1 Introduction

Many health care professionals and organizations across the country are looking for effective ways to address the dramatic increase in childhood obesity. This crisis will require a variety of responses at all levels of our culture. Those of us who regularly care for children and adolescents need to assume a prominent role in the management of obesity in the outpatient setting.

The essential goals of an effective pediatric weight management clinic are three-fold: 1) identify patients who have unhealthy levels of excess adiposity and related comorbid conditions, 2) help patients and families make permanent healthy lifestyle changes and 3) provide ongoing care and feedback in order to optimize long-term health outcomes. A fourth goal, the prevention of obesity in healthy populations, is outside the scope of this article, but is explicated in the Expert Committee’s recommendations on child and youth overweight and obesity [1].

Running a successful pediatric weight management program requires attention to several areas. The efficacy of interventions is important; we will touch on this, and more can be found in this volume and elsewhere [2]. In this article, we will identify what we believe to be the key aspects to consider when laying out and sustaining a pediatric weight management clinic.

2 Starting a program

2.1 Location

One of the earliest questions that comes up when designing a weight management clinic is whether it should be situated as a centrally located subspecialty referral clinic or a disbursed community-centered enterprise. We believe this is a false choice. Both aspects are necessary—a close connection to subspecialty expertise and strong ties to the “boots on the ground” in primary care. The “staged-care” approach requires both clinical facilities: the primary care-based team to evaluate and manage overweight children and obese children without co-morbid conditions and the interdisciplinary subspecialty team to manage obese children with co-morbid conditions and morbidly obese children [3].

2.2 Personnel—building the team

Who should lead the pediatric weight management clinic? Although many different types of providers have skills required to care for obese children, we believe physicians have the variety of skills and training background that is necessary for a comprehensive clinical approach to weight management. While the weight management program should draw from many disciplines, a physician leader is essential.

Which type of physician is best suited to serve in this effort? Since no unified training program exists to prepare clinicians for tackling this problem and since the problem covers so many different specialty areas, qualified physicians may come from several different areas. Practically speaking, the best-qualified physician is one who has sufficient interest in the area of weight management to navigate the difficult task of establishing and sustaining the clinic. Physicians interested in spearheading a pediatric weight management program can acquire the necessary knowledge and skills through several sources (Table 1).

Table 1 Information resources for establishing a pediatric weight management program
Full size table

In addition to physicians, other providers are needed to start a weight management clinic. Pediatric Nurse Practitioners (PNP’s) and Physician Assistants have the training and versatility to take on a number of roles in the clinic, from provision of direct care in the clinic to coordinating the care the entire team provides. Nurses and medical assistants are essential to the day-to-day functioning of the clinic to provide care coordination to patients and to do follow-up calls to insure adherence to therapy.

Due to the multitude of problems that are faced by overweight and obese children and adolescents, a multi-disciplinary team approach is best for an effective pediatric weight management clinic. One essential team member is a nutrition expert, usually a registered dietician, with special training related to disordered eating. It has been our experience that many dieticians are trained to provide comprehensive advice on dietary change in a single patient care session; few pediatric dieticians are experienced in providing incremental dietary change. This latter counseling style is one the dietician must adopt in a weight management clinic.

Dieticians have the opportunity to obtain specialized training certification in childhood and adolescent weight management [4]. With the massive amounts of media attention on eating and nutrition, much confusion exists in patients and families on making the healthiest choices. A team member dedicated to this topic can help immensely in the counseling of patients.

Another helpful member of the team is a clinician with special interest or training in the psychological aspects of excess weight, usually a clinical psychologist. Most of the overweight and obese patients we see do not have diagnosable psychological disorders or specific eating disorders, but the few that do can have trouble adhering to the changes necessary to make significant health improvements. However, nearly all the patients we see benefit from counseling around making permanent healthy lifestyle changes. The medical clinician will provide this care in many cases, but in more difficult cases may be augmented by clinicians with additional mental health experience and training. In addition, when serious psychopathology or an eating disorder is suspected, the clinic psychologist is the logical person to screen the child for these concerns.

Since a large part of successful weight management relates to increasing physical activity, it is beneficial to bring exercise experts onto the weight management team. Depending on the clinic, this may take the form of a medical clinician with special interest or training in exercise medicine (sports medicine physicians, athletic trainers, physical therapists) or others with exercise-related training (i.e. exercise physiologists). Unfortunately, reimbursement for these services is not as well established as for nutrition and psychology-related services.

Most clinicians who manage obese patients develop expertise in the care of the co-morbid conditions of obesity. Criteria should be established for referral of children with co-morbid conditions; each clinician will need to determine which problems he/she feels comfortable handling without consultation. All clinics must identify appropriate subspeciality referrals. At minimum this would include a pediatric endocrinologist (to manage Type 2 diabetes and polycystic ovary syndrome), a pediatric gastroenterologist/hepatologist (to evaluate more severe cases of non-alcoholic fatty liver disease), and a pediatric cardiologist. Many obese children and adolescents suffer from obstructive sleep apnea, and require the care of a pediatric sleep physician. In addition, it is important to know which sleep study labs in the community can safely accommodate children and their parents. If available, a pediatric hyperlipidemia specialist is of value. At times skin conditions such as acanthosis nigricans may be severe enough to enlist the skills of a dermatologist.

Physicians in a pediatric weight management clinic should familiarize themselves with the full spectrum of therapies, including available medications and bariatric surgery. It is valuable to build a relationship with a surgeon trained in pediatric bariatric surgery. The pediatric weight management clinician should be a partner with the surgeon in the evaluation and long-term follow-up of children who undergo bariatric surgery. Increased medical attention is needed before and after surgery. The choice of procedures should be made in close consultation with the surgeon.

2.3 Equipment

One aspect of establishing a new clinic that may be overlooked is equipment. If the weight management program is based in a clinic that has been setup for the care of children of normal size and weight, the supplies may be inadequate. For example, commonly used scales to measure weight may be inaccurate in higher weight ranges or unable to measure weight altogether in heavier patients. Special scales that measure accurately up to 500 pounds are available. Other equipment, such as blood pressure cuffs, should be checked to make sure larger size cuffs are included. Measuring tape should be longer than usual so large waistlines can be measured. Exam tables should be sturdy enough to support larger patients, and for the comfort of the patient and other family members, chairs without armrests should be sought out.

2.4 Institutional support

The importance of support for a new pediatric weight management clinic at all levels of its institution cannot be overstated. Although many patient, families, and health-care workers may voice support for extra focus on weight-related concerns in the clinic setting, the conventional wisdom states that these clinics are revenue-neutral at best, and a considerable drag on financial resources at worst. New clinical enterprises will have startup costs, but weight management clinics can be profitable if run well. These realities must be spelled out clearly for financial supporters of the clinic if long-term support is to be expected.

The American Academy of Pediatrics has developed resources for members with respect to coding and billing for the evaluation and management of pediatric obesity; this information can be found under the AAP Childhood Overweight and Obesity webpage. (Table 1) This topic is discussed further in a later section of this article.

2.5 Marketing

How the clinic is perceived by other clinicians and the public should be considered from the start. The name of the clinic creates a first impression and should be chosen with care. Avoiding words that may be accurate but have picked up negative connotations, such as obesity or overweight, is one approach; this is supported by data in adults on language preferences [5]. Words that have more of a positive connotation, such as fitness or wellness, may successfully communicate the goals of the clinic without stigmatizing the patients and families who attend. Stigmatization of obese children and effects on self-esteem is a problem that is worsening, and careful use of language in the setting of a weight management program is prudent [6]. On the other hand, if the name is so obscure that potential patients and referring physicians cannot find it easily by searching online, it may limit the patient population.

The task of building community partnerships is difficult in the near term, but rewarding if the clinic is to be a long-term resource for the community. In a pediatric clinic, relationships with health-related and other personnel at the local schools will help immensely with patients’ adherence to the treatment course. Teaming up with other community organizations that share the common goals of healthy eating and physical activity is important, whether it be through formal contractual agreements or a basic knowledge of each other’s activities.

2.6 Referral base

If the pediatric weight management clinic is based in primary care, the connection between individual primary care providers and the multi-disciplinary weight management team will be naturally closer. If the weight management clinic is based in a subspecialty center, this connection will be more difficult to maintain. In either case, there are multiple methods to foster close relations. Formally, discussions should occur with the leadership at the organizations involved to decide when and under what circumstances enrollment in the weight management program should be offered to patients. After this is decided, the process should be as automated and labor-free as possible. Informally, personal relationships with the referring providers can be cultivated in a variety of ways, starting with setting up meetings to explain what the new clinic will offer, to clear and consistent communication about patient care, to educational meetings sharing methods to improve weight management across the entire clinic organization.

2.7 Focus—medical-model or other?

Early on in the genesis of a new weight management clinic, decisions must be made regarding the general thrust and focus of the clinic. Will it be based in western medicine, with a focus on discovering pathology, performing laboratory testing, and prescribing tested treatments? Or will the focus be closer to the field of psychology, with more effort given to learning about the patient and family and individualizing behavioral counseling? We believe there is value in both approaches, and each should be employed at varying times in the patient’s course.

In this dual approach, patients are interviewed and examined by a weight-management-focused physician or PNP upon enrollment into the clinic. The focus of the history and physical is the assessment of risk for co-morbid conditions related to excess fat mass. A common and useful method for assessing excess fat mass is the calculation of body mass index percentile for age and gender. The BMI percentile for weight and sex is then categorized into normal, overweight, or obese ranges, using clinical judgment to decide whether the BMI correlates with the extent of adiposity [7].

Other methods, such as dual-energy x-ray absorptiometry, can be used to assess adiposity, but BMI percentile has the advantage of being cheap and widely available. Waist circumference is also convenient to measure, is a better estimate of visceral adiposity, and has been associated with features of metabolic syndrome in some studies of children [8]. We support its routine measurement in weight management clinics, where it can be useful to track over the course of treatment. At this time it should be used in addition to, not instead of, BMI.

If the patient is assessed as having elevated health risk (either by assessment as obese/morbidly obese OR by identification of specific indicators in the history and physicial exam), comorbid conditions should be identified through appropriate history, exam, and laboratory tests [8]. These conditions may include diabetes mellitus, hypertension, sleep apnea, dyslipidemia, acanthosis nigricans, vitamin D deficiency, polycystic ovarian syndrome, and others [9]. Table 2 is a list of studies performed on most patients upon enrollment into our program; different clinics may choose different tests. Although recommendations exist as to when these studies might be utilized, more evidence is needed to delineate the best laboratory screening regimen [8]. Identification of a co-morbid condition necessitates treatment. Most weight management programs treat straightforward co-morbid conditions within the clinic, reserving referral for more severe clinical situations. This is a decision that must be made by those coordinating the clinic.

Table 2 Potential laboratory studies performed upon enrollment in a pediatric weight management program
Full size table

At the same initial visit, extensive history around eating and activity patterns is taken, and counseling is provided. Many methods exist for assessing energy intake and activity. In our clinic, we perform a 24-hour diet recall at every visit, and ask children to complete six-day diet diaries intermittently [10]. We have found that enforcing daily diet diaries is difficult. It is well-established that obese patients tend to under-record food eaten in diet diaries [11]. We find more useful the pattern of eating and the choice of foods. Both the primary provider and the dietician review these records, and suggest options for diet modification to the patient.

Regarding physical activity assessment, methods range from simple questionnaires to complex calorimetry. Both activity and inactivity (e.g. screen time) must be assessed. Questionnaires have the most potential for wide application due to their low cost; unfortunately many validated measures are difficult to use regularly in a clinical setting [8].

Once energy intake and activity has been assessed, the counseling method utilized is patient-centered, using techniques such as motivational interviewing to assist patients and families in making permanent healthy lifestyle changes. In general, small concrete changes the family can commit to are sought. Attempts at complete life-style alteration in a short period usually fail. The changes are focused on improving health; losing weight is a secondary effect of these changes. The changes are also suggested for the whole family. Table 3 is a list (not inclusive) of examples of changes suggested by our clinic.

Table 3 Examples of healthy lifestyle change options given to families
Full size table

Subsequent visits involve some discussion of comorbid conditions, monitoring, and treatment adjustments, but the majority of the continuing visits are focused on counseling. These visits may range from weekly to quarterly, depending on the needs and availability of the patient and family. Although some randomized controlled trials investigating intensive treatment programs have been successful [12-14], the potential clinical benefit of intense programs must be balanced against the amount of school missed by the patient and the financial and other costs to the family in the form of time, travel, and missed work.

One program that has been studied is the Bright Bodies program at Yale University School of Medicine [15]. Investigators randomized 209 obese children to the treatment group (intensive family-based program including exercise, nutrition, and behavior modification, occurring biweekly and bimonthly) or control group (traditional clinical weight management counseling every 6 months). The intervention group had better outcomes at 12 months; for instance, the mean change in BMI was −1.7 in the intervention group and +1.6 in the control group.

In our clinic the provider who sees the child and family at each visit may be the physician, the PNP, or the psychologist. However, if use of weight loss medications or bariatric surgery is contemplated, the case is usually discussed with the physician.

A model that deserves further study for use in pediatric weight management clinics is the Chronic Care Model(CCM). This model, which includes “attention to self-management support, delivery system design, decision support, information technology, community linkages, and the health care organization as a whole,” has been used to improve diabetes care [17] and has also been investigated as a method to improve obesity care [18].

2.8 Billing/reimbursement

One disincentive working against establishment of new pediatric weight management clinics is the difficulty receiving reimbursement when the coded diagnosis is overweight or obesity [16]. It is important to remember that the reason for treating obesity is not obesity per se, but the health problems that arise from obesity. Co-morbid conditions can be coded if the clinic is treating them, either directly or through weight loss. In our clinic, the initial intake visit is billed based on evaluation and management (E&M) codes; follow-up visits are coded based on counseling time. Fortunately there is some evidence that reimbursement is improving in some areas [19].

3 Maintaining a program

Once the immense time and resources are invested into starting a pediatric weight management program, the focus shifts to keeping the program functioning optimally. Good communication, education, quality improvement, and improving patient self-management are necessary for maintaining a program and providing optimal chronic care.

3.1 Good team communication

One difficulty of the multi-disciplinary model is keeping all the team members and the patient on the same page. This goal requires clear and consistent communication and can be achieved through several methods. First, the physical layout of the clinic should be such that communication between team members in the course of patient care is supported. Second, regular brief team meetings to discuss patient care can be helpful. Third, medical record systems should be designed to encourage quick, efficient transfer of information among team members; increasingly these systems are electronic, but electronic systems retain the capacity to disappoint. Whatever the format, patient records should follow a consistent pattern to increase the ease with which they can be created and reviewed.

Strategies to maintain good communication with the extended network of subspecialists involved with the pediatric weight management clinic are similar to those of the core team. If possible, close physical proximity to these other providers should be sought, as this will increase the likelihood of both formal and informal contacts. A further step to integrate services for the patient would be to coordinate clinic schedules of the various specialties.

3.2 Continuing education

In the last several years there has been a vast expansion of the medical literature on the topic of childhood and adolescent obesity [20,21]. As attention to the problem increases, this will only continue. As new strategies and therapies are tested, it is challenging but crucial that those involved in the weight management clinic are attentive to the latest advances. Many educational resources exist in this area in the form of online learning environments, conferences, and many others [22].

3.3 Continuous quality improvement

The clinical knowledge obtained through various educational opportunities will be wasted if not applied to patient care—this can be accomplished in a variety of ways. As mentioned earlier, regular team meetings will help increase communication, but they are also useful for applying the latest advances into practice. Using protocols is one method to systematize up-to-date evidence-based practices. These protocols should be written and reviewed frequently, utilizing the latest available data and expertise. Another method to improve the delivery of care in the pediatric weight management clinic is to monitor outcome data. Information on outcomes can be helpful internally for planning changes in the clinic, but also useful when discussing the clinic with referring providers or administrators.

3.4 Improving adherence and maintaining success

Clinicians who have been running a pediatric weight management clinic for even a short amount of time will often report that adherence is major obstacle to running a successful clinic. This lack of adherence to recommended treatment plans can come in the form of having difficulties making agreed upon behavioral changes, not taking prescribed medications, or missing follow-up appointments. Practical strategies to reduce some of the missed follow-ups should be employed, such as reminder mailings and phone calls shortly before the time of the visit.

One aspect of this issue, non-return to the clinic, has been studied [23]. In 2006 Barlow and Ohlemeyer reported on a questionnaire sent to 85 families who attended the clinic for a short period of time. Some of the most common reasons cited were: distance, scheduling conflict, and insurance issues.

Dovetailing with adherence issues is the problem of maintaining healthy lifestyle changes over the long-term. Although this issue deserves more attention, some researchers have investigated longer-term maintenance [24,25]. Wilfley et al (2007) reported on a trial which randomized overweight children to treatment with 4 months of treatment designed to improve maintenance or control. Those in the treatment groups had significantly better outcomes compared to the control group, but this effect declined over the course of two year follow-up [24].

4 Conclusion

Building and maintaining a successful pediatric weight management program is a daunting, fulfilling task. Close attention must be paid to all aspects of the process: finding the best location, recruiting a well-qualified care team, lobbying for the support of the entire institution, promoting the program to the public, communicating effectively with referring providers, sustaining financial viability, and finding an approach to patient care that is effective. Maintaining the clinic in the long term requires vigilant attention to team communication, team education, quality improvement, and long-term outcomes in patients. It is vital to children’s health across the nation that more resources are spent on tackling the problem of overweight and obesity, and building effective weight management programs is a key part of that effort.