Department of Pediatrics and Department of Epidemiology and Prevention (Dr Brown), Wake Forest School of Medicine, Winston-Salem, NC; Department of Pediatrics and Duke Center for Childhood Obesity Research (Dr Perrin), Duke University School of Medicine, Durham, NC.
Department of Pediatrics and Department of Epidemiology and Prevention (Dr Brown), Wake Forest School of Medicine, Winston-Salem, NC; Department of Pediatrics and Duke Center for Childhood Obesity Research (Dr Perrin), Duke University School of Medicine, Durham, NC.
Acad Pediatr. 2018 Sep-Oct;18(7):736-745. doi: 10.1016/j.acap.2018.05.004. Epub 2018 May 29.
Despite extensive public health and clinical interventions, obesity rates remain high, and evidence-based preventive strategies are elusive. Many consensus guidelines suggest that providers should screen all children after age 2 years for obesity by measuring height and weight, calculating body mass index (BMI), and sensitively communicating weight status in the context of health to the family at each visit. However, preventive counseling should begin in infancy and focus on healthy feeding, activity, and family lifestyle behaviors. For children with overweight or obesity, the American Academy of Pediatrics outlines 4 stages of treatment: 1) Primary care providers should offer "prevention plus," the use of motivational interviewing to achieve healthy lifestyle modifications in family behaviors or environments; 2) children requiring the next level of obesity treatment, structured weight management, need additional support beyond the primary care provider (such as a dietitian, physical therapist, or mental health counselor) and more structured goal setting with the team, including providers adept at weight management counseling; 3) children with severe obesity and motivated families may benefit from referral to a comprehensive multidisciplinary intervention, such as an obesity treatment clinic; and 4) tertiary care interventions are provided in a multidisciplinary pediatric obesity treatment clinic with standard clinical protocols for evaluation of interventions, including medications and surgery. Although it is certainly a challenge for providers to fit in all the desired prevention and treatment counseling during preventive health visits, by beginning to provide anticipatory guidance at birth, providers can respond to parents' questions, add to parents' knowledge base, and partner with parents and children and adolescents to help them grow up healthy. This is especially important in an increasingly toxic food environment with numerous incentives and messages to eat unhealthfully, barriers to appropriate physical activity, and concomitant stigma about obesity. Focusing on key nutrition and physical activity habits and establishing these healthy behaviors at an early age will allow children to develop a healthy growth trajectory. However, much more work is needed to determine the best evidence-based practices for providers to counsel families on improving target behaviors, environmental modifications, and parenting skills and to decrease abundant disparities in obesity prevalence and treatment.
尽管广泛采取了公共卫生和临床干预措施，肥胖率仍然居高不下，而且难以实施基于证据的预防策略。许多共识指南建议，医生应在每次就诊时通过测量身高和体重、计算体重指数（BMI），并在健康背景下敏感地向家庭传达体重状况，对 2 岁及以上的所有儿童进行肥胖筛查。然而，预防咨询应从婴儿期开始，并侧重于健康喂养、活动和家庭生活方式行为。对于超重或肥胖的儿童，美国儿科学会概述了治疗的 4 个阶段：1）初级保健提供者应提供“预防加”，使用动机访谈来实现家庭行为或环境中健康生活方式的改变；2）需要下一层次肥胖治疗的儿童，即结构化体重管理，需要超出初级保健提供者（如营养师、物理治疗师或心理健康顾问）的额外支持，以及与团队更结构化的目标设定，包括擅长体重管理咨询的提供者；3）严重肥胖且有动力的家庭的儿童可能受益于转介到全面的多学科干预，如肥胖治疗诊所；4）三级保健干预措施在多学科儿科肥胖治疗诊所中提供，有标准的临床干预评估方案，包括药物和手术。尽管提供者在预防保健就诊期间将所有期望的预防和治疗咨询都纳入进来确实具有挑战性，但通过从出生开始提供预期指导，提供者可以回答家长的问题，增加家长的知识库，并与家长和儿童青少年合作，帮助他们健康成长。在一个充满毒性的食物环境中，有许多不健康饮食的激励措施和信息、适当体育活动的障碍以及肥胖相关的污名化，这一点尤其重要。关注关键的营养和体育活动习惯，并在早期建立这些健康行为，将使儿童能够发展出健康的生长轨迹。然而，还有更多的工作需要确定提供者为改善目标行为、环境改变和养育技能，以及减少肥胖流行和治疗方面的大量差异，向家庭提供咨询的最佳循证实践。
