Obesity

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

 

Introduction

Childhood obesity affects one in twelve children and adolescents in Western Australia (WA). Early intervention during childhood and halting excessive weight gain can prevent obesity related diseases, such as early cardiovascular disease, type 2 diabetes, some cancers, stroke, arthritis, sleep apnoea, negative self-image, and poor mental health.

Childhood obesity is primarily managed in the community setting, but for children and adolescents with severe and/or complicated obesity, a referral can be made to the Perth Children’s Hospital Healthy Weight Service (PCH HWS).

Children and young people who are considered high risk for progressing to type 2 diabetes are also managed through this service. The Healthy Weight Service provides a comprehensive assessment and creation of individualised lifestyle modification programs for children and their families with the multi-disciplinary team.

Pre-referral investigations 

1. Take patient medical history:

• Patient antenatal, newborn, and developmental history
• Height, weight and BMI trajectory
• Known medical, surgical, and mental health conditions
• Previous weight management attempts
• Current medications
• Allergies
• Immunisations
• Causes and complications of obesity (i.e., thyroid disease, obstructive sleep apnoea musculoskeletal, polycystic ovarian syndrome, diabetes, hypertension, liver dysfunction, headache)
• Family history (obesity, type 2 diabetes, gestational diabetes, obstructive sleep apnoea, liver disease, hypertension, weight loss surgery, mental health disorders)
• Social history, motivation / support for change

2. Perform examination:

• Height
• Weight
• Blood pressure
• Presence of acanthosis nigricans
• BMI, BMI z-score, and BMI z-score as a percentage of the 95th percentile as per
  • CDC Growth calculator for 2 to 20 years
  • WHO Growth Standard for 0 to 24 months

3. Blood investigations:

For children over 5 years within the last 6 months (include Oral Glucose Tolerance Test where appropriate):

• Full blood picture
• Fasting glucose
• Fasting insulin
• HbA1c
• Fasting lipid profile
• C peptide
• Iron studies
• Thyroid function test
• C-reactive Protein\
• Liver function test including AST
• Oral Glucose Tolerance Test when HbA1c level is 5.7% - 6.4% in children ≥ 10 years (or pubertal)

Note: Children who have classic symptoms of diabetes should NOT have an OGTT and should have a random glucose to confirm the diagnosis.

Children with a diagnosis of diabetes must be discussed urgently with the PCH on call Endocrinologist via PCH switchboard (08) 6456 2222.

If blood investigations cause considerable distress for the young person, please indicate this in the referral information.

Pre-referral management

Consider the following:

• Provide education and resources (see PCH Healthy Weight Service webpage)
• Chronic disease management plan via GP
• Referral to community-based dietitian / nutritionist
• Source local community-based physical activity options. Consider eligibility for KidSport vouchers
• Referral to the Better Health program
• Referral to Healthy Lifestyle Program (East Perth)
• Referral to Foodbank WA’s Food Sensations® for Parents of 0-5 years
• Referral to the Optimal Weight for Life (OWL) program at JustKidsHealth clinic for 2-18 year olds in the southern Perth region
• Referral to General Paediatrics – private or public via Central Referral Service
• Referral to the PCH Healthy Weight Service if child meets one of pathways below.

When to refer

The child or young person must be under 16 years of age at the time of referral and meet the criteria of one of the following pathways. Pictorial version also available here. Measurements and evidence of investigations must be included for all categories. Children and young people referred via pathways D, E or F should have 6 + months of community-based weight management interventions prior to referral. Please include details of interventions with the referral.

A: Prediabetes:

BMI >= 85th percentile and one of the following:

• Fasting glucose 5.6 – 6.9 mmol/L (Impaired Fasting Glucose (IFG))
• 120-minute OGTT glucose 7.8 – 11.0 mmol/L (Impaired Glucose Tolerance (IGT))
• HbA1c 5.7 – 6.4 %

B: High medical need:

BMI >= 120% of 95th percentile and high medical need, where obesity is compromising health such as at least one of the following:

• Metabolic dysfunction-Associated Fatty Liver Disease (MAFLD) diagnosed by gastroenterologist
• History of Slipped Upper Femoral Epiphysis (SUFE)
• Intracranial hypertension diagnosed via neurologist
• Moderate/Severe Obstructive Sleep Apnoea (OSA) diagnosed via sleep study
• Requires weight loss for surgery to proceed
• Currently being treated pharmacologically for hypertension
• Requires weight loss for solid organ transplant to proceed
• Known obesity syndrome diagnosed via genetic testing excluding Prader-Willi Syndrome (provide results of genetic testing)

C: Under 24 months:

Under 24 months of age with a BMI z-score >= +3

D: Other factors:

BMI >= 135% of 95th percentile and at least 2 other factors:

• Under 60 months
• Family identifies as Aboriginal or Torres Strait Islander
• MAFLD: ALT > 1.5 x upper laboratory limit
• Dyslipidaemia: LDL >= 3.0 mmol/L +/- Triglycerides >= 2.5 mmol/L
• Hypertension >= 95th on at least 2 occasions
• On pharmacotherapy that increases the risk of insulin resistance such as anti-psychotics
• Musculoskeletal complications that limit ability to undertake daily activities
• Mild OSA diagnosed by sleep study/awaiting sleep study

E: Extreme obesity:

BMI >= 150% of 95th percentile

F: Under 24 months:

Under 24 months of age with a BMI z-score >= +2.5

How to refer

• All internal referrals must be sent via the eReferral system.
• All external referrals must be sent via the Central Referral Service (CRS).

Essential information to include in your referral

Please ensure the patient meets the referral criteria for the selected pathway before referring to HWS and include:

• Weight, height/length, and date of measurement
• BMI, BMI z-score, and BMI z-score as a percentage of the 95th percentile as per
  • CDC Growth calculator for 2 to 20 years
  • WHO Growth Standard for 0 to 24 months
• Blood investigation results for children over 5 years within the last 6 months (include Oral Glucose Tolerance Test where appropriate):
  
  • Full blood picture
  • Fasting glucose
  • Fasting insulin
  • HbA1c
  • Fasting lipid profile
  • C peptide
  • Iron studies
  • Thyroid function test
  • C-reactive Protein
  • Liver function test including AST
  • Oral Glucose Tolerance Test when HbA1c level is 5.7% - 6.4% in children ≥ 10 years (or pubertal)
• Whether the child or young person is cared for under WACHS and suitable for HWS/WACHS Shared Care
• Details of community-based interventions for Referral Pathways D, E or F

Useful resources

Pictorial version of HWS Referral Pathways also available.

 

For additional information and patient resources, please refer to the PCH Healthy Weight Service webpage. 

References

1. Health-and-Wellbeing-of-Children-in-WA-2019.pdf

2. Pre-diabetes ranges as per ADA Standards of Care in Diabetes 2024 and ISPAD Clinical Practice Consensus Guidelines 2022

Reviewer/Team:	Endocrinology Department	Last reviewed:	Aug 2024
		Review date:	Aug 2026

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