|Year : 2015 | Volume
| Issue : 1 | Page : 21-25
Obese child: A practical approach
Majed Mohammed Al-Saleh, Mohammad A Al-Zahrani
Department of Family Medicine, Health Affairs, Aseer Region, Saudi Arabia
|Date of Web Publication||12-Jun-2015|
Mohammad A Al-Zahrani
Department of Family Medicine, Health Affairs, Aseer Region
Source of Support: None, Conflict of Interest: None
Obesity is a common health problem in pediatric age group particularly in a society that is not practicing healthy lifestyles. The early detection and management of obese children can prevent later complications of obesity.
Keywords: Approach, obese child, obesity
|How to cite this article:|
Al-Saleh MM, Al-Zahrani MA. Obese child: A practical approach. Saudi J Obesity 2015;3:21-5
| Introduction|| |
Obesity is a common health problem in pediatric age in Saudi Society. 
The prevalence of childhood obesity in Saudi Arabia is escalating and approaching figures reported in the developed countries. Less healthy dietary habits and poor food choices may be responsible for this high prevalence. 
Childhood obesity is associated with an increased incidence of hypertension, dyslipidemia, diabetes mellitus, asthma, mental health disorders, and adult obesity. ,
The United States Preventive Services Task Force recommends that clinicians screen children 6 years and older for obesity, and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status,  it is also recommended that children should avoid watching TV for long period. 
The aim of this article is to provide family physicians (FP) with a practical approach, which will enable them to care for obese children at primary care and family practice.
| Case scenario|| |
Ali is an 8-year-old boy who attended to family medicine clinic with his father seeking help regarding gaining weight. How FP should deal with such a child?
Family physician should start consultation with welcoming Ali and his father, thanks them for attendance to clinic, establishing with them a good rapport in order to conduct a successful consultation.
FP starts by collecting bio-data and then asking an open-ended question, such as "how is Ali's health status?" Father and son ideas, concerns should be adequately explored, effect of obesity on Ali's life such (sleeping, walking), the real reason and expectation from this visit are important issues that should be addressed in initial visit.
| Present illness history and systematic review|| |
Present complaint and past medical history, dietary and physical activity should be covered completely. The following important points are mandatory:
- Duration of obesity
- Onset of weight gain, progress, aggravating factors.
- Effect of obesity on quality of life including (snoring during sleep, shortness of breath, back pain and joint pain)
- Other associated symptoms related to secondary obesity (hair fall, cold intolerance, depressed mood, polyuria, polydipsia, and jaundice)
- Detailed dietary history should include; number of meals, snacks, intake fast food, intake soft drinks, taking breakfast regularly, intake of fruits and vegetables
- Other important issue is physical activity and sedentary life. FP should explore the patterns of daily physical activity, practicing sport at schools (type, frequency, duration) and watching TV or play stations if any
- Family history of chronic diseases such as obesity, diabetes, hypertension, dyslipidemia and cardiovascular diseases is another aspect that should be covered.
Details history from the parent showed that Ali is an 8 years old in the second elementary school who is in good health since birth but showed to gain weight for the last 3 years, dietary history revealed that Ali intakes soft drink like sweet juices, sometime cola but less milk. Every weekend, Ali's father takes him to nearby mall for shopping and eating some fried potatoes, chips and playing some games. Most of days Ali does not eat his breakfast and given some money to buy from school cafeteria. After coming from school, Ali eat his launch which consists of Kabsa, and soft drink (MIRINDA) but no fruits or vegetables. Ali sleeps for 3 h and gets up at 4:00 PM to read and to deal with his homework for about 1-h. After that, Ali used to o watch TV for about 3 h without performing any physical activity. While watching TV, Ali eats some chocolate and creams. At school, Ali plays with his friends one sport session per week. Ali's mood was normal and no relevant stressor. Father addressed his concern about Ali's weight stating that he is afraid that his son has night snoring and afraid that his son may develop diabetes. Family history revealed that Ali's mother is obese and hypertension on medications. There is no history of smoking in family and nor conflict with good income for family needs. Ali's performance at school is good.
| Physical examination|| |
After taking history, then FP should proceed to perform a comprehensive physical examination after taking the permission of Ali and his father.
Physical examination should include:
- General look and body built
- Blood pressure (BP)
- Weight, height and body mass index (BMI)
- Thyroid and neck
- Heart and chest
- Abdomen including waist/hip ratio
- Back and joints
Physical examination revealed the following findings:
Ali was looking very obese, with a normal gait, no jaundiced or pallor, there was no skin pigmentation. Vital sign showed: BP = 100/70 mmHg, temperature 36.7°C, weight = 51 kg, height = 130 cm. BMI calculated and plotted in growth chart 30.1 kg/m 2 [[Figure 1]A: Intial BMI].
Head, neck, ENT, thyroid were normal, heart and chest examination showed no abnormality or significant finding. Abdomen showed centrally obese but no organomegaly. There was no lower limbs swelling or deformity.
Family physician appreciated Ali and his father awareness regarding gaining weight as important step to successful management of obesity. FP explained the findings to father stating that Ali's weight was above normal as plotted in the BMI chart and there is no obvious cause for weight gain except intake unhealthy diet and physical inactivity. FP told Ali's father that snoring is most likely due to obesity, and those with obesity are at high risk of diabetes, hypertension and dyslipidemia. FP informed Ali's father that relevant investigations are necessary to rule out secondary causes of obesity and to screen for some health problems such as hypothyroidism, diabetes, and dyslipidemia.
| Investigations|| |
At this visit the following investigations were requested:
Fasting blood glucose, thyroid function test (thyroid-stimulating hormone, FT3, FT4), lipid profile (low density lipoprotein, high density lipoprotein, triglyceride and total cholesterol), liver function test (aspartate transaminase and alanine transaminase), renal function test (urea and creatinine).
| Management|| |
Before closing this visit, FP discussed with Ali and his father the readiness to reduce weight and to follow-up at clinic regularly.
Ali's father responded that he is worry about his son' weight and he will do the best effort to help his son to reduce weight. FP thanked Ali's father and asked him to write the diet diary of his son for 1-week till the results of investigation appear.
Family physician agreed with Ali and his father that the target weight loss will be 2 kg/month, that is, 0.5 kg/week and the final goal is to lose 21 kg which will bring his BMI to 17.2 kg/m 2 "taking in mind that his height is expected to increase", so a duration of 10 months is seated as the amount of time needed to achieve the shared goal. Before leaving clinic FP provided Ali's father "The Big Five" - Scoring worksheet to assess the dietary and exercise habits of Ali. 
| Follow-Up|| |
2 nd visit
In the second visit FP should maintain good rapport, discuss the results of investigations, discuss the diet diary, physical activity and any new concern, idea or expectation, detail advices about diet and physical activity should be provided.
Ali and his father attended after 2 weeks according to appointment.
Family physician welcome Ali and his father and thanked them as they complied with appointment. Brief history was taken, weight, height were checked and BMI was calculated and plotted in BMI chart.
The "Big Five" - Scoring worksheet to assess the dietary and exercise habits of Ali was discussed with patient and his father and the following advices were given to Ali regarding diet: 
- Eat five or more servings of fruits and vegetables daily
- Use television and computer for no more than 2 h/day
- Do not keep a television in child's bedroom
- Do not consume sugar-sweetened beverages e.g. Pepsi
- Eat breakfast daily and can use low or free fat milk and whole grain bread
- Limit meals outside the home like fast food
- Eat two meals per week containing fish
- Have family meals at least 5-6 times/week
- Allow child to self-regulate food intake and avoid food restriction.
- Drink a glass of water before each meal and decrease salt in food to ovoid fluids retention in the body
- Eat slowly and grind food well
- Do not fill stomach or fill the palate with a large amount of food 
- Eat three main meals and 2 healthy snacks
- Ensure that parents and children eat meals together.
Family physician motivated Ali's family in management plan to help him to reduce his weight such as reduce oil when cocking the food in home and replaced saturated fat by unsaturated fat.
- Try to avoid animal oil sources and use a plant oil, e.g. olive oil.
Family physician counsel Ali about exercise as an intervention for losing weight in obese child and his readiness to practicing exercise by using physical activity readiness questionnaire. 
Family physician discussing type, duration and frequency of the exercise with Ali.
Participate in at least 60 min of moderate to vigorous physical activity per day for 5 days/week and no more than 2 days without exercise, e.g., fast walking starting with 10 min worming then active exercise 40 min and slow down for another 10 min.
Advise Ali to use proper shoes and chose the proper time for practicing exercise.
Do not practice exercise after heavy meal or if there is sore throat and should stop if feeling a chest pain.
- Ali was advised to practicing muscle-strengthening activity at least 3 days/week and bone-strengthening activity at least 3 days/week 
- Family physician advises Ali to increase his daily activity through climbing stair instate of using elevators, participating with his family in homework, e.g., cleaning the garden.
After this session FP gave Ali and his father educational materials about obesity, diet and exercise and asked them to complete the requested investigation and give appointment after 1-month.
3 rd visit
Ali attended to his appointment on time and was thanked for his compliance to clinic times.
In this visit, FP aimed mainly to assess the following issues along with patient sharing:
- Any new complaints or concerns
- Compliance with diet and exercise
- Exploring barriers to compliance with medical advices
- Completeness of score sheet (log book) for diet and physical activity
- Checking weight and if target achieved or not
- Discussion of previous visit's investigation result.
During this session, Ali stated that he has no complaint and is highly practicing the action plan that was agreed.
His father raised up the issue of calculating the diet calories and was advised not to do so as is not the first choice strategy in childhood obesity in comparison to adolescents, and that the evidence for such intervention is of a low quality.
Instead his FP gave him "traffic light" format as a teaching tool, grouping foods based on their nutrient quality and calorie density, and then explaining which foods should be eaten most often (Red: Eat rarely; Yellow: Eat less often; Green: Eat more often). 
Ali's compliance with healthy diet at home was excellent but when goes outside for social visits he has a hard times with eating.
He was exercising only 30 min/day which was anyhow fair start.
These barriers to compliance were discussed and an action plan was agreed to fulfill the gaps e.g., eating a healthy home meal before leaving to social meetings.
His weight was measured at 49.5 kg (lost 1.5 kg) and his FP congratulate him for his great job though was not reaching the goal of 0.5 kg/week.
All of the previous investigations are normal and were discussed with Ali and his father with a great amount of reassurance.
At the end of this visit Ali was advised to pay a little bit more effort and to check his weight only once weekly as this will encourage him more if reaching target and to come anytime if his weight is not going down as planned follow up visit wasgiven after one.
4 th visit
Ali came back on time to his FP who again assessed his barriers and needs.
Ask about compliance, complaints and any new concerns.
He stated that he is very happy, he stated that he has lost another 2 kg as he measured at home using an electronic weight scale.
On measuring Ali's weight he even lost more and actually he has lost 2.5 kg since his last visit, his current weight is 47 kg and BMI is now 27.8 kg/m 2 .
He has now an excellent compliance to all advices on different types of physical activity and states that traffic light eating plan is helping him a lot.
He asked about using weight loss medications and was warranted as there are not recommended for his age group.  Moreover, that he does not actually need them at all.
At the end of this visit he was given a star chart to fill it up weekly and agreed with his father that every 4 stars achieved, a gift will be given for cheering Ali.
Ali was advised to share his healthy lifestyle with his schoolmates.
A follow-up visit after 2 months were given along with clinic contact number in case of need.
Ali called clinic by phone after 1-month and was again reassessed briefly (7 min total time of phone interview).
He is very motivated and is now programmed on his new healthy lifestyles and says he is enjoying his life very much.
There were no new concerns or complaints and is reaching target of 2 kg loss in the last month.
He was congratulated for his invaluable effort, thanked for his call and encouraged a lot to call when he needs to do so.
5 th visit
In this visit Ali's logbook was reviewed extensively by his FP.
Family sharing through changing Ali's family eating habits were noted and encouraged.
They started to participate in walking and exercise as well.
Today, he has no complaints or concerns and is looking much more attractive boy with his new look.
His weight is now 43 kg (lost 4 kg in the last 2 months) and was promoted a gift for this achievement.
He was encouraged to increase his walking in duration and intensity (a goal of 90 min/day for five days was agreed on).
He left the clinic, and follow-up visit was given 8 weeks later.
6 th visit
- Ali is progressing well and smoothly with previous visit plan
- He has no complaint or new concerns
- His FP measure his weight by himself and is 39 kg
- He was thanked and encouraged to continue his efforts
- He stated that his mother who is obese has started to participate with him and she is now losing weight
- He was asked to bring her with him next visit after 2 months.
7 th visit
- Ali is now very happy as he approaching the sited goal gradually
- His weight is now 35 kg and BMI is 20.7 kg/m 2
- He started to wear now fitting clothes and has an improved exercise capacity,
- Follow-up after 2 months was agreed.
8 th visit
Ali brings his parents along with him, his mother was very thankful for Ali's FP as well as his father.
Ali's weigh now a 30 kg, his height is 132 cm and has a BMI of 17.2 kg/m 2 and his age is 8 years 10 months [[Figure 1]B: Current BMI].
He and his parents were congratulated for his great result and his mother is also losing weight and will have a follow-up with the same FP.
Ali and his family were told that the aim is to maintain lifelong healthy habits otherwise the weight is expected to build up back.
A contact through phone, any time is welcomed and follow-up Q 3 months is insured.
| Conclusion|| |
Childhood obesity can be managed effectively by qualified FP through a good counseling from FP and a motivation from the patient. The changing in family lifestyle plays a fundamental role in prevention and management of childhood obesity last but not least. Sharing of the whole family in the management of obesity has a positive outcome on patient improvement.
| References|| |
AlSheri A, AlFattani A, AlAlwan I. Obesity among Saudi children. Saudi J Obeity 2013;1:3-9.
Amin TT, Al-Sultan AI, Ali A. Overweight and obesity and their relation to dietary habits and socio-demographic characteristics among male primary school children in Al-Hassa, Kingdom of Saudi Arabia. Eur J Nutr 2008;47:310-8.
Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al.
Health consequences of obesity. Arch Dis Child 2003;88:748-52.
Berenson GS; Bogalusa Heart Study group. Health consequences of obesity. Pediatr Blood Cancer 2012;58:117-21.
Al-Ghamdi SH. The association between watching television and obesity in children of school-age in Saudi Arabia. J Family Community Med 2013;20:83-9.
Rao G. Childhood obesity: Highlights of AMA Expert Committee recommendations. Am Fam Physician 2008;78:56-63.
Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics 2007;120 Suppl 4:S164-92.
Khawaji AA, Al. Asmery BA. Approaching young patient with obesity in family practice. Saudi J Obesity 2013;1:10-3.
Thomas S, Reading J, Shephard RJ. Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can J Sport Sci 1992;17:338-45.
Saguil A, Stephens M. Fort Belvoir Community Hospital Family Medicine Residency, Fort Belvoir, Virginia, and Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, Interventions to Prevent Childhood Obesity. Available from: http://www.summaries
. cochrane.org/CD001871 [Last cited in 2015 April 27].
Amador M, Ramos LT, Moroño M, Hermelo MP. Growth rate reduction during energy restriction in obese adolescents. Exp Clin Endocrinol 1990;96:73-82.
Alli (orlistat) [prescribing information]. Moon Township, PA: Glaxo Smith Kline; September, 2014.