Pediatric Obesity- Assessment, Treatment, and Prevention: Endocrine Society Clinical Practice Guideline
M3 India News desk Sep 12, 2017
Earlier this year, the Endocrine Society issued the Clinical Practice Guideline advising healthcare providers on how to prevent and treat childhood obesity with lifestyle changes.
Along with recommendations for prevention and treatment, the guideline also provides recommendations on how to evaluate affected children for medical or psychological complications, when to evaluate children for rare genetic causes of obesity and when to consider medications or surgery for the most severely affected older adolescents.
Here is a quick summary.
Diagnosis
Recommendations-Overweight and obesity in children ≥ 2 years of age and adolescents should be diagnosed using body mass index (BMI) or BMI percentile norms given by Centers for Disease Control and Prevention (CDC).
Child or adolescent >2years of age
should be diagnosed as overweight if BMI is ≥85th percentile but less than 95th percentile of age, obese if BMI is ≥ 95th percentile, and extremely obese if BMI is ≥ 120% of the 95th percentile or ≥35kg/m2. The variations in BMI should be taken into account as they correlate differently to comorbidities based on race, ethnicity, and also that increased muscle mass increases BMI.BMI percentile should be calculated, plotted, and reviewed at least once in a year during well-child or sick-child visits.
Child with age <2 years of age
should be diagnosed as obese if the sex-specific weight for recumbent length is ≥ 97.7th percentile on the WHO charts, as this method is valid in US and international pediatric groups.
Laboratory evaluations for endocrine etiologies should be avoided unless the patient’s stature and/or height velocity are attenuated.Patients with BMI ≥ 85th percentile should be evaluated for potential comorbidities.Measuring insulin concentrations for evaluation of obesity is not recommended.
Genetic testing is recommended for those with extreme obesity before the age of 5 years who have clinical features of genetic obesity syndromes such as extreme hyperphagia and/or a family history of extreme obesity.
Approximately 7% of children with extreme obesity may have rare chromosomal abnormalities and/or genetic mutations that cause their obesity.
Treatment
Recommendations- Clinicians should encourage BMI reduction for patients with obesity as a change in BMI is associated with improvements in triglycerides, high-density lipoprotein, and systolic blood pressure.
7 % weight loss may be a more realistic goal for children and adolescents with extreme obesity.
Very large changes may not be necessary. Although a BMI decrease of 1.5 kg/m2(reported in the meta-analysis commissioned by the first Task Force) may seem small, if maintained for the long term, overweight or obese children and adolescents may benefit by maintaining weight as they grow; BMI will decline as linear growth proceeds, and lifestyle modification may reduce fat mass, increase lean body mass, and improve cardiovascular fitness
Prescribe and support intensive, age-appropriate, culturally sensitive, and family-centered lifestyle modifications (Dietary, physical activity, behavioral).
- Reduction in consumption of fast foods, refined sugar, sugar-sweetened beverages, high fructose corn syrup, high fat, high sodium, and processed foods.
- Whole fruit consumption should replace fruit juice
- Portion control education
- Reduction in saturated dietary fat intake for children >2 years of age
- Increased intake of dietary fiber, fruits and vegetables
- Intake of timely and regular meals and avoiding binge eating
- Single portion packing should be encouraged
- A minimum of 20 minutes of moderate to vigorous physical activity should be prescribed, along with a calorie-controlled diet. Inactivity should be discouraged.
- Sedentary activities should be reduced and clinicians should support and encourage patients to limit non-academic screen time to 1to 2 hours in a day.
- Maladaptive rearing patterns related to diet and activity should be identified and the healthcare team should educate families about healthy food and exercise habits.
- Unhealthy intra-family communication patterns should be probed into and measures be taken to improve the patient’s self-esteem.
- Psychosocial comorbidities to be addressed.
Recommendations- Pharmacotherapy to be advised only after the failure of a formal program of intensive lifestyle modification.
Recommendations are against the use of obesity medications in children and adolescents <16 years of age who are overweight but not obese, except in the context of clinical trials.
Pharmacotherapy approved by Food and Drug Administration (FDA) should be administered only with a concomitant lifestyle modification program of high intensity. Only experienced clinicians with thorough knowledge of adverse reactions should prescribe anti-obesity agents
After taking anti-obesity medication for 12 weeks, if the patient does not have a reduction of >4% BMI/BMI z score, the medication should be discontinued and the patient should be reevaluated.
Bariatric surgery is suggested under the following conditions:
- If the patient has attained Tanner 4 or 5 pubertal development, appropriate adult height and BMI of > 40kg/m2 or has extreme comorbidities with BMI >35kg/m2
- Persistent extreme obesity despite compliance with a formal program of lifestyle modification, with or without pharmacotherapy
- Confirmation of stability and competence of the family unit through a psychological evaluation
- If the patient demonstrates compliance to healthy diet and physical activity principles
- Only if the patient has access to an experienced surgeon with appropriate pediatric and bariatric infrastructure at the clinic and has a team capable of long-term follow-up for metabolic and psychosocial needs of the patient and his family
- Bariatric surgery should be avoided in pre-adolescent children, pregnant, or adolescents planning to conceive within 2 years of surgery, one who has not mastered the principles of a healthy diet or activity habits and one who has eating disorder, unresolved substance abuse or untreated psychiatric disorder
Prevention
Clinicians should promote and participate in healthy dietary and physical activity education of patients, their parents, and communities. Schools should be encouraged to provide adequate education about healthy eating habits.Comprehensive behavior changing interventions are recommended to prevent obesity. The obesity prevention plan and efforts should engage the entire family rather than just the individual patient.To reach the widest audience, such programs can be integrated with school or community-based programs.
Healthy Lifestyle Habits
- Engage in at least 20 minutes, ideally 60 minutes, of vigorous physical activity at least 5 days a week.
- Inculcate healthy sleep patterns
- Unavoidable technology-related screen time should be balanced with increased opportunity for physical activity.
- Family dynamics should be assessed and family stressors should be addressed to decrease the development of obesity.
Based on its innumerable health benefits, breastfeeding is recommended. However, it is only a suggestion for the prevention of obesity, as evidence supporting the association between breastfeeding and subsequent obesity is inconsistent.
Pediatric obesity can be prevented by setting few achievable short-term and long-term goals by lifestyle modification. Increasing evidence demonstrates the effectiveness of bariatric surgery in most seriously affected teenagers who have failed lifestyle modification. However, the surgery requires a well-experienced team and long-term follow-up resources.
-
Exclusive Write-ups & Webinars by KOLs
-
Daily Quiz by specialty -
Paid Market Research Surveys -
Case discussions, News & Journals' summaries
