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Prevention and Management of Obesity – Pediatric – Ambulatory

Prevention and Management of Obesity – Pediatric – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


1
Prevention and Management of Obesity
– Pediatric – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 5
METHODOLOGY ............................................................................................................ 6
INTRODUCTION ............................................................................................................. 7
RECOMMENDATIONS ................................................................................................... 8
UW HEALTH IMPLEMENTATION.................................................................................. 8
REFERENCES ................................................................................................................ 8
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

2
CPG Contact for Content:
Name: Ellen Connor, MD – Pediatrics-Endocrinology
Phone Number: (608) 262-6229
Email Address: elconnor@pediatrics.wisc.edu
CPG Contact for Changes:
Name: Janna Lind, MSN, RN – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6695
Email Address: jlind@uwhealth.org
Guideline Author(s): Institute for Clinical Systems Improvement (ICSI)
Coordinating Team Members:
Ellen Connor, MD – Endocrinology-Pediatrics
Deirdre Burns, MD – Pediatrics
David Bernhardt, MD – Pediatrics
Blaise Nemeth, MD – Pediatric Fitness Clinic
Magnolia Larson, DO – Family Medicine
Nicole Weathers, MD – Family Medicine
Cassandra Vanderwall, MS, RD, CD, CDE, CPT – Clinical Nutrition
Diane Olson, RDN, CDE – Clinical Nutrition
Alisa Sunness, RDN – Clinical Nutrition
Karen Block – Clinical Support-Health Ed.
Melody Cole, MS, RDN, CD, CDE – Clinical Staff Education
Melissa Jones, BSN, RN – Clinical Staff Educations
Cindy Gaston, PharmD – Drug Policy Program
Elaine Rosenblatt, MSN, FNP-BC – UWMF
Jen Grice, PharmD – Center for Clinical Knowledge Management
Lindsey Spencer, MS – Center for Clinical Knowledge Management
Review Individuals/Bodies:
Alexander Young, MD – Family Medicine
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (05/28/2015)
Release Date: May 2015
Next Review Date: May 2017
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
UW Health has agreed to endorse the 2013 Prevention and Management of Obesity for
Children and Adolescents created by the Institute for Clinical Systems Improvement
(ICSI).1
In lieu of the recommendations in the ICSI 2013 guideline, UW Health recommends the
following modifications or additions:
1. In addition to the blood pressure screening recommendations for patients age 3
through 17, UW Health recommends screening in patients under the age of 3 years
with specific risk conditions (see below) or changes in risk. Patients under the age of
3 years may have their blood pressure obtained every 6 months during health
supervision visits2 or other non-specific acute illness visits. (UW Health Class IIb, LOE C)
Positive risk factors for blood pressure screening include: 2-5
ξ History of prematurity, low birth weight, or neonatal complications
requiring ICU care
ξ Congenital heart disease (repaired, unrepaired, or family history)
ξ Elevated body mass index (BMI)/obesity
ξ Recurrent UTI, hematuria, or proteinuria
ξ Known renal disease or urologic malformations
ξ Solid organ transplant
ξ Malignancy or bone marrow transplant
ξ Treatment with drugs known to raise blood pressure
ξ Other systemic illnesses associated with hypertension (i.e.,
neurofibromatosis, evidence of elevated intracranial pressure, tuberous
sclerosis, etc.).
For more details on blood pressure screening recommendations, see the UW Health
Standard Rooming Criteria – Pediatric/Adult – Ambulatory Guideline or UW Health
Preventive Health Care - Pediatric/Adult – Ambulatory Guideline.
2. Per the UW Health Preventive Health Care - Pediatric/Adult – Ambulatory Guideline,
universal lipid screening is recommended in patients age 9-11 years using non-
fasting total cholesterol and HDL measurements.6,7 (NHLBI Grade B, strongly
recommended)
Key Practice Recommendations
1. Obesity prevention messages should be targeted at all families, starting at the time
of the child’s birth. (ICSI Strong Recommendation, High Quality Evidence)
2. An assessment of diet, physical activity and sedentary behaviors should be done
annually, preferably at a well child visit. This assessment should be used to target
appropriate messages to each family. (ICSI Strong Recommendation, High Quality Evidence)
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

4
3. Clinicians should counsel children and families to:
ξ Limit their child’s consumption of sugar-sweetened beverages
ξ Eat a diet with the recommended quantities of fruits and vegetables
ξ Eat breakfast daily
ξ Eat meals together as much as possible
ξ Limit eating out, especially eating at fast food restaurants
ξ Adjust portion sizes appropriately for age
ξ Avoid television for children under the age of two
ξ Limit television and “screen time” to less than two hours per day
(ICSI Strong Recommendation, High Quality Evidence)
4. Clinicians should encourage children and adolescents to engage in moderately
intense physical activity for at least 60 minutes per day. (ICSI Strong Recommendation,
High Quality Evidence)
5. BMI should be calculated and documented in the medical record on all children ages
2-18 at least annually, ideally at a well child visit. (ICSI Strong Recommendation, High
Quality Evidence)
6. Health risks that increase the likelihood of obesity and/or related comorbidities
should be assessed annually. (ICSI Strong Recommendation, High Quality Evidence)
7. All children should have blood pressure checked annually starting at age 3. (ICSI
Strong Recommendation, High Quality Evidence)
8. All children ages 9-11 should be universally screened for dyslipidemia, using either a
non-fasting non-HDL cholesterol or a fasting lipid profile. At other ages, a fasting
lipid profile should be done if indicated by family history and/or risk factors. (ICSI
Strong Recommendation, High Quality Evidence)
9. Clinicians should use motivational interviewing techniques as a tool for encouraging
behavior change. (ICSI Strong Recommendation, Moderate Quality Evidence)
10. Lifestyle interventions should be provided for overweight and obese youth. (ICSI
Strong Recommendation, High Quality Evidence)
Companion Documents
1. Healthy Habits and Growth Concerns Algorithm for Pediatric Patients and Families
2. Healthy Habits and Growth Concerns Conversation Tips
ξ General Conversation Tips
ξ Patients and Families READY to Make Changes
ξ Patients and Families NOT READY To Make Changes
ξ Patients and Families COMMITTED to Change
3. Medications Associated with Weight Gain
Related UW Health Clinical Practice Guidelines
1. Standard Rooming Criteria – Pediatric/Adult – Ambulatory Guideline
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

5
2. Preventative Health Care – Pediatric/Adult – Primary Care Guideline
3. Diabetes - Pediatric/Adult - Inpatient/Ambulatory Guideline
4. Eating Disorders - Pediatric/Adult - Ambulatory Guideline
Internal Resources
1. Nutrition Services Flyer
2. Pediatric Fitness Clinic - Information for Referring Providers
External Resources
1. Let's Go! 5210 - Healthcare
2. AAP Institute for Healthy Childhood Weight
Pertinent UW Health Policies & Procedures
1. UWMF Policy- Measuring Weight in Adults and Children
2. UWMF Policy- Measuring Height in Adults and Children
3. UWHC Policy #8.02- Assessment and Reassessment of Patients and
Documentation in Clinics
Patient Resources
1. HFFY#518 Pediatric Healthy Eating: Picky Eating or Problem Feeding
2. HFFY#240 Pediatric Healthy Eating: Helping Your Child Like Vegetables
3. HFFY#492 Pediatric Healthy Eating: Everyday Foods vs. Sometimes Foods
4. Pediatric Fitness Clinic
5. 5210 Nutrition Resource
6. AFCH Overweight and Obesity Webpage
7. Heathwise: Feeding: First Year : Pediatric
8. Heathwise:Feeding: Newborn : Pediatric
9. Heathwise:Healthy Eating : Teen: General Info
10. Heathwise:Obesity : Pediatric
11. Heathwise:Weight Issues : Teen: General Info
12. Heathwise:Weight Management : Teen: General Info
13. Heathwise:Weight: Overweight : Pediatric
External Resources
1. Let's Go! 5210 - Families
2. Go Slow Whoa Nutrition Resource
3. Choose My Plate Nutrition Resource
4. Kids Eat Right
Scope
Disease/Condition(s): Obesity, Overweight
Clinical Specialty: Endocrinology, Family Medicine, Pediatrics, Nursing, Nutrition,
Preventive Medicine, and Surgery
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

6
Intended Users: Primary Care Physicians, Specialty Care Physicians, Advanced
Practice Providers, Registered Dieticians, Nursing, Pharmacists
Objective(s):
To establish evidence-based recommendations on the prevention, diagnosis, and
management of obesity in pediatric patients.
Target Population: All children and adolescents ages 0 to 18 years.
Interventions and Practices Considered:
ξ Promotion of a healthy lifestyle
o 5210 Let’s Go - childhood obesity prevention program
o Family-based approaches
ξ Treatment for obesity based on stage
ξ Nutrition recommendations
ξ Physical activity recommendations
ξ Behavior management strategies
Major Outcomes Considered:
ξ Effectiveness of weight management interventions
ξ Effect on weight management interventions on prevention and management of
type 2 diabetes mellitus, cardiovascular risk factors, and other co morbidities.
Guideline Metrics:
Meaningful Use
1. Percentage of patients 3-17 years of age who had an outpatient visit with a Primary
Care Physician (PCP) or Obstetrician/ Gynecologist (OB/GYN) and who had
evidence of the following during the measurement period. Three rates are reported.
ξ Percentage of patients with height, weight, and body mass index (BMI) percentile
documentation
ξ Percentage of patients with counseling for nutrition
ξ Percentage of patients with counseling for physical activity
Methodology
Methods Used to Collect/Select the Evidence:
Identification and selection of the evidence was completed by the Institute for Clinical
Systems Improvement (ICSI). Literature search terms for the current revision of this
document included pediatrics, children, childhood obesity published since November
2005, systematic reviews, randomized control trials, meta-analysis, restricted to human
studies, limited to pediatrics in the following topic areas: prevention, screening,
treatments/drug studies, medications, gastric bypass and/or bariatric surgery, lipid and
cholesterol screening, activity recommendations, screen time (TV, computer, video
gaming), genetic studies, family-based therapy, readiness for change, motivational
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

7
interviewing, goal setting, managing chronic conditions, binge eating disorders, binge
eating disorder assessment and scale.
Rating Scheme for the Strength of the Evidence:
The quality of the evidence was rated using the Grading of Recommendations
Assessment, Development and Evaluation (GRADE). See table below.
Table 1. ICSI GRADE Scheme
Category Quality Definitions Strong Recommendation Weak Recommendation
High Quality
Evidence
Further research is
very unlikely to
change our
confidence in the
estimate of effect.
The work group is confident
that the desirable effects of
adhering to this
recommendation outweigh the
undesirable effects. This is a
strong recommendation for or
against. This applies to most
patients.
The work group recognizes that
the evidence, though of high
quality, shows a balance
between estimates of harms and
benefits. The best action will
depend on local circumstances,
patient values of preferences.
Moderate
Quality
Evidence
Further research is
likely to have an
important impact on
our confidence in
the estimate of
effect and may
change the
estimate.
The work group is confident
that the benefits outweigh the
risks but recognizes that the
evidence has limitations.
Further evidence may impact
this recommendation. This is
likely a recommendation that
applies to all patients.
The work group recognizes that
there is a balance between
harms and benefits, based on
moderate quality evidence, or
that there is uncertainty about
the estimates of the harms and
benefits of the proposed
intervention that may be affected
by new evidence. Alternative
approaches will likely be better
for some patients under some
circumstances.
Low Quality
Evidence
Further research is
very likely to have
an important impact
on our confidence
in the estimate of
effect and is likely
to change. The
estimate or any
estimate of effect is
very uncertain.
The work group feels that the
evidence consistently indicates
the benefit of this action
outweighs the harms. This
recommendation might change
when higher quality evidence
becomes available.
The work group recognizes that
there is significant uncertainty
about the best estimates of
benefits and harms.
Introduction
Childhood obesity has risen at an alarming pace over the past decade, making obesity
the most prevalent health problem among children in the majority of the developed
countries. Since 1980, obesity prevalence among children and adolescents in the
United States has almost tripled. One in three children (31.7%) is overweight or obese
and approximately 17% (or 12.5 million) of children and adolescents 2-19 years of age
are obese. The body of research linking obesity in childhood to short- and long-term
health consequences and obesity in adulthood is increasing. Obesity is associated with
hypertension, dyslipidemia, atheroma, type 2 diabetes mellitus, the metabolic
syndrome, systemic inflammation and oxidative stress. Concern is growing for the future
health of our nation, the economic burden and the effect obesity will have on our health
care system.1
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

8
Recommendations
Recommendations related to the prevention, diagnosis and management of obesity in
pediatric patients can be found in the 2013 ICSI guideline online at
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines
/catalog_endocrine_guidelines/obesity__children/
UW Health Implementation
Implementation Plan/Tools
1. Guideline will be housed on a U-Connect webpage dedicated to UW Health CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools, including:
Smart Sets
Pediatric Overweight/Obese BMI [5079]
Registry
Obesity Registry
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
References
1. Fitch A, Fox C, Bauerly K, et al. Prevention and Management of Obesity for Children and
Adolescents. Institute for Clinical Systems Improvement; 2013.
2. COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE BRIGFPSW. 2014
recommendations for pediatric preventive health care. Pediatrics. 2014;133(3):568-570.
3. Force USPST. Screening for Hypertension in Children and Adolescents. 2013;
http://www.uspreventiveservicestaskforce.org/uspstf13/hypechild/hypechldfinalrec.htm#copy
right. Accessed March 27, 2014.
4. Bright Futures. In: Hagan J, Shaw J, Duncan P, eds. Guidelines for Health Supervision of
Infants, Children, and Adolescents. Third ed. Elk Grove Village, IL: The American Academy
of Pediatrics; 2008.
5. Adolescents NHBPEPWGoHBPiCa. The fourth report on the diagnosis, evaluation, and
treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 Suppl
4th Report):555-576.
6. Bamba V. Update on Screening, Etiology, and Treatment of Dyslipidemia in Children. J Clin
Endocrinol Metab. 2014:jc20133860.
7. National Heart L, and Blood Institute. Explore Hypotension. 2010;
https://www.nhlbi.nih.gov/health/health-topics/topics/hyp/signs.html.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

All patients
age 0 to 18
Perform yearly, preferably at a well child visit:
-Measure height & weight . Plot on weight-for-length (ages 0-23 months) or
BMI percentile (ages 2-18 years) growth chart.
-BP screening starting at age 3.
-Screen for healthy habits: May include questionnaire, 5210 discussion.
-Assess for medical risks related to obesity: May include family history,
genetic considerations, review of systems, physical exam.
Review growth chart with patient and family.
See General Conversation Tips
Any Concerns?
-BMI percentile acceleration
-Early rebound age 4-6
-BMI >85
th
percentile*
-Poor health habits
-Social concerns
Ask permission
to discuss
healthy habits
Ready to
Discuss?
See
Committed
Conversation
Tips
See
Not Ready
Conversation
Tips
Ask permission
to discuss
healthy habits
Ready to
Discuss?
Ready to
Change?
See
Ready
Conversation
Tips
See
Not Ready
Conversation
Tips
Share medical risks
of BMI or
concerning findings
from today’s visit.
Lipid Screening (age 9-
11), AST, ALT, fasting
glucose, and other tests
as indicated by health
risks
Consult to
Specialist(s)
-If comorbid conditions
are present
Encourage follow up visit with
PCP in 1- 3 months
-To support change in healthy
habits & slow weight gain
-Consider Consult to Peds Fitness
if no improvement in 3-6 months
-Minimal interval between visits: 1
year
Consult to
Nutrition
-To support
change in healthy
habits & slow
weight gain
Consult to Pediatric Fitness
for any of the following:
-%0I percentile • 99
th
or
comorbid conditions
-No improvement after 3-6
months PCP follow up care
-&onsider for %0I • 95
th
percentile and patient/family
ready to change
Re-assess BMI &
healthy habits at next
follow up or well child
visit
No
Yes
Yes
No
YesNo
No
Yes
Healthy Habits and Growth Concerns Algorithm
for Pediatric Patients and Families
Lipid Screening
(age 9-11)
Follow up based on
patient characteristics
Consult to Behavioral
Health/Social Work and/
or contact Patient
Resources
-For concerns such as
family stress, food
insecurity, mental health
concerns
Highest Risk
Highest Risk
Social Concerns
First Line
Treatment
First Line
Treatment
Last reviewed/revised: 05/2015
Contact CCKM for revisions
UW Health Obesity – Pediatric – Ambulatory Guideline
Adapted from Fitch A, Fox C, Bauerly K, et al. Prevention
and Management of Obesity for Children and Adolescents.
Institute for Clinical Systems Improvement; 2013.
*Recognize some children with BMI >
85
th
percentile will have increased
musculature, not increased body fat.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:CCKM@uwhealth.org 05/2015

HEALTHY HABITS AND GROWTH CONCERNS CONVERSATION TIPS
Last reviewed/revised: 05/2015 | Contact CCKM for revisions. | UW Health Obesity – Pediatric – Ambulatory Guideline
Ada pted from: Miller, W. R. & Rollni ck, S. (2013 ) Mot ivational Int erviewing : Helpi ng P eop le Change (3
rd .
edition). New York: The Gui lford Press .
General Conversation Tips
Pediatric Obesity is a sensitive topic and each patient and family must be handled with respect and kindness.
Often the child has been ridiculed by peers and the parents may feel that they are failures or are at a loss of
what to do. 7he goal of “'o no harm” has never been more critical than with this future generation. Listed
below are some general tips when working with overweight/obese children and their families:
1. Ask permission to discuss the child’s %0I with the patient and family. &onsider referring to how the
child is growing rather than how much the child weighs. Gently and factually acknowledge and point
out any trends such as BMI percentile acceleration. Explain the growth chart and the definition of BMI,
as needed. Once you have shared the information, ask the patient and/or family their thoughts.
Example: “What are your thoughts on how Joey has grown over the past few months? ”
2. Use the 5210 Healthy Habits Questionnaire to assess the patient and families overall lifestyle habits.
Refer to the bottom of the questionnaire for information that the patient has indicated that they need
from you.
3. $void referring to the child’s weight as a “problem”. $void labeling the child “obese” or “overweight”.
Arguments about the appropriateness of a diagnostic label can be counterproductive when it comes to
behavior change.
4. Express early and frequent empathy throughout the conversation.
5. Listen attentively to what the patient and family are saying, drawing on their experience, reasons and
ability to change.
6. Honor autonomy, realizing that patient and family can, and do, make decisions about their health.
Acknowledging freedom of choice typically diminishes defensiveness and facilitates change.
7. Change requires a partnership, a collaboration of expertise. The Health Care Provider is the expert on
the diagnosis; the patient and family is the expert on themselves.
8. Allow for patient/family directed goal setting. It does not become a goal for the patient and/or family
unless they embrace it as their own.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

HEALTHY HABITS AND GROWTH CONCERNS CONVERSATION TIPS
Patients and Families READY to Make Changes
Using the 5210 Healthy Habits Questionnaire notice any topics at the bottom that the patient and/or
family may have checked indicating that they would like to change.
Ask Permission to share 5210 information with the patient and family. “I see you have marked that
you would like information on nutrition, exercise and screen time. Tell me out of these three, which is
the one that you would liNe to start with today"” 2nce they have picked a topic then:
Ask “:hat would be some of your reasons for wanting to BBBBBBBBBBBBBBBBBBB"”
(Eat healthier, be more active, limit screen time, whatever behavior they choose)
Reflect the patients answer, highlighting any strengths or key pieces of the conversation.
Ask “6o what do you thinN you will do"” or “:hat is your ne[t step"”
Summarize the patients answer, again highlighting any strength or key pieces of the
conversation, especially change talk. Example: “6ounds liNe you have thought about this.
Based on what you told me, you have decided to limit your soda to one small can a day and
increase your water by � cups each day.”
Sharing information: Use the elicit-provide-elicit approach:
Elicit: ³Tell me what you already know, or would like to know aboutBBBBBBBBBBBBBBBBB"”
Provide: One handout from the 5210 literature, sharing the information in manageable chunks.
Elicit: “:hat are your thoughts on what I just shared with you"” 2r “:hat is one thing that
stood out for you in this handout"” 2r “:hat is your ne[t step"”
Set a small patient goal based on this conversation.
Schedule a Follow-up appointment.
Last reviewed/revised: 05/2015 | Contact CCKM for revisions. | UW Health Obesity – Pediatric – Ambulatory Guideline
Ada pted from: Miller, W. R. & Rollni ck, S. (2013 ) Mot ivational Int erviewing : Helpi ng P eop le Change (3
rd .
edition). New York: The Gui lford Press .
Type of Visit Well Child
Topic of Conversation Healthy Habits
Length of Conversation 5-10 minutes
Purpose 5210 Intervention
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

HEALTHY HABITS AND GROWTH CONCERNS CONVERSATION TIPS
Last reviewed/revised: 05/2015 | Contact CCKM for revisions. | UW Health Obesity – Pediatric – Ambulatory Guideline
Ada pted from: Miller, W. R. & Rollni ck, S. (2013 ) Mot ivational Int erviewing : Helpi ng P eop le Change (3
rd .
edition). New York: The Gui lford Press .
Patients and Families NOT READY to Make Changes
Signs that the patient and family may not be ready to change:
ξ Angry, agitated, denying that there is a problem.
ξ Patient and/or family shuts down, agrees politely, quiet and/or ready to leave.
ξ 3atient and�or family gives “sustain talN” or reasons to stay the same. 0ay be identified by
words such as “ All of the above scenarios are examples of discord. Discord is a predictor of poor patient
outcomes. By simply reducing discord clinical outcomes are improved.
Strategies to decrease discord and increase readiness to change at a future visit:
1. Honor Autonomy- 'irectly acNnowledging a person’s freedom of choice diminishes
defensiveness and can facilitate behavior change. Examples: ³,W�LV�XS�WR�\RX�WR�GHFLGH�ZKDW
FKDQJHV��LI�DQ\��\RX�PDNH�´�Or ³,W�LV�\RXU�GHFLVLRQ��\RXU�FKRLFH�´ Or ³2QO\�\RX�FDQ�GHFLGH�WR
PDNH�WKHVH�FKDQJHV�´
2. Express Empathy- (mpathy is the ability to understand the other’s frame of reference. (arly
and frequent empathy goes a long way for reducing discord. Examples: ³,W�PXVW�EH�YHU\�KDUG
WR�NHHS�XS�ZLWK�WKH�RWKHU�NLGV�LQ�3K\�(G�´��Or ³,W�LV�GLIILFXOW�WR�ZRUN�WZR�MREV�DQG�SXt a meal on
WKH�WDEOH�HYHU\�QLJKW�´
3. Ask permission to provide information and leave the door open to revisit the topic in the
future. Example: ³It sounds like it might not be the right time for a change. If it is okay with
you, I would like to give you some information and UHYLVLW�WKLV�WRSLF�DW�D�IXWXUH�DSSRLQWPHQW�´
Then provide a handout on 5210 and schedule the follow-up appointment.
If patient and family declines information, honor autonomy and leave the door open to
discuss healthy habits in the future. Example: “It is certainly your decision. If it is okay with
\RX��,�ZRXOG�OLNH�WR�UHYLVLW�WKLV�WRSLF�DW�RXU�QH[W�DSSRLQWPHQW� ´ Then schedule the follow-up
appointment.
Type of Visit Well Child
Topic of Conversation Healthy Habits
Length of Conversation 3-5 minutes
Purpose Preparing the patient and family for
future healthy habit intervention
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

HEALTHY HABITS AND GROWTH CONCERNS CONVERSATION TIPS
Last reviewed/revised: 05/2015 | Contact CCKM for revisions. | UW Health Obesity – Pediatric – Ambulatory Guideline
Ada pted from: Miller, W. R. & Rollni ck, S. (2013 ) Mot ivational Int erviewing : Helpi ng P eop le Change (3
rd .
edition). New York: The Gui lford Press .
Patients and Families COMMITTED to Change
Ask� “:hat do you do to stay healthy"” or “7ell me about your healthy habits.”
Reflect patient and/or family answer to support current healthy behaviors.
Affirm� 6hine a light on the patient and family’s strengths and efforts to change. 7his is more
meaningful than “Good job�” 2r directing the patient and family to “.eep it up.”
Examples: “It sounds liNe you are maNing healthy choices by eating more fruits and
vegetables throughout the day.” 2r “The changes that you made in increasing your activity have
really made a difference in your health.” 2r “7aNing the television out of the bedroom has really
decreased your screen time.”
Sharing Information: If the patient and/or family ask for information, use the elicit-provide-
elicit approach:
Elicit� ³Tell me what you already Nnow� or would liNe to Nnow aboutBBBBBBBBBBBBBBBBB"”
Provide: One handout from the 5210 literature, sharing the information in manageable chunks.
Elicit: “:hat are your thoughts on what I just shared with you"” 2r “:hat is one thing that
stood out for you in this handout" 2r “:hat is your ne[t step"”
Set a small patient goal based on this conversation.
Schedule a Follow-up appointment.
Type of Visit Well Child
Topic of Conversation Healthy Habits
Length of Conversation 1 to 3 minutes
Purpose Support Self Efficacy for patients and
families who are currently engaging in
healthy habits
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

Last revised: 05/2015 | Last reviewed: 05/2015 | Contact CCKM for
revisions. UW Health Obesity – Pediatric – Ambulatory Guideline
Select Medications Associated with Weight Gain* 1- 4
Medication Class
Medication Assoc iated
with Weight Gain Alternative Agents
A ntico nv ulsa nts carbamaze pi ne S eizure con tr o l: lamo trigine, phe nytoin, topiramat e,
zonis amide
Neuropathi c pain con trol: duloxeti ne
gabapent in
pregabalin
valproic acid
5

Antipsyc hotic s
6 - 10
asenapine Luras idone
aripipra zole
chlo rpro mazi ne
clozapine
iloperido ne
olanzapine
quetiap ine
risperido ne
ziprasido ne
Moo d stabili z ers
lithiu m Not applica b le
Antidepres sa nts , anxiolyti cs
6

phenelzine Antidepres sa nt: b upropio n , venlafa xin e
Neuropathi c pain con trol: duloxeti ne
mirtazapi ne
4

paro xetine
amitripty line
11

nortriptylin e
11

Antihista min e
cetiri zine loratadine
Antihyperte n siv es proprano lol
carvedilol, nebiv o lol
minoxidil
Glu cocorticoi ds predniso ne
Not appli cabl e
methyl pred ni so lone
dexamethas o ne
Co ntraceptio n
medroxypro g estero ne
12 - 14

Combined ora l contrac eptiv es ,
15

e thinyles trad iol/ etono gest rel ring
16
megestro l
Insulin
a ll i nsulin s
17,1 8
Metfor mi n
19

*includes information from both pediatric and/or adult literature
References
1. Fitch A, Everling L, Fox C, et al. Institute for Clinical Systems Improvement. Prevention and Management
of Obesity for Adults. Updated May 2013. https://www.icsi.org/_asset/s935hy/ObesityAdults.pdf.
Accessed May 17, 2015.
2. PL Detail-Document, Drugs Associated with Weight Gain. Pharmacsit's Letter/Prescriber's Letter. April
2015.
3. Adverse Events Redefining Drug Safety. http://www.adverseevents.com/. Accessed May 17, 2015.
4. Domecq JP, Prutsky G, Leppin A, et al. Clinical review: Drugs commonly associated with weight change:
a systematic review and meta-analysis. J Clin Endocrinol Metab. 2015;100(2):363-370.
5. Pickrell WO, Lacey AS, Thomas RH, Smith PE, Rees MI. Weight change associated with antiepileptic
drugs. J Neurol Neurosurg Psychiatry. 2013;84(7):796-799.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org

Last revised: 05/2015 | Last reviewed: 05/2015 | Contact CCKM for
revisions. UW Health Obesity – Pediatric – Ambulatory Guideline
6. Dent R, Blackmore A, Peterson J, et al. Changes in body weight and psychotropic drugs: a systematic
synthesis of the literature. PLoS One. 2012;7(6):e36889.
7. Lachman A. New developments in diagnosis and treatment update: Schizophrenia/first episode psychosis
in children and adolescents. J Child Adolesc Ment Health. 2014;26(2):109-124.
8. Martinez-Ortega JM, Funes-Godoy S, Diaz-Atienza F, Gutierrez-Rojas L, Perez-Costillas L, Gurpegui M.
Weight gain and increase of body mass index among children and adolescents treated with
antipsychotics: a critical review. Eur Child Adolesc Psychiatry. 2013;22(8):457-479.
9. Pringsheim T, Lam D, Ching H, Patten S. Metabolic and neurological complications of second-generation
antipsychotic use in children: a systematic review and meta-analysis of randomized controlled trials. Drug
Saf. 2011;34(8):651-668.
10. Kumar A, Datta SS, Wright SD, Furtado VA, Russell PS. Atypical antipsychotics for psychosis in
adolescents. Cochrane Database Syst Rev. 2013;10:Cd009582.
11. Blumenthal SR, Castro VM, Clements CC, et al. An electronic health records study of long-term weight
gain following antidepressant use. JAMA Psychiatry. 2014;71(8):889-896.
12. Bonny AE, Secic M, Cromer B. Early weight gain related to later weight gain in adolescents on depot
medroxyprogesterone acetate. Obstet Gynecol. 2011;117(4):793-797.
13. Bonny AE, Ziegler J, Harvey R, Debanne SM, Secic M, Cromer BA. Weight gain in obese and nonobese
adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal
contraceptive method. Arch Pediatr Adolesc Med. 2006;160(1):40-45.
14. Vickery Z, Madden T, Zhao Q, Secura GM, Allsworth JE, Peipert JF. Weight change at 12 months in
users of three progestin-only contraceptive methods. Contraception. 2013;88(4):503-508.
15. Warholm L, Petersen KR, Ravn P. Combined oral contraceptives' influence on weight, body composition,
height, and bone mineral density in girls younger than 18 years: a systematic review. Eur J Contracept
Reprod Health Care. 2012;17(4):245-253.
16. Mohamed AM, El-Sherbiny WS, Mostafa WA. Combined contraceptive ring versus combined oral
contraceptive (30-mug ethinylestradiol and 3-mg drospirenone). Int J Gynaecol Obstet. 2011;114(2):145-
148.
17. Pontiroli AE, Miele L, Morabito A. Increase of body weight during the first year of intensive insulin
treatment in type 2 diabetes: systematic review and meta-analysis. Diabetes Obes Metab.
2011;13(11):1008-1019.
18. Hermansen K, Davies M, Derezinski T, Martinez Ravn G, Clauson P, Home P. A 26-week, randomized,
parallel, treat-to-target trial comparing insulin detemir with NPH insulin as add-on therapy to oral glucose-
lowering drugs in insulin-naive people with type 2 diabetes. Diabetes Care. 2006;29(6):1269-1274.
19. Park MH, Kinra S, Ward KJ, White B, Viner RM. Metformin for obesity in children and adolescents: a
systematic review. Diabetes Care. 2009;32(9):1743-1745.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2015CCKM@uwhealth.org