New Algorithm for Pediatric Obesity Offers Practical Help

Kristin Jenkins

October 17, 2016

A new algorithm designed to help physicians navigate the diagnosis, evaluation, and treatment of obesity in pediatric patients, from infancy through adolescence, is now available.

Coauthor of the algorithm, Suzanne Cuda, MD, associate professor of pediatrics at Baylor College of Medicine in Houston, Texas, told Medscape Medical News that many clinicians faced with the growing number of children and adolescents who are obese — and increasingly, severely obese — feel they don't have the medical, psychological, and social resources they need to intervene effectively.

"Clinicians feel that their toolbox is empty," she said. "We hope that clinicians are able to use [the new algorithm] as a resource in clinical settings."

It is free and can be downloaded at www.PediatricObesityAlgorithm.org.

Regular updates to the algorithm will incorporate new and relevant information as medical knowledge evolves, she added, noting that "studies are badly needed to identify therapeutic interventions of all sorts to treat children with obesity."

The comprehensive document details assessment, differential diagnosis, symptom review, diagnostic workup, and physical examination, as well as nutritional, general-intake, and activity recommendations. Chapters on comorbidities, miscellaneous topics associated with obesity, such as medication-related weight gain and genetic disorders, lead up to worksheets for a staged treatment approach.

The document was compiled by specialists in obesity medicine who referred to studies from the medical and scientific literature and drew on their own clinical experiences. All are members of the Obesity Medical Association (OMA).

The algorithm, which was presented at the 2016 OMA meeting in Chicago last month, is also designed as a study guide for clinicians taking the American Board of Obesity Medicine certification exam.

In 2013, the OMA released guidelines for the treatment of obesity in adults. To date, it has been downloaded 8000 times, according to an OMA spokesperson.

Asked to comment on the new pediatric algorithm, Asheley Skinner, PhD, of Duke Clinical Research Institute at Duke University School of Medicine in Durham, North Carolina, said it "demonstrates the great complexity of obesity. Having a living document like this algorithm can be very helpful to clinicians who are trying to understand the current state of obesity research and who need some guidance on how to help their patients," she told Medscape Medical News in an interview.

However, Dr Skinner also expressed a number of concerns, including the lack of new information and the algorithm's "minimal guidance" on the use of medications.

Since much of the current literature suggests that most obesity interventions "provide little or no long-term weight-loss benefit…I'm not sure that an algorithm with a primary message of 'eat healthy foods and move more' is likely to have much effect on how clinicians, particularly primary-care pediatricians, will approach obesity," she commented.

Pediatric Obesity Is a Growing Problem in the US and Globally

Current data show there is no letup in childhood obesity. The US Centers for Disease Control and Prevention estimates that obesity affects 12.7 million, or 17%, of infants, children, and adolescents ages 2 to 19 in the United States. And obesity disproportionately affects children born into minority groups and children "whose families toil at the lower end of the socioeconomic spectrum," Dr Cuda noted.

The incidence of severe obesity in childhood, defined as a body mass index (BMI) equal to or greater than the 95th percentile, is also increasing. Severe obesity often goes unrecognized until significant comorbidities such as type 2 diabetes mellitus and steatohepatitis — once considered "adult diseases" — develop. Even then, emphasized Dr Cuda, "little or no attention [is given] to the underlying obesity."

And the problem is not confined to the United States.

The absolute numbers for child and adolescent obesity worldwide have been rising rapidly, particularly in low- and middle-income countries. On World Obesity Day last week, a statement from the World Obesity Federation (WOF) declared that few countries are doing enough to address "this damaging health issue."

Without effective intervention, experts predict that 15.8% of the overall global population of school-age children will be overweight and 5.4% will be obese by 2025.

In hard numbers, that means 268 million children of school age will be overweight and 91 million will be obese.

To reverse this trend, what's needed are higher standards of health promotion in schools, multidisciplinary teams of trained specialists in the community, and universal access to interventions ranging from family-based strategies to bariatric surgery, says the WOF.

Dr Skinner agrees. "Obesity is not simply a matter of children and parents with too little willpower to stop eating or being too lazy to be active," she explained. "Food availability, agricultural policies, environmental pollution, cultural factors, school physical-education rules, and hundreds of other factors will have to go into any comprehensive effort to address obesity. Without it, few children with obesity will have long-term success on any diet and activity recommendations."

Management of Childhood Obesity Is Fraught

The new pediatric algorithm is not intended to replace clinical judgment but provides an in-depth look at what therapies and approaches work best, said coauthor Wendy Scinta, MD, who is medical director of Medical Weight Loss of New York in Fayetteville.

Because doctors don't have the resources to treat kids with obesity appropriately, they often "end up providing misguided advice or referring them to another provider," she added. Now, with the new algorithm, "clinicians can compare their approaches with what the medical literature recommends for patients in each age group," she said in a statement.

Dr Skinner laments, however, the fact that this document focuses on individual treatment rather than the system-level changes needed for long-term success.

Shifting the blame for obesity away from the individual and understanding the complex social and environmental factors involved is "the first step" toward better management, she said.

"As long as that stigma is in place — that individuals are responsible for obesity, and treating obesity should be directed at individuals — none of the other aspects of this complex problem will be given the full consideration they deserve," she asserted.

To this end she says the lack of information on mental-health issues is also a "glaring omission" of the new pediatric algorithm. Depression is a common comorbidity in children with obesity, who often experience social isolation, weight stigma, and bullying. Addressing the psychosocial issues that give rise to obesity will "likely have the biggest impact on current quality of life for children and families and is highly correlated with future weight loss and health," she explained

One thing the experts all agree on is that the management of pediatric obesity remains extremely challenging.

For one, pediatric patients are almost completely dependent on a parent or other caretaker for early recognition and timely intervention, Dr Cuda told Medscape Medical News.

And even when children with obesity and their families do present to primary clinics for acute-care appointments or physicals — which is rare — clinicians face "very real time constraints." To treat the child, clinicians must work with the family, including parents juggling job and family responsibilities and "struggling to make ends meet," she explained.

"Many of our parents don't have the resources to make the changes we ask them to make to modify the child's diet and provide opportunities for more exercise, less screen time, and more sleep," Dr Cuda added.

This is compounded by the fact that clinicians often lack access to nutritional support from providers with pediatric experience. In addition, they may not be connected to specialists in behavioral management or exercise.

And many physicians who do manage obesity find themselves caught in an uphill battle to get appropriate reimbursement, Dr Cuda said.

Dr Skinner agrees that, in primary care, treatment of obesity is "incredibly difficult."

Clinicians are doing what they can with the tools available to them, she noted, but a recent review supports her assertions that the brief intervention possible in the busy primary-care setting has virtually no effect on weight (Pediatrics. 2016;e20160149).

The good news is that clinicians are already playing important roles in obesity prevention, which now eclipses treatment as the primary focus of research, Dr Cuda stressed.

"If a clinician is interested in working to prevent obesity in children, a good place to start is with either their city or state pediatric associations or societies. Through these bodies they can learn what is going on and discover how they can contribute."

The authors report no external funding was reported and no relevant financial relationships.

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