New Guidelines Update MDs on Childhood Obesity Management

Pam Harrison

February 03, 2017

Clinical-practice guidelines for the assessment, treatment, and perhaps most important, prevention of obesity in childhood and adolescence have been issued by an Endocrine Society–appointed task force, in order to update previous recommendations released a number of years ago.

"Pediatric obesity remains an ongoing serious international health concern, affecting about 17% of US children and adolescents, threatening their adult health and longevity," Dennis Styne, MD, University of California, Davis, Sacramento, and colleagues write in the new guidelines, published in the March issue of the Journal of Clinical Endocrinology and Metabolism. They were jointly formulated by the European Society of Endocrinology and the Pediatric Endocrine Society.

"Since the publication of the original guidelines 8 years ago, there have been an additional 1778 references added to PubMed concerning pediatric obesity, [and] we have incorporated the most relevant data from these to update and enhance the original text," Dr Styne said.

The good news is, as previously reported by Medscape Medical News, rates of childhood obesity in the United States appear to have stabilized in recent years.

The not-so-good news is that task-force members were obliged to add new definitions for "extreme obesity," a group that unfortunately continues to increase in prevalence.

Children over the age of 2 years are considered to be extremely obese if they have a body mass index (BMI) ≥120% of the 95th percentile or ≥35 kg/m2, depending on ethnicity.

A child or adolescent whose BMI puts them into the ≥85th percentile but under the 95th percentile for age and sex is considered overweight, while those whose BMI puts them into the ≥95th percentile for age and sex are considered obese. Toddlers under 2 years of age are considered obese if their sex-specific weight for recumbent length is ≥97.7th percentile on the World Health Organization charts, task-force members note.

Assess Obese Children for Comorbidities

The task-force members recommend that clinicians routinely evaluate children and adolescents once they reach a BMI at or above the 85th percentile for obesity-related common comorbidities such as prediabetes or overt diabetes, dyslipidemia, and hypertension.

On the other hand, they advise against doing routine lab evaluations in an attempt to identify the few rare endocrine etiologies that give rise to pediatric obesity, unless justified by telltale clinical features.

Similarly, for genetic drivers of childhood and adolescent obesity, genetic testing should be limited to children with early-onset obesity, a family history of extreme obesity, or hyperphagia, an abnormally heightened appetite, they advise.

As was true for earlier guidelines, task-force members place considerable emphasis on the prevention of obesity, arguing that "achieving effective, long-lasting results with lifestyle modification once obesity occurs is difficult."

The cornerstone to both prevention and treatment of obesity is, of course, lifestyle.

Prevention Is Better Than Cure….

Here, as task-force members detail, the strategy must be multipronged and directed not only at the child or adolescent themselves but at their family and indeed the educational and social context in which they live.

Clinicians, for example, need to prescribe and then support healthy eating habits, most of which are self-evident, including avoidance of calorie-dense, nutrient-poor foods and beverages. Patients should also be discouraged from constant "grazing," especially after school and supper, and parents encouraged to plan for regular meals instead.

Boosting activity levels is also critical to weight control, and children and adolescents need to engage in a minimum of 20 minutes a day — and ideally 60 minutes — of vigorous physical activity at least 5 days a week.

Less obvious aspects contributing to an overall healthy lifestyle strategy include the promotion of healthy sleep patterns. Parents also should be encouraged to limit their child's screen time (outside of school-based assignments) to no more than 2 hours a day and discourage other digital-based, sedentary behaviors.

And acknowledging the psychological burden that often accompanies obesity, task-force members recommend that children and adolescents be evaluated for the presence of psychosocial problems if such issues are suspected.

And members of the healthcare team should also address family dynamics and attempt to diagnose any maladaptive rearing patterns that may be contributing to a child's obesity.

Bariatric Surgery Should Be Last Resort

In contrast to earlier guidelines, task-force members no longer recommend breastfeeding to prevent obesity, as evidence supporting earlier recommendations to do so was considered to be weak.

And "all but one of the pharmacological agents targeting obesity are not approved until 16 years of age," task-force members caution.

However, if a physician determines that lifestyle interventions are simply not working, they may invoke pharmacological therapy provided they are experienced in the use of these agents.

Finally, evidence has increasingly delineated both the benefits and the risks of bariatric surgery in adolescents, and task-force members detail various surgical options in the new guidelines.

However, if a bariatric procedure is considered, it must be executed only in mature pubertal patients with severe, obesity-related comorbidities.

The patient and their family must also be highly motivated to lose weight and commit to being adherent to the long-term exigencies that accompany any bariatric procedure, the task-force members emphasize.

"Despite a significant increase in research on pediatric obesity since the initial publication of these guidelines 8 years ago, further study is needed of the genetic and biological factors that increase the risk of weight gain and influence the response to therapeutic interventions," Dr Styne and colleagues observe.

"Particular attention to determining ways to effect systemic changes in food environments and total daily mobility, as well as methods for sustaining healthy BMI changes," is of paramount importance, they conclude.

The guidelines were funded by the Endocrine Society. Dr Styne had no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

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J Clin Endocrinol Metab. Published online January 31, 2017. Abstract

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