2.  30 states have pediatric populations in which at least 30% of children are overweight/obese.  Significant short- and long-term morbidity associated with being overweight  Physiological and psychological  $1000/year increase in medical costs on average for people who are overweight/obese

5.  Plot BMI percentile in ALL children  Show BMI percentile to parents at and talk about healthy lifestyle choices at EVERY visit  See those over the 85 th monthly for 4-6 months What to do?

6. http://www.mcph.org/Major_Activities/KeepMEHealthy/Guide_to_Effective_Communication.pdf

7.  5 fruits and veggies  2 hours or less of screen time  1 hour of physical activity  0 (restrict) soda, juice and other sugar sweetened beverages

10.  4 staged-approach 1.Prevention Plus 2.Structured Weight Management 3.Comprehensive Multidisciplinary Intervention 4.Tertiary Care Intervention

11.  BMI ≥85 th  PCP monthly for 6 months  Goal: weight maintenance  No improvement? Stage 2

12.  This warrants monthly 15 minute office visits for 4-6 months  Things to discuss  BMI, PMH, Family history  Food intake: Fruits/veggies, soda, juice, fast food, portions, breakfast  Screen time/ daily activity  Feedback on current behaviors  Positive/Constructive

13. Set agenda Which behaviors is the patient/family interested in changing, or would be easiest to change. Agree on possible targets. Assess motivation and confidence Rate each on a scale of 0-10 Summarize and probe possible changes Schedule follow-up visits as appropriate

14.  Calorie restriction  Structured daily meals/snacks  Over 60 minutes of active play per day  Less than one hour of screen time per day  Increased behavioral monitoring  Reinforcement for meeting behavioral goals  No improvement for 6 months? Stage 3

15.  Increased intensity of behavioral change strategies  Greater frequency of patient/provider contact  Inclusion of team members  Psychologist  Registered Dietitian  Exercise Specialist  Physician  Weekly visits for 8-12 weeks, followed by monthly visits  Individual or group

16.  Meal Replacement  Very low calorie diet  Medication  Surgery  Multidisciplinary Team

18. Age (in years) Weight Maintenance Weight Loss <1b/mo Weight loss <2lb/wk 2-585 th -94 th ≥95 th BMI>21 6-1185 th -94 th 95 th -98 th BMI≥99 th 12-18 85 th -94 th 95 th -98 th BMI≥99 th

21.  Overweight/obesity affects many children in this country with significant physiological, psychological and financial sequelae.  Anticipatory guidance AT EVERY VISIT, even for appropriate weight children, is essential to fight this epidemic.  Treatment begins in your office.