Eating Disorder Screening Tool

Kartini Clinic for Children and Families is introducing a new treatment approach for childhood obesity. While Kartini has always treated binge eating disorders – as well as metabolic conditions that contribute to unwanted weight gain – the FDA’s recent approval of new interventions, along with comprehensive new clinical guidelines from the American Academy of Pediatrics (AAP), has significantly changed the practice landscape.

The AAP’s guidelines emphasize that childhood obesity is a complex, chronic disease influenced by biological, social, environmental, and genetic factors, necessitating a comprehensive, family-centered, and non-stigmatizing approach to care. The guidelines also detail methods for identifying risk factors and co-morbidities, the appropriate use of pharmacotherapy and metabolic informed treatment, and crucially, recommending intensive health behavior and lifestyle treatment (IHBLT) as a primary intervention.

These last three factors – pharmacotherapy, metabolic science and an intensive treatment program – are essential components of Kartini Clinic’s partial hospitalization (PHP) and virtual Intensive Outpatient (vIOP) programs for all diagnoses – and now including childhood obesity and metabolic dysfunction.

To help explain this treatment paradigm, we’ve summarized 6 questions to explain what we believe to be some of the most important elements of the AAP’s clinical guidelines for evaluating and treating children and adolescents with obesity. 

For more information on our BED program or any other aspect of treatment at Kartini Clinic, please contact our Intake team, on their dedicated intake line, 971.319.6800, or at help@kartiniclinic.com. We also offer a free and entirely confidential screening tool available to all parents and providers. 

1. How is childhood obesity defined and why is it considered a chronic disease?

Childhood obesity is defined as having a Body Mass Index (BMI) at or above the 95th percentile for a child’s age and sex. Severe obesity is even more precisely defined as a BMI at or above 120% of the 95th percentile for age and sex, or a BMI of 35 kg/m² or higher, whichever is lower.

Obesity is recognized as a complex, chronic disease, similar to conditions like asthma or diabetes. This classification stems from its multifactorial etiology, involving complex genetic, physiologic, socioeconomic, and environmental contributors. Unlike a temporary illness, obesity is long-lasting, has persistent negative health effects, and can lead to significant morbidity and mortality over time. The scientific and medical communities, including the National Institutes of Health (NIH) since 1998 and the American Medical Association (AMA) since 2013, have formally acknowledged obesity as a chronic disease requiring ongoing medical attention due to its altered anatomy, physiology, and metabolism. This understanding emphasizes that it is not merely a consequence of personal choices but a complex health condition.

2. How does weight bias and stigma affect children with obesity and their medical care?

Weight bias and stigma have profound negative impacts on children and adolescents with obesity, affecting their mental health, social well-being, and willingness to seek and adhere to medical care. Individuals experiencing weight stigma often face victimization, teasing, and bullying, which can lead to negative behaviors such as binge eating, social isolation, and decreased physical activity. Internalized weight bias can also significantly harm mental health. Acknowledging the complex genetic and environmental factors contributing to obesity is essential in reducing stigma and fostering productive discussions focused on the child’s health rather than blame.

3. What are the recommended approaches for evaluating a child or adolescent for overweight and obesity?

The evaluation of children and adolescents for overweight and obesity is a crucial step in providing comprehensive obesity treatment. It involves several key components:

• Routine Screening: Pediatricians and other healthcare providers should measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific CDC growth charts annually for all children 2 to 18 years of age. This helps screen for overweight, obesity, and severe obesity. While BMI is the most appropriate clinical screening tool, its communication to patients and families should be non-stigmatizing, using person-first language and neutral terms like “unhealthy weight.”

• Comprehensive Patient History: A detailed history is essential, including:

• • Chief Complaint: Understanding the family’s concerns about the child’s growth and health.

• • History of Present Illness: Tracing the trajectory of weight gain, including prenatal and postnatal factors, and previous weight control attempts.

• • Family History: Assessing for obesity-related comorbidities and potential genetic causes within the family.

• • Medication History: Identifying medications associated with weight gain.

• • Social History: Understanding family living arrangements, eating routines, social groups, and the presence of social determinants of health (SDoHs) and adverse childhood experiences (ACEs).

• • Nutrition and Physical Activity History: Gathering information on dietary intake, eating behaviors (e.g., snacking, dining out, portion sizes), screen time, sedentary behavior, and physical activity levels.

• • Physical Examination: A complete physical exam is necessary to identify obesity-related findings, including vital signs (especially blood pressure with an appropriately sized cuff), skin changes (e.g., acanthosis nigricans, striae), liver enlargement, pubertal status, and orthopedic issues (e.g., hip or knee pain, gait abnormalities).

• • Behavioral Health and Disordered Eating Concerns: Given the increased rates of behavioral health issues in patients with obesity, screening for weight-based bullying, depression, anxiety, ADHD, and disordered eating behaviors (e.g., meal skipping, diet pill use, purging) is vital.

• • Laboratory Evaluation: Based on BMI classification and findings from the history and physical exam, laboratory tests are conducted to evaluate for obesity-related comorbidities. For children 10 years and older with obesity, evaluation for lipid abnormalities, abnormal glucose metabolism, and abnormal liver function (ALT test for NAFLD) is recommended. For those with overweight and specific risk factors, or younger children with obesity, selective testing may be considered.

This comprehensive evaluation helps tailor treatment plans, detect comorbidities early, and facilitate patient and family engagement through shared decision-making.

4. What are the main components of effective intensive health behavior and lifestyle treatment (IHBLT) for childhood obesity?

Intensive Health Behavior and Lifestyle Treatment (IHBLT) is considered the foundational approach for managing childhood obesity and its comorbidities. The most effective IHBLT programs share several key components:

• Intensity and Duration (Dose): The most crucial factor is the “dose” of the intervention, measured in contact hours. Effective programs deliver 26 or more hours of face-to-face, family-based counseling on nutrition and physical activity over a 3-to-12-month period. Higher doses, particularly 52 or more hours, demonstrate even stronger and more consistent reductions in BMI and improvements in cardiometabolic comorbidities.
• Face-to-Face Delivery: While virtual and mobile health tools show promise, the strongest evidence for IHBLT effectiveness comes from programs delivered in face-to-face settings, whether in group formats in healthcare or community locations, or through home visits.
• Family-Based Approach: Parent or whole-family involvement is critical. Family-based interventions are more effective than child-only interventions in achieving and sustaining BMI reduction, especially for preadolescent children. Parents are taught self-management skills, positive parenting strategies, and how to create a supportive home environment.
• Multicomponent Content: Effective programs integrate various components focused on:
  • Healthy Eating: This includes nutrition skill-building (e.g., meal preparation, grocery shopping, portion control, label reading) rather than strict structured diets. It often addresses sugar-sweetened beverages, snacking, and dining out habits.
  • Physical Activity: Programs promote a combination of aerobic and non-aerobic physical activity, aiming for guidelines of 60 minutes per day of moderate to vigorous activity. Activities are often non-competitive, cooperative, and fun to enhance engagement.
  • Behavior Change Strategies: These involve goal-setting, body acceptance, and managing bullying. Some successful programs also incorporate mental health support and parenting skills.
  • Patient-Centered and Non-Stigmatizing: Treatment should always be delivered using motivational interviewing (MI), which focuses on identifying and reinforcing the patient’s and family’s intrinsic motivation for change. It emphasizes respect for autonomy, collaborative goal-setting, and a non-judgmental approach to address the complex biological, social, and structural drivers of obesity.

IHBLT is appropriate for both typically developing children and those with special healthcare needs, though adaptations may be required. Prompt referral to IHBLT is crucial, as delaying treatment can reduce the likelihood of success.

5. When is pharmacotherapy  considered for pediatric obesity?

Pharmacotherapy and metabolic science are considered important adjuncts to intensive health behavior and lifestyle treatment (IHBLT) for children and adolescents with obesity, particularly for those with more severe disease or significant co-morbidities.

• Pharmacotherapy: Pediatricians and other healthcare providers should offer weight loss pharmacotherapy to adolescents aged 12 and older with obesity (BMI ≥ 95th percentile) when medically indicated. This decision is made considering the medication’s indications, risks, and benefits, always in conjunction with IHBLT:

• • Ages 8-11: For children aged 8 through 11 with obesity, weight loss pharmacotherapy may be offered as an adjunct to IHBLT, based on specific medication indications, risks, and benefits. The evidence base for this younger age group is still evolving.
  • Medications: Examples of medications discussed include liraglutide (FDA approved for ages 12+), orlistat (FDA approved for ages 12+), and setmelanotide (for specific genetic deficiencies, ages 6+). Metformin may also be considered in certain cases, particularly if other indications (like prediabetes or PCOS) are present, though its direct weight loss efficacy is modest. The choice of medication is individualized, requiring prescribers to have expertise in patient selection, efficacy, adverse effects, and monitoring.

Pharmacotherapy is an integral part of a comprehensive obesity treatment plan and should always be combined with ongoing IHBLT.

6. Why is a coordinated “medical home” approach emphasized for managing childhood obesity?

A coordinated “medical home” approach is strongly emphasized for managing childhood obesity because obesity is a complex chronic disease requiring intensive, long-term, and integrated care, similar to other chronic conditions like asthma or diabetes. The medical home model provides several benefits:

• Centralized Care Coordination: The child’s medical home (typically primary care providers) serves as the central coordinator, ensuring streamlined care and efficient use of resources. This involves collaborating with subspecialists (e.g., obesity treatment specialists, endocrinologists, dietitians, psychologists, physical therapists, social workers) and connecting families to community resources (e.g., food provision programs, recreation programs).
• Comprehensive and Longitudinal Care: Obesity requires ongoing medical monitoring and treatment throughout childhood, adolescence, and into young adulthood. The medical home facilitates continuous, coordinated care, including regular BMI assessment, comorbidity evaluation, anticipatory guidance on healthy behaviors, and support for the patient’s journey over time.
• Patient- and Family-Centered Approach: The medical home fosters a partnership with children and families, recognizing their unique social and cultural contexts, preferences, and challenges. It promotes shared decision-making, where families are actively involved in setting goals and choosing treatment paths, rather than having interventions imposed on them.
• Addressing Multilevel Factors: The medical home acknowledges the biological, social, and structural drivers of obesity. It encourages screening for social determinants of health (SDoHs) and adverse childhood experiences (ACEs) and helps families navigate barriers to treatment such as transportation, financial constraints, and access to healthy food options.
• Non-Stigmatizing Environment: By integrating care within a trusted, familiar setting, the medical home can help mitigate the impact of weight bias and stigma often experienced by children with obesity. This involves using person-first language and creating a supportive, empathetic environment.

In essence, a medical home ensures that comprehensive, individualized, and compassionate care is delivered, addressing not only the physical aspects of obesity but also its social, emotional, and environmental dimensions.