICLINE
Chantix Initial: Treatment Duration:
0.5 mg tablets Starter pack (days 1-30) 12 wks
1 mg/twice a day (days 31-84)
Inclusion of this adult dosage chart is strictly for the convenience of the prescribing provider. Consult with the Physicians’ Desk Reference
for complete information and contraindications. This chart does not indicate or authorize insurance coverage for any of these medications.
For insurance benefit coverage, contact insurance directly.

Source: Jonathan Winickoff, MD


Tobacco Treatment Guideline to improve quit rates; ••Advise
however, combination use is considered off-label.
Examples include use of the patch all day and chewing
`• Look for “teachable moments.”
gum or using a lozenge when experiencing a craving. `• Personalize the health risks of tobacco use.
••Prescription NRTs, including nicotine inhaler and nasal `• Use clear, strong, personalized messages: “Smoking
spray. Some incidence of addiction to these products is harmful for you (and your child). Would you like to
has occurred. Prescription NRTs are typically covered by quit?” “How can I help you?”
insurance plans.
••Assess
••Other prescriptions that are non-nicotine include the
`• Determine whether the patient or parent is willing to
selective serotonin reuptake inhibitor, bupropion, or
the selective nicotinic modulator, varenicline. make a behavior change.

`• Bupropion (Zyban). Reduces cravings and is `• Establish whether he or she is willing to try to quit
prescription only. Begin using 7 to 14 days before tobacco use at this time.
quit date and continue for 12 weeks after quitting.
••Assist
`• Varenicline (Chantix). Prescription only, a selective `• Provide information about tobacco use cessation to
nicotinic receptor modulator. May be more effective all tobacco users.
than bupropion. Also used for 12 weeks.
`• Strongly urge 100% smoke-free (and tobacco-free)
Adolescent Tobacco Users home and car.

Evidence is mixed on adolescent-specific approaches. `• Help patients and parents set realistic and specific
The same techniques for cessation should be used with goals.
adolescents that you would use with adults, tailored to
• “Quit” date
the adolescent.
• “Smoke-free home and car” date
How Should You Screen and Counsel for `• Help your patient prepare.
Tobacco Cessation?
• Get support.
Use the AAR or “5 As” Approach3
• Anticipate challenges.
There are 2 acceptable approaches to tobacco cessation • Practice problem-solving.
in the pediatric office setting. At a minimum, with parents
as well as youth, ASK about tobacco use and secondhand • Provide information about pharmacotherapy and
smoke exposure, ADVISE to quit, and REFER for assistance patient resources.
to local resources or quit lines.
• Provide supplemental materials.
More effective, but more time consuming, are the 5 As.
• Refer to telephone quit lines—preferably with
••Ask “active” fax referral process that can be initiated

in the medical office. Many quit lines will call the
`• Obtain an applicable history from all patients and client directly, rather than having the smoker make
families. the initiative to call by themselves. Many states
`• Ask about current and past tobacco use, have fax referral forms for medical practitioners to
secondhand smoke exposure, and tobacco use use. The United States universal quit line number
before and during pregnancy. Some 70% of women is 1-800-QUIT NOW. This will refer directly to the
who quit smoking during pregnancy will relapse in state from which the phone call is initiated.
the first year of their baby’s life.

12

S E C O N D H A N D S M O K E E X P O S U R E A N D T O B A C C O C E S S AT I O N

••Arrange follow-up CPT and ICD-9-CM Codes
`• Plan to follow up on any behavioral commitments
that your patient makes. 305.1 Tobacco abuse
V15.89 Other specified personal history
`• Schedule follow-up in person or by telephone presenting hazards to health
soon after an important date, such as a quit date or
(secondhand smoke exposure)
anniversary.
989.84 Toxic effects of tobacco—Use when the
Anticipate With Younger Patients pediatrician documents that a child’s
illness is directly worsened or exacerbated
Anticipating is sometimes called the “sixth A.” Discuss by exposure to tobacco smoke.
tobacco use with preteens and teens during health
E869.4 Secondhand tobacco smoke. This E-code
supervision visits. Include tobacco use with discussions of
was created to identify nonsmokers who
other risk behaviors, including alcohol, substance abuse,
have been exposed to secondhand
and sexual activity.
smoke. This cannot be used as a principal
Be Prepared for the Unwilling and Not Ready diagnosis, but may be used when the
secondhand smoke is the external cause
For the unwilling/not ready of the patient’s condition.
The “5 Rs” 99406 Smoking and tobacco cessation
counseling visit, intermediate, greater
Relevance than 3 minutes up to 10 minutes
••Discuss with the family and/or patient why quitting 99407 Intensive, >10 minutes
is particularly relevant to them, being as concrete as These behavior change intervention codes are reported when the
possible. service is provided by a physician or other qualified health care
professional. The service involves specific validated interventions,
Risks including assessing readiness for change and barriers to change,

••Encourage the patient to identify the risks of smoking, advising change in behavior, providing specific suggested actions and
motivational counseling, and arranging for services and follow-up
highlighting the risks that are particularly salient to the care. The medical record documentation must support the total time
spent in performing the service, which may be reported in addition to
patient.
other separate and distinct services on the same day.
Rewards The American Academy of Pediatrics publishes a complete line of coding publications

••Encourage the patient to identify the benefits of excellent resources, visit the American Academy of Pediatrics online bookstore at
www.aap.org/bookstore/.

smoking, highlighting the benefits that are particularly
salient to the patient. family, including those members not at the medical visit,
about the importance of creating completely smoke-
Roadblocks free places. Changing the acceptability of smoking
••Discuss and identify with the patient what they feel are inside homes and cars can be an important step toward
smoking cessation.
the current barriers and help to identify solutions (eg,
pharmacology) that could address these roadblocks.
What Should You do When You Identify
Repetition
Tobacco Exposure or Use?
••Discuss and use motivational techniques at every ••For patients who use tobacco, follow the 5 As. Until
encounter. Encourage and remind patients that have
failed attempts that most people have many failed the patients quit, advise them to make their home and
attempts prior to cessation. car smoke-free. Congratulate families for the efforts
they are making to protect children from the harms of
Another suggestion is to write a prescription for a 100% secondhand smoke, and encourage them to continue
smoke-free home and car. This conveys a message to the to move toward quitting completely.

••For those who have quit, offer congratulations! Books

••For those who quit during pregnancy, offer Treating Tobacco Use and Dependence. Guideline products
congratulations. Encourage them to stay quit after for consumers, primary care clinicians, specialists,
delivery, and offer support to help them stay quit. health care administrators, insurers, and purchasers of
••For those who are exposed to secondhand tobacco insurance are available. See the Web site: http://www.
surgeongeneral.gov/tobacco/. Also available at the Smoke
smoke, advise them to make their home smoke-free.
Free Homes Program Web site.
••For those who may be using tobacco periodically, US Department of Health and Human Services. The Health
advise them to stop before they become hooked.
Consequences of Involuntary Exposure to Tobacco Smoke:
A Report of the Surgeon General. Executive Summary. US
What Results Should You document? Department of Health and Human Services, Centers for
Smoking status of the family and household members Disease Control and Prevention, Coordinating Center for
should be documented, including former smoking status Health Promotion, National Center for Chronic Disease
given the risk of relapse. Prevention and Health Promotion, Office on Smoking and
Health; 2006
Include in the problem list, summary list, and electronic
medical record (EMR). Articles

Follow up at every opportunity—develop a reminder 27 Tobacco Use Health Indicators. Healthy People 2010.
system, either paper-based or EMR. http://www.healthypeople.gov/default.htm

Web Sites
Resources
The AAP Richmond Center of Excellence: www.AAP.org/
Evidence-based Guidelines Richmondcenter
Provides materials and resources for pediatricians and
AAP Policy StatementsUS Department of Health and
other pediatric clinicians.
Human Services. The Health Consequences of Involuntary
Exposure to Tobacco Smoke: A Report of the Surgeon The Smoke Free Homes Program: http://www.
General. Executive Summary. US Department of Health kidslivesmokefree.org/
and Human Services, Centers for Disease Control and Provides materials and resources for pediatricians and
Prevention, Coordinating Center for Health Promotion, other pediatric clinicians.
National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health; 2006 References
2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco 1. American Academy of Pediatrics Committee on Substance
Use and Dependence: Clinical Practice Guideline. Rockville, Abuse. Tobacco’s toll: implications for the pediatrician. Pediatrics.
MD: US Department of Health and Human Services, Public 2001;107(4):794–798
Health Service; 2008 2. Kulig JW. Tobacco, alcohol, and other drugs: the role of the
pediatrician in prevention, identification, and management of
3. American Academy of Pediatrics Committee on substance abuse. Pediatrics. 2005;115(3):816–821

Environmental Health. Environmental tobacco smoke
3. American Academy of Pediatrics Committee on Environmental
and smoking cessation. In: Etzel RA, Balk SJ, eds. Pediatric
Health. Environmental tobacco smoke: a hazard to children.
Environmental Health. 2nd ed. Elk Grove Village, IL: Pediatrics. 1997;99(4):639–642
American Academy of Pediatrics; 2003:147–163
4. Aligne CA, Stodal JJ. Tobacco and children: An economic
evaluation of the medical effects of parental smoking. Arch Pediatr
Tools
Adolesc Med. 1997;151:652

Smoke Free Homes: The Professional’s Toolbox: http://
www.kidslivesmokefree.org/toolbox/

14


SANdRA G. HASSINK, md
mARY LOU PULCINO, NP

WEIGHT MAINTENANCE
AND WEIGHT LOSS
Bright Futures identifies healthy weight promotion as 1 of 2 critical themes within the
guidelines. Recommendations in Bright Futures are consistent with the Prevention
and Prevention Plus stages outlined in the Expert Committee Recommendations
Regarding the Prevention, Assessment, and Treatment of Child Adolescent
Overweight and Obesity.1 With the widespread acceptance and dissemination of the
Expert Committee Recommendations, coupled with the special significance Bright
Futures places on healthy weight promotion, additional interventions included in the
Expert Committee Recommendations are discussed.

Why Is It Important to Include Weight Figure 1. percentiles by age and gender
BMI
maintenance and Weight Loss in
Anticipatory Guidance? 40
Focusing on childhood obesity is now an urgent priority 35
for pediatricians.2 Almost one-third of children (31.7%) 30 Girls BMI >85%
older than 2 years have a body mass index (BMI) greater Boys BMI>85%
25
than 85%,3 16.9% have a BMI greater than 95%, and 11.9% % Girls BMI >95%
have a BMI greater than 97%. Almost 10% of children 20
Boys BMI >95%
aged birth to 2 years have weight for height greater than 15
Girls BMI >97%
the 95th percentile. There are differences in prevalence of 10 Boys BMI >97%
overweight and obesity by age, with significant increases 5
in BMI over the 85th, 95th, and 97th percentiles from
0
toddlers to 6- to 11-year-olds. There was no significant
2-5 yr 6-11 yr 12-19 yr
difference in BMI percentiles between 6- to 11-year-olds
and adolescents (Figure 1).3 Data from Ogden et al (2)
Data from Ogden et al.3
While there is no difference between prevalence of There are differences in prevalence of high BMI percentile
obesity in boys and girls in the total population, Mexican-

by race/ethnicity. Hispanic boys were more likely to have
American boys were more likely to have higher BMIs at a higher BMI than non-Hispanic white boys, and non-
each BMI classification than Mexican-American girls, and Hispanic black girls were more likely to have high BMIs
Hispanic boys were more likely to have a BMI greater than non-Hispanic white girls (Figure 2).3
than 95% than Hispanic girls. There were no differences
between non-Hispanic white and non-Hispanic black There are persistent disparities “associated with
boys and girls.3 socioeconomic status, school outcomes, neighborhoods,
type of health insurance, and quality of care” 4 that will
continue to need to be addressed.

15

W E I G H T LO S S

Figure 2. percentiles by age and gender
BMI Should You Screen/Assess for
Overweight or Obesity?
Body mass index screening is recommended for
40
all children1 as a first step toward universal obesity
35
prevention and treatment. This means that all children
30 Girls BMI >85%should have BMI calculated and classified at every well-
25 Boys BMI>85%child visit. Bright Futures recommends assessing BMI
% Girls BMI >95% all children beginning at age 2 and plotting weight
for
20
Boys BMI >95% length for children younger than 2. Body mass
for
15
Girls BMI >97%index screening should be incorporated into the office
10 Boys BMI >97% workflow with help from the office team. An electronic
5 calculator, BMI table,8 or BMI wheel can be used to
0
Data from Ogden et al.3 calculate BMI, and BMI charts8 can be used to classify BMI
2-5 yr 6-11 yr 12-19 yr percentile. Severity categories are based on BMI, which
Prevention isfrom Ogden et al (2)
Data
crucial because obesity is progressive. If is calculated from height and weight (wt [kg] /ht [m2] or
untreated, a 13-year-old adolescent with a BMI greater wt [lbs]/ht [in] 2 x 703) and plotted on BMI growth charts
than 95% has a 64% chance of being an obese 35-year- to obtain BMI percentile referenced to age and gender
old, and chances of being an obese adult increase with based on population data. The report recommended the
the age of the obese teen. Even more worrisome is that
5
classification of BMI percentiles as
an obese 5-year-old has a 30% probability of becoming
an obese adult,5 and higher weight gain in the first 5 •• Underweight: less than 5th percentile
months of life has been correlated with obesity at 4.5 •• Normal weight: 5th to 84th percentile

••
years.6
Overweight: 85th to 94th percentile

••
With another generation of obese children entering
adulthood, health care costs for obesity-related illness Obese: 95th to 99th percentile
continues to escalate, accounting for 9.1% of total health
care spending in 2008.7 The economic costs of obesity
•• Morbid (severe) obesity: greater than 99th percentile

add to the cost to the child, family, and society of the Classification of BMI category is the first step toward
loss of a healthy childhood. Obesity alters the trajectory further assessment and treatment.
of healthy growth and development in the domains of
physical and mental health, emotional well-being, and How Should You Screen/Assess for
psychosocial functioning.1 Overweight and Obesity?
A whole host of obesity-related comorbidities, such
In discussing obesity prevention and treatment, the
as type 2 diabetes, polycystic ovarian syndrome, non-
Expert Committee Recommendations suggested a staged
alcoholic steatohepatitis, hypertension lipid disorders,
approach, which applied both to BMI classification and
upper airway obstructive sleep apnea syndrome,
the resources needed to carry out obesity prevention and
Blount’s disease, and slipped capital femoral epiphysis,
treatment.1
affect obese children. Weight maintenance and weight
loss are necessary to help prevent progression of these
conditions.1
••Prevention is universal for children with BMI between
the 5th and 84th percentile and includes review of
healthy lifestyle behaviors, and the normal family
risk, review of systems, and physical examination that
would take place in the primary care office at well visits
and other opportune visits.


••Prevention plus targets children with BMI between of obesity-related comorbidities. These findings can
the 85th and 94th percentile classified as overweight often provide motivation for families to change to
and includes review of healthy lifestyle behaviors, healthier lifestyle behaviors. The American Academy of
family risk, review of systems, physical examination, Pediatrics (AAP) 5-2-1-0 Pediatric Obesity Clinical Decision
and laboratory screening. Recommended labs include Support Chart supports decision-making on assessment,
lipid panel with addition of fasting glucose and liver evaluation, and laboratory testing.8
function studies if the child has additional risk factors.
Practitioners should target any problem dietary and What Anticipatory Guidance Should You
activity behaviors, review risks, and use patient- Provide if You Find Abnormal Results?
directed behavioral techniques to encourage lifestyle
change. This intervention would occur in primary care Prevention
practice and include monthly revisits.

••Structured weight management includes overweight All children in the BMI range from 5% to 84% should
have prevention counseling at well visits and at any other
children with health risk factors and children whose
opportune patient-physicians encounters. The content of
BMI is greater than 95% classified as obese.
this visit may be a review of the following:

••5—Consume at least 5 servings of fruits and
Evaluation includes review of healthy lifestyle
behaviors, family risk, review of systems, physical
examination, and laboratory screening. Recommended vegetables daily.
labs include lipid panel, fasting glucose and liver
function studies, and other studies as clinically
••2—View no more than 2 hours of television per
day. Remove televisions from children’s bedrooms.
indicated. The practitioner would provide increased No television viewing is recommended for children
structure and goal setting, and could include referral younger than 2.
to a dietitian or exercise specialist. This intervention
could be a structured program or a series of structured ••1—Be physically active at least 1 hour per day.
revisits at the primary care level.
••0—Limit consumption of sugar-sweetened beverages
••Comprehensive multidisciplinary interventions (eg, soda and sports drinks).
would occur in a multidisciplinary obesity program,
It is also important to continue to encourage and promote
which could include a pediatrician, dietitian, exercise
maintenance of breastfeeding, which has a positive effect
specialist, social worker, and mental health provider
on obesity prevention9 in addition to all its other benefits.
experienced in pediatric obesity. This stage would
be for children who did not have success in previous Beginning with the 5-2-1-0 message allows you to work
stages and for children with severe obesity and/or with the family on considering what healthy lifestyle
obesity-related comorbidities, and would occur at a changes they are interested in trying, helping parents
hospital clinic level. and children strategize about how to implement these

••Tertiary care intervention occurs in the hospital changes, and working to set goals to measure progress.
setting for children with severe obesity and/or obesity- Be positive and support small incremental steps for
related comorbidities and includes a multidisciplinary change.
obesity team as well as pediatric subspecialists. This
Families find it helpful to have a reminder of their goals

intervention would be prepared to offer intense
medical and surgical treatment and occur at the when they leave the visit (Figure 3).
hospital level.

For all overweight/obese patients it is important to
assess for obesity comorbidity risk in the family history
and review of systems as well as signs and symptoms

17

W E I G H T LO S S

Figure 3. Prescription for Healthy Active Living

Prevention plus that work toward the desired behavior change helps
patient and families succeed. Motivational interviewing
is recommended for children with BMI between the 85th is a technique that was recommended by the Expert
and 94th percentile for age and gender (overweight) Committee to help engage the family and patient in
and is structured to be provided in the primary care dialogue about change.1
office setting. The most efficient way to provide this
intervention is to use a team approach. For example, The healthy eating and physical activity habits
the person in the office who measures the height and recommended for prevention plus in addition to 5-2-1-0
weight may be the one to calculate and classify BMI, the and breastfeeding include
office nurse may hand out a questionnaire to parents
about healthy lifestyle behaviors, the physician may offer
••Prepare meals at home rather than eating at
restaurants.
counseling and goal setting, and the check-out staff may
ensure a timely revisit. ••Eat together as a family at the table at least 5 to 6 times
per week.
Behavior change begins with the provider helping
the family/patient recognize the need for change by ••Eat a healthy breakfast daily.
providing information about the child’s current health
status. It is important to assess willingness and capacity ••Include the entire family in making healthy lifestyle
changes.
to change as a way of engaging the patient and family
in moving toward action. Setting small achievable goals


••Allow the child to self-regulate his/her meal when ••If there is no improvement in BMI/weight after 3
parents have provided a healthy meal in an appropriate to 6 months of monthly visits, the patient should
portion size. be advanced to the next stage of comprehensive

••Assist families in shaping recommendations to be multidisciplinary intervention.
consistent with their cultural values. Comprehensive multidisciplinary Intervention
The goal for this stage is weight maintenance that with This treatment usually is delivered in a pediatric weight
continued growth will reduce BMI. If after 3 to 6 months management program by a multidisciplinary team
of monthly revisit the patient has not improved, proceed composed of a behavioral counselor, a registered
to Stage 2. dietitian, an exercise specialist, and an obesity specialist.
Structured Weight management Tertiary Care Intervention
The primary difference between prevention plus and This hospital-based intervention includes a
structured weight management is that there is a specific multidisciplinary team providing care that includes
plan to support the patient and family around behavior a physician experienced in obesity management, a
change. This could be carried out in a primary care office registered dietitian, behavioral counselor, and exercise
with additional support from a dietitian, counselor, specialist with expertise in childhood obesity and its
physical therapist, or exercise therapist with training in comorbidities. Standard clinical protocols should be used
pediatric obesity. for patient selection and evaluation before, during, and
Goals for this stage include the goals as above for after intervention. Bariatric surgery, including gastric
prevention plus in addition to bypass or gastric banding, has shown to be effective but
is available at only a few centers.
`• Development of a plan for utilization of a balanced
macronutrient diet emphasizing low amounts of Obesity treatment can be successful.10–14 Components
energy-dense foods of effective treatments have included dietary and
physical activity interventions, behavioral therapy, family
`• Increased structured daily meals and snacks involvement, and access to multidisciplinary teams.13,15
`• Supervised active play of at least 60 per day Key to building treatment capacity for pediatric obesity
are reimbursement models that support multidisciplinary
`• Screen time of 1 hour or less per day care, support for training the needed medical personnel,
ongoing parenting and family support to sustain
`• Increased monitoring (eg, screen time, physical
treatment effects, and continuing research into treatment
activity, dietary intake, restaurant logs) by provider,
effectiveness.
patient, and/or family

••This approach may be amenable to group visits with ICD9-CM Codes
patient/parent component, nutrition, and structured
activity. The AAP obesity coding fact sheet16 (available at aap.

••The goals for this stage are weight maintenance that org/obesity) is a resource for practitioners and includes
comprehensive coding information on obesity prevention
decreases BMI as age and height increases. Weight loss and related comorbidities for practitioners.

should not exceed 1 lb/month in children aged 2 to
11 years, or an average of 2 lb/wk in older overweight/
obese children and adolescents.

19

W E I G H T LO S S

Resources 7. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical
spending attributable to obesity; payer- and service-specific
estimates. Health Aff (Millwood). 2009;28(5):w822–w831
Web Sites
8. American Academy of Pediatrics. Prevention and Treatment of
Clinicians: American Academy of Pediatrics aap.org/ Overweight and Obesity. American Academy of Pediatrics Web
obesity/health-professionals.html Site. http://www.aap.org/obesity/clinical_resources.html

9. Lamb MM, Dabelea D, Yin X, et al. Early life predictors of
Parents
higher body mass index in healthy children. Ann Nutr Metab.
2010;56(1):16–22
HealthyChildren.org: http://www.healthychildren.org/
English/health-issues/conditions/obesity/Pages/default. 10. Whitlock EA, O’Connor EP, Williams SB, Beil TL, Lutz KW.
aspx Effectiveness of weight management programs in children and
adolescents. Evid Rep Technol Assess (Full Rep). 2008;(170):1–308
Families 11. Nowicka P, Hoglund P, Pietrobelli A, Lissau I, Flodmark CE. Family
weight school treatment; 1 year results in obese adolescents. Int J
American Academy of Pediatrics: http://www.aap.org/ Pediatr Obes. 2008;3(3):141–147
obesity/families_at_home.html
12. Jelaltan E, Saelens IS. Empirically supported treatments in
pediatric psychology; pediatric obesity. J Pediatr Psychol.
References 1999;24;223–248

1. Barlow SE. Expert committee recommendations regarding 13. American Dietetic Association. Position of the American Dietetic
the prevention assessment and treatment of child and Association: individual-, family-, school-, and community-
adolescent overweight and obesity summary report. Pediatrics. based interventions for pediatric overweight. J Am Diet Assoc.
2007;120(suppl 4):S164–S192 2006;106:925–945

2. Davis AMM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, 14. Garipagaoglu M, Sahip Y, Darendeliler F, Akdikemen O, Kopuz
Resnicow K. Recommendations for prevention childhood obesity. S, Sut N. Family-based group treatment versus individual
Pediatrics. 2007;120;S229–S253. http://www.pediatrics.org/cgi/ treatment in the management of childhood obesity; randomized
content/full/120/Supplement_4/S164 prospective clinical trail. Eur J Pediatr. 2009;168(9):1091–1099

3. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence 15. US Preventive Services Task Force Screen for Obesity in
of high body mass index in US children and adolescents, 2007– Children and Adolescents. US Preventive Services Task Force
2008. JAMA. 2010;303(3):242–249 recommendations statement. Pediatrics. 2010;125;361–367

4. Bethell C, Simpson L, Stumbo S, Carle AC, Gombojav N. National, 16. American Academy of Pediatrics. Obesity and related co-
state, and local disparities in childhood obesity. Health Aff morbidities coding fact sheet for primary care pediatricians.
(Millwood). 2010;29(3):347–356 American Academy of Pediatrics Web site. http://www.aap.org/
obesity/pdf/ObesityCodingFactSheet0208.pdf
5. Guo SS, Wu W, Chumlea WC, Roche AF. Predicting overweight and
obesity in adulthood from body mass index values in childhood
and adolescence. Am J Clin Nutr. 2002;76:653–658

6. Dubois L, Girard M. Early determinants of overweight at 4.5 years
in a population based longitudinal study. Int J Obes. 2006;30;610–
617


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