A 15-year-old boy is brought to your office by his mother for a check-up. The patient states that he feels fine and does not understand why his mother insisted on bringing him to see a physician when he has no complaints. You ask his mother if she could return to the waiting area so that you can complete your assessment.

During the patient's physical examination, you note that he is at the 75th percentile for height, at 70 inches (see the Web site: www.cdc.gov/growthcharts), and that his systolic blood pressure is above the sex-, age-, and height-specific 90th percentile value, at 129 mm Hg (see the Web site: www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm). You glance back through the patient's medical record and notice that at 13 years of age, he was also at the 75th percentile for height (65 inches), and his blood pressure was above the corresponding sex-, age-, and height-specific 95th percentile value at 128 mm Hg. He has consistently been at the 88th percentile for body mass index. You tell the boy that although he is growing well, you are concerned about his weight and blood pressure, which have tended to be on the higher side. When you ask him about his diet, he reports that he eats breakfast and supper at home, but that he prefers to buy lunch at school and eat hamburgers or hot dogs and fries with his friends. He drinks at least 2 sweetened soft drinks daily.

When questioned about sports and other physical activities, he says that he "shoots some hoops" at least 3 times each week and also plays intramural soccer. When asked specifically about "screen time" (watching television, playing video games, or surfing the Internet), he reports that he frequently stays up until 2 AM surfing the Web or playing video games. On weekends, he visits friends, and they often play video games or watch movies for most of the afternoon. He estimates that he spends about 30 hours per week in front of a screen. He does not smoke cigarettes, consume alcohol, or use any illicit drugs.

Although the boy's health would be optimized if he lost weight and minimized his screen time, you realize that a series of visits may be needed to negotiate some changes in his habits. You congratulate him for his participation in intramural soccer and basketball, and for avoiding tobacco, alcohol, and drugs. You add, however, that you are concerned that his weight and blood pressure are higher than they should be. You explain that as he gets older, he could develop high blood pressure and heart disease. After some negotiation, you both decide that his first goal will be to take his lunch to school at least 3 days each week. His mother has already offered to prepare lunch for him. You also set a goal of no more than 2 hours of screen time on weekdays, which he will track on a calendar. You plan to see each other again in about 2 months, at which time you hope to address his consumption of sweetened soft drinks.