Pediatric Obesity: Clinical Decision Tools*
Contributing clinicians from the Be Forever Fit Program at Harbor-UCLA in partnership
with UniHealth Foundation:
Gangadarshni Chandramohan, MD1; Sudhir Anand, MD1; Ruey K. Chang, MD2; George
Gershman, MD3; Catherine S. Mao, MD4; Peter Tieh, MD4; Suzanne Rizi Mokhtari,
MD5, MPH; Annie Hsueh, PhD6; Astrid Reina, PhD6; Jennifer K. Yee, MD4.
*Adapted from decision tools created by the UCLA UniHealth-Fit for LA project
1Department
of Pediatrics, Division of Nephrology, Harbor-UCLA Medical Center
2Department
of Pediatrics, Division of Cardiology, Harbor-UCLA Medical Center
3Department
of Pediatrics, Division of Gastroenterology, Harbor-UCLA Medical Center
4Department
of Pediatrics, Division of Endocrinology, Harbor-UCLA Medical Center
5Department
of Pediatrics, Division of Hospitalist Medicine, Harbor-UCLA Medical Center
6Department
of Psychiatry, Division of Psychology, Harbor-UCLA Medical Center
1) General Obesity Management
2) Blood Pressure
3) Lipids
– with addendums 3a and 3b
4) Liver Function Tests
5) Diabetes Screening
6) Polycystic Ovary Syndrome
7) Mental Health
– with addendum handouts
General Obesity Management
Assess Behaviors & Attitudes
- Document: Motivation, Eating (e.g. 24 hr recall), Physical Activity, Sedentary
Time
- Consider using patient lifestyle log
Assess Medical Risks
1) Family History, 2) Review of Systems, 3) Physical Examination (BMI, BP1)
Underweight
BMI <5%
Healthy
Weight
BMI 5-84%
Overweight
BMI 85-94%
Obese
BMI 95-98%
BMI ≥99%
Evaluation for
health risks
related to
underweight
Health
Risks
Yes
Check fasting lipid profile2, AST/ALT3,
fasting glucose and insulin levels,
HbA1c4
If BMI ≥95% & additional risks:
Get additional tests
No
Prevention and Counseling:
- Empathize/Elicit – Provide – Elicit.
- Assess action step + Self-efficacy (Confidence Level),
Motivate.
STAGE 1: Prevention Plus
Health Weight,
BMI 85-94
without risk
Maintain weight
velocity
- Reassess in 1
year
BMI 85-94% + Risk
BMI 95-98%
- Maintain weight / Maintain weight or
decrease velocity
gradual loss
- Reassess q3-6 mos - Reassess q3-6
mos
BMI ≥99%
Gradual to
moderate wt loss
- Reassess q3-6
mos
STAGE 2: Structured Weight Management
If no improvement after 3-6 mos and family wil
STAGE 3: Comprehensive Multidisciplinary Intervention
Consider Referral to BFF
1-See
BP Guidelines (Pg 2.)
Lipid Guidelines (Pg 3.)
3-See NASH Guidelines (Pg 4)
4-See Diabetes Screen Guidelines (Pg 5)
2-See
If BMI >95% + no improvement after 3-6
mos and family willing
STAGE 4: Tertiary Care Intervention
Consider Bariatric Surgery Referral for
BMI >40 or >50 + co-morbidites
Page 1
Blood Pressure Measurement
Normal BP
(both systolic and
diastolic BP <90%)
Prehypertension
(Systolic +/or diastolic
BP ≥ 90% but <95%
OR
BP >120/80 even if
<90% for age/gender/
ht
Hypertension
(either systolic +/or
diastolic BP >95% )
Stage I HTN
(systolic +/or
diastolic BP
95th-99th%
+5mmHg)
Therapeutic
Lifestyle
Changes
Stage 2 HTN
(systolic +/or
diastolic BP
>99th%
+5mmHg)
Repeat BP over 3 visits &
4 extremity BPs over 2
weeks.
Repeat BP in
2mo
Obese, family hx CVD, CKD, DM,
other risk factors
*Diagnostic Workup
with eval for targetorgan damage
*Diagnostic workup
with eval for targetorgan damage
AND
Consider Referral/
(e)Consult with Peds
Nephro
Home BP log
BP>90%ile
Diagnostic workup
with eval for targetorgan damage*
Consider ACE
Inhibitors if
persistently
hypertensive
Primary or Secondary
HTN
Overweight
Normal BMI
r
(e)Consult
Peds Nephrology
for further
evaluation
Rx Specific
for Cause
Weight
reduction
Monitor q
6mo
Primary HTN
Secondary HTN
Therapeutic
Lifestyle
Changes
Normal BMI
BP≥90%
**Drug Rx
Primary or Secondary
HTN
Normal BMI
**Drug Rx
Overweight
Weight
reduction and
**Drug Rx
Overweight
Still BP≥90%
Weight reduction
*Diagnostic workup: For Stage 1 HTN, consider electrolytes, U/A, fasting glucose, cardiac ECHO, FLP, renal u/s w/ dopplers,
thyroid function tests, drug screen, polysomnography, retinal exam. Testing is considered based on individual patient
findings including obesity.
For Stage 2 HTN, diagnostic workup should include plasma renin, aldosterone, and fractionated metanephrine levels
**Drug therapy: indications include symptomatic HTN, secondary HTN, hypertensive target-organ damage, DMI or II,
persistent HTN despite nonpharm measures. Consider ACE inhibitors for patients with BP ≥90%ile while being worked up.
Monitor potassium and creatinine while on ACEIs.
The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
Page 2
*CVD risk factors:
Lipid Screening
Age ≤ 2 years
BMI < 85%ile
Age > 2 years
BMI < 85%ile
BMI <85% & No CVD risk
factors*
Reassess risk
factors
1. FH of dyslipidemia or early CVD (♂ <55, ♀ <65)
2. BMI ≥ 85%ile
3. BP > 95%ile
4. Cigarette smoking
5. Diabetes Mellitus
Therapeutic
Lifestyle
changes
Unknown FH
Reassess risk factors
yearly & Therapeutic
Lifestyle changes
Fasting Lipid
Screening
LDL 110-130 or
Total Cholesterol
170-199
LDL < 110 or Total
Cholesterol < 170
Recheck Lipids
Q3-5 yrs
HDL < 25 or
TG >150
LDL > 130 or
Total Cholesterol
>200
Therapeutic
Lifestyle changes
Therapeutic
Lifestyle changes &
Plant Sterols*
Recheck Lipids
Q6 mo
LDL > 500 (familial
hypercholesterolemia)
CVD risk factors
LDL > 190 & No
CVD risk factors
LDL > 130 & DM
LDL > 160 & CVD
risk factors
(e)Consult Peds
Cardiology
(e)Consult Peds Cardiology
& Consider meds for ≥ age
8
Age < 8 yrs
Recheck lipids
Q6 mo
Recheck lipids
Q6 mo
Flax seed oil
(1tsp/day) or
ground
flaxseed
Age ≥ 8 yrs
Consider Meds &
recheck lipids Q6 mo
Fiber (dose = age in
yrs + 5gm/day; max
dose 20g/day)
Statin
Daniels, Stephen; Greer, Frank.: Lipid Screening and Cardiovascular Health in Childhood . Pediatrics, 2008. 122(1):
198-208.
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents,
NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and
Adolescents: Summary Report. Pediatrics. 2011 Dec;128 Suppl 5:S213-56.
Page
3
CVD Risk Factors
Diabetes mellitus
Family history of:
Cigarette smoking
•  early CVD event (♂<55 or ♀< 65 years old)
OR
HTN (BP ≥95th
percentile)
•  parent with total cholesterol ≥ 240 mg/dL OR
BMI ≥85th percentile
•  known dyslipidemia
Lipid Screening By Age
• 
Age 1-9 – check fasting lipid panel if family h/o CVD, parent w/ dyslipidemia or
child has other risk factors or high-risk condition
• 
Age 9-11- universal screen w/ non-fasting or fasting lipid panel
– 
Non-fasting: calculate non-HDL cholesterol: TC-HDL
• 
If non-HDL ≥145 mg/dL ± HDL <40mg/dL
–  Obtain fasting lipid panel twice (separated by 2 wks) & average
OR
– 
Fasting lipid panel
• 
If LDL cholesterol ≥ 130 mg/dL ± non-HDL cholesterol ≥ 145 mg/dL ±
HDL cholesterol ≥ 40 mg/dL ± triglycerides ≥ 100 mg/dL
• 
If < 10 y, ≥ 130 mg/dL if ≥ 10 y:
• 
Repeat fasting lipid panel, average result
• 
Age 12-16 – check fasting lipid panel if family h/o CVD, parent w/ dyslipidemia or
child has other risk factors or high-risk medical condition
• 
Age 17-21 - universal screen w/ non-fasting or fasting lipid panel
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in
Children and
Adolescents, NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and
Risk
Addendum 3a
Lipid Screening in Childhood
Screening – Fasting Lipid Panel
Recommended for all children older than 2 years of age with any of the following risk factors:
•  Positive family history of dyslipidemia or premature
CVD event (men<55 or women <65 years old)
•  Unknown family history
•  Diabetes mellitus
• 
• 
• 
• 
Cigarette smoking
HTN (BP ≥95th percentile)
BMI 85-95th percentile
BMI ≥95th percentile
Interpreting Lipids Panels
The American Heart Association suggests abnormalities
•  TG > 150 mg/dL
•  HDL < 35 mg/dL
No TG or HDL recommendations from the NCEP
(National Cholesterol Education Program)
LDL>95th percentile range for age or HDL<5th percentile
range for age are abnormal
Retest every 3-5 years if levels are within normal range
Medications
Recommended LDL Concentrations for Pharmacologic Treatment of Children ≥ 8 Years of Age*
*
Patient Characteristics
Recommended Cut Points
No other risk factors for CVD
LDL is persistently >190 mg/dL despite diet therapy
Other risk factors present, including obesity,
HTN, smoking, or FamHx premature CVD
LDL is persistently >160 mg/dL despite diet therapy
Children with diabetes mellitus
Pharmacologic treatment should be considered when LDL ≥130 mg/dL
* Pharmacologic intervention < 8 years of age is only
for severely elevated LDL (>500 mg/dL) as in familial
hypercholesterolemia
•  Follow more aggressive treatment of LDL in children with DM, renal disease, congenital heart disease, collagen
vascular disease, or cancer survivors.
•  Goal of medications is to lower LDL<160 mg/dL, or <130 mg/dL, or <110 mg/dL when there is strong family
history of CVD or with other risk factors such as obesity, DM, or metabolic syndrome.
•  Statins inhibit cholesterol synthesis and increase LDL clearance
•  Monitor CK levels (rhabdomyolysis) and LFTs,(hepatic side effects)
•  Fiber supplements can help reduce plasma LDL
•  Supplemental fiber dose = child s age in years + 5 gm (max 20 gm/day)
•  Plant sterols (additive found in orange juice, yogurt drinks, dietary supplements) decrease absorption of
dietary
cholesterol but decrease absorption of fat-soluble-vitamins and beta carotene
Daniels and Greer, Lipid Screening and Cardiovascular Health in Childhood, Pediatrics, 2008,122:198
Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and
Adolescents,
NHLBI. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children
Addendum
and
3b
NAFLD=Non Alcoholic Fatty Liver Disease
Definition: Histologic findings of macrovascular steatosis on liver biopsy
Diagnosis: Elevated ALT/AST ratio (2:1 ) and steatosis in absence of other causes of fatty liver
Age: >10yrs
Age: 3-19yrs
BMI 85-94%
& Risk Factors*
BMI >95%
AST and ALT
*use highest of two values
< 50
Repeat every 2 years
≥ 50
Lifestyle interventions and
repeat LFTs in 6 months
<50
Repeat annually
≥ 50
(e)Consult Peds GI
GOAL: Loss of 10% excess body weight, normalized AST/ALT
*Caution: rapid weight loss is associated with cholelithiasis
Normal Values (U/L)
Age
AST
ALT
Infant 25-75
13-45
1-3y
20-60
4-6y
15-50
7-9y
15-40
10-11y 10-60
12-19y 15-45
Adult M
10-40
Adult F
7-35
NAFLD Prevalence: 9% all children, up to 80% obese children
+Predictor elevated ALT in obese children: Male, Hispanic, elevated BMI
+Predictor NASH to Fibrosis: Obesity, Insulin Resistance
Complications: Fibrosis leading to Cirrhosis
Risk factors: DM, obesity, acanthosis, family history
*GGT: 1-15y 0-23 U/L
Adult Male: 11-50
Adult Female: 7-32
Page 4
Diabetes Screening
HbA1c
Fasting Glucose
Levels
<100
Normal
100-125
Elevated.
Confirm that
glucose was
fasting.
Recheck
based on BMI
Guidelines
>= 126
Elevated, suggests
diabetes.
Confirm lab was fasting.
If random >200, proceed
(e)Consult Pediatric Diabetes
≤5.6
Normal
5.7- 5.9
Mildly
elevated
Repeat
HbA1c, order
2 hr OGTT, or
check one
month three
times a week
pre and
postprandial
glucose
(e)Consult
Risk Factors
Peds Endo
Polyuria, polydipsia
Unexplained weight loss
High risk ethnic group
(African American, Hispanic,
SE Asian)
Family History + DM2
On antipsychotics
Reassess
and
recheck in
12 mos
• 
• 
• 
• 
• 
Risk factor
assessment
0-1 Positive
Reassess in
3-6 months
Oral Glucose Tolerance Test
Interpretation
2 hour: <140
Normal
Reassess patient
according to BMI
guidelines
≥ 6.0-6.4
Abnormal
2 hr: 140-199
Abnormal.
Impaired
glucose
tolerance
(e)Consult Peds
Diabetes
≥ 6.5
Highly
suggestive of
DM
Repeat HbA1c, ,
do 2 hr OGTT,
draw GAD65
and islet cell
antibodies.
(e)Consult Peds
Diabetes.
>=2 positive
Order 2 hr
OGTT , or
check one
month three
times a week
pre and
postprandial
glucose and
consider
metformin
Any result >= 200
Abnormal glucose
tolerance,
response in
diabetic range
(e)Consult Peds
Diabetes
Page 5
PCOS
*Sultan and Paris Diagnostic Criteria
1.  Amenorrhea or Oligomenorrhea (>35d/
cycle or <6-9 menses/yr) >2yr after
menarche
2.  Clinical Hyperandrogenism (persistent
acne, severe hirsutism, alopecia)
3.  Biochemical Hyperandrogenism (plasma
testosterone >50ng/dL, LH/FSH ratio>2)
4.  Insulin Resistance (acanthosis nigricans,
fasting glucose>100, glucose
intolerance, central obesity)
5.  Positive Ultrasound Findings (enlarged
ovaries, peripheral microcysts, increased
stroma)
Concern for PCOS?
Send AM Labs:
DHEA-S, androstenedione, free testosterone
(will include total), 17-OH progesterone, TSH
and total T4, fasting glucose. Add FSH, LH,
estradiol if amenorrhea present. Consider
abdominal ultrasound
Fulfills 4/5 of the Sultan and Paris
criteria* or 3/3 Rotterdam criteria** for
PCOS?
**Rotterdam Criteria
1.  Chronic anovulation (amenorrhea or
oligomenorrhea, ie, >35d/cycle or
<6-9menses/yr, >2yr after menarche)
2.  Hyperandrogenism (hyperandrogenemia
with elevated testosterone, DHEAS or
androstenedione, or progressive
hirsutism)
3.  Polycystic ovaries (characteristic follicular
appearance and volume>10 mL)
Yes
No
BMI >95%ile?
Fulfills 2/3 Rotterdam
criteria?
(Hyperandrogenism and
anovulation)
Yes
***Pharmacotherapy Options
Metformin (esp if obese): Start 500mg
PO daily for 2 weeks, then 500 mg PO
bid. Increase to 850mg PO BID as
tolerated at next visit, then increase
further to 1000mg PO BID (max for
10-16 years)
Hormonal agents:; NuvaRing and
Ortho-Evra patch also ok
Antiandrogens: Spironolactone ,
No
Yes
Send Additional
Labs
(lipid panel, fasting
glucose and insulin,
Hb A1c)
Labs Abnormal?
Yes
No
PCOS probable,
but not confirmed
Encourage
Weight
Maintenance
Encourage
5-10% Weight
Loss
Start Pharmacotherapy ***
and (e)Consult Pediatric
Endocrinology
Consider
Pharmacotherapy***
if Symptoms Persist
No
Consider DDx
(late onset CAH,
prolactinoma,
thyroid
dysfunction,
Turner s)
(e)Consult
Pediatric
Endocrinology if
ovulatory
dysfunction
continues >2 yrs
after menarche
(e)Consult Pediatric
Endocrinology
Bremer, A. Polycystic Ovary Syndrome in the Pediatric Population. Metabolic Syndrome and Related Disorders. 2010; 8(5):
375-94.
Carmina E, Oberfield SE, Lobo RA. The diagnosis of polycystic ovary syndrome in adolescents. Am J Obstet Gynecol
2010;203:201.e1-5
Brufani ,C et al. Use of metformin in pediatric age. Pediatric Diabetes.2011;12(6):580-88.
Diamanti-Kandarakis, E. PCOS in adolescents. Best Practice &Clinical Obstetrics and Gynaecology. 2010; 24(5): 173-83.Page
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