Pediatricians Must Act Earlier to Prevent Severe Obesity

Jenni Laidman

August 18, 2014

Pediatricians need to act earlier and more aggressively to address weight problems in their patients, or more young people will join the ranks of the severely obese, say the authors of a new editorial in the August issue of Childhood Obesity.

But more interventions to help young people conquer obesity are also desperately needed, Stephen R. Daniels, MD, PhD, pediatrician in chief at Children's Hospital in Colorado, Aurora, told Medscape Medical News.

It will take new medications and expanded access to weight-loss surgery to make a significant dent in the number of severely obese children and adolescents, he says. Dr. Daniels wrote the editorial with Aaron S. Kelly, PhD, associate professor of pediatrics and medicine, University of Minnesota Medical School, Minneapolis.

"In general, pediatricians have been slow to diagnose obesity. It's not completely clear why, but one reason may be a bit of nihilistic sense; they feel there isn't anything they can do," Dr Daniels observes.

Number of Severely Obese Children Is Growing; 6% of Kids Now Affected

The number of severely obese children is growing, even as obesity rates in the United States have declined among 2- to 5-year-olds and remained stable, at about 17% overall since 2003–2004, according to a study published in the Journal of the American Medical Association earlier this year.

Children are considered obese when they have a body mass index (BMI) at or above the 95th percentile. A child is severely obese when he or she has a BMI 20% higher than the 95th percentile.

Nearly 6% of all US children age 18 or younger are severely obese, the equivalent of 1 or more children in every elementary, middle, and high school classroom, the authors write.

Severely obese children have higher blood pressure, elevated triglyceride levels, more inflammation, and greater oxidative stress than even their overweight or obese peers. They also show more signs of subclinical atherosclerosis, impaired glucose tolerance, and prediabetes, they add.

Dr. Daniels says more children should be diagnosed for excess weight and at a younger age and at an earlier point in the course of weight gain. But even with earlier diagnosis, pediatricians face the challenge of a narrow selection of treatments, few of which are effective, he notes.

"It's difficult, because you're talking about an issue that's largely based on lifestyle, although certainly there are genetic and other components. And pediatricians know that a child's environment is very important," he told Medscape Medical News. "Behavioral interventions are very intensive and take time."

Is Hope on the Horizon? Testing of Obesity Drugs Needed in Kids

One promising advance is the growing number of medical programs that specialize in child obesity, giving pediatricians a resource for referrals, he explained. Further, as the concept of the "medical home" takes hold, pediatricians will begin working with a team of caregivers, including dieticians and social workers, he said.

But even with these improvements, care teams still lack the kind of weapon physicians use against nearly every other disease — medicine.

"One of the frustrating things is there are no good pharmacologic approaches. The history of trying to find medications that can treat obesity is fraught with failures, with drugs that were not effective or with major safety issues involved," Dr Daniels said. "With children or adolescents, those safety concerns become that much more important."

He believes that when a weight-loss medication is approved for adults, testing should begin immediately for the pediatric population.

"Unfortunately, at present, only 1 weight-loss medication (orlistat [Xenical, Genentech]) is approved by the US Food and Drug Administration [FDA] for use in adolescents."

Orlistat has been shown to have minimal efficacy and notable side effects, which hamper its widespread use," Drs. Daniels and Kelly write.

Two new weight-loss medications have recently been approved by the FDA for use among adults (lorcaserin [Belviq, Eisai] and phentermine/topiramate [Qsymia, Vivus]), and others are in the developmental pipeline. "Adolescent clinical trials of the 2 recently approved medications need to begin in earnest, and studies of the newer agents need to be initiated as soon as approval in adults is granted by the FDA," they note.

Weight-Loss Surgery an Option Among Adolescents

A more promising option may be surgery, Dr. Daniels says.

"If you asked me a number of years ago, 'Would you ever consider doing bariatric surgery in an adolescent?' I would have said, 'No! Are you crazy? That's just nuts!' But the truth is, for these kids who are dramatically overweight and are beginning to develop really important medical issues related to their obesity, the whole discussion has changed," he observed, noting that more centers are starting to perform weight-loss surgery on adolescents.

There is thus far no evidence that lifestyle modifications alone help severely obese adolescents, Dr. Daniels told Medscape.

"And so far, pharmacological agents don't help. It really leaves you with bariatric surgery," either gastric bypass or the gastric sleeve. The once-popular gastric band has proven largely ineffective in the long-term treatment of obesity, he noted.

"We now have some short-term data suggesting these operations can be done safely in the right hands, and they can be effective," Dr. Daniels said. He stressed, however, that an adolescent who goes through bariatric surgery also needs significant ongoing support before and after the procedure.

Although the general practice is to wait until the adolescent has finished growing before embarking on bariatric surgery, Dr. Daniels said doing these procedures earlier may prove to have greater long-term benefits.

"We tend to think of weight-loss surgery as a sort of last resort, but I sometimes wonder if we intervened earlier in the process whether it would be more preventive. Some of these adolescents are incredibly overweight, with a BMI of 50 or 55. Even with the substantial weight loss you get from bariatric surgery with a teenager, they're still going to end up with a BMI above 30," he said.

"Certainly that's better than 50, but if we intervened earlier and could get a normal BMI, that would be better. That raises the question, how early could you consider surgery as an approach?"

Introducing bariatric surgery in younger patients also raises ethical concerns, such as the age at which a child or adolescent would have the ability to help in the decision-making process, he said.

But as those questions are being addressed, early behavioral intervention for a child on a weight-gain trajectory is the best solution. "If child is already obese, that's potentially already too late," he stressed. "I would like to see pediatricians starting earlier in the process, identifying children who are headed toward severe obesity and seeking interventions."

The authors report no relevant financial relationships.

Child Obes. 2014;10:283-284. Editorial

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