3 Nutritional Challenges in Special Conditions and Diseases Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167 DOI: 10.1159/000360331

3.5 Management of Child and Adolescent Obesity Louise A. Baur

Key Messages • The BMI [weight (kg)/height (m)2] should be plotted routinely on a BMI-for-age chart • The principles of obesity management include: management of comorbidities; family involvement; a developmentally appropriate approach; the use of a range of behavior change techniques; longterm dietary change; increased physical activity, and decreased sedentary behaviors • Orlistat may be useful as an adjunct to lifestyle change for more severely obese adolescents, and metformin for adolescents with clinical insulin resistance • Bariatric surgery should be considered with severely obese adolescents • Coordinated models of care for health service delivery are needed for the management of pediatric © 2015 S. Karger AG, Basel obesity

Introduction

Child and adolescent obesity is a prevalent problem in most westernized and rapidly westernizing countries and is associated with both immediate and longer-term complications. Effective treatment of those affected by obesity is vital.

Clinical Assessment

Clinical history should aid in assessing current and potential future comorbidities as well as modifiable lifestyle practices (table 1) [1–4]. The BMI [weight (kg)/height (m)2], a clinically useful measure of body fatness in those aged >2 years, should be plotted on nationally recommended BMI-for-age charts [5], e.g. the WHO Child Growth Standards. However, the cutoff points used to define overweight and obesity are somewhat arbitrary and may vary between countries. For example, in the UK the cutoff points for overweight and obesity are the 91st and 98th percentiles, respectively, compared with the 85th and 95th in the USA. Hence, local recommendations should be checked. A waist circumference-toheight ratio of >0.5 is associated with increased cardiometabolic risk in school-aged children [6]. Waist circumference-for-age charts are available for some countries. Physical examination is used to assess obesityassociated comorbidities as well as signs of underlying genetic or endocrine disorders (table 2). The level of investigation is dependent on the patient’s severity of obesity and age, the clinical findings and associated familial risk factors. Baseline investigations may include fasting lipid screening, glucose, liver function tests and, possibly, insulin [1–4]. Second-line investigations

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Key Words Obesity · Children · Adolescents · Assessment · Management

Table 1. Elements of history-taking in obese children and adolescents

General history

Prenatal and birth – history of gestational diabetes and birth weight Infant feeding – duration of breastfeeding Current medications – glucocorticoids, some antiepileptics and antipsychotics

Weight history

Onset of obesity and duration of parental and child concerns about their weight Previous weight management interventions Previous and current dieting behaviors

Complications history

Psychological – bullying, poor self-esteem, depression Sleep – snoring, symptoms suggestive of sleep apnea Exercise tolerance Specific symptoms related to gastroesophageal reflux, gallstones, benign intracranial hypertension, orthopedic complications, enuresis, constipation Menstrual history (girls)

Family history

Ethnicity Family members with a history of: obesity, type 2 diabetes, gestational diabetes, cardiovascular disease, dyslipidemia, obstructive sleep apnea, polycystic ovary syndrome, bariatric surgery, eating disorders

Lifestyle history

Diet and eating behaviors – breakfast consumption, snacking, fast-food intake, beverage consumption, family routines around food, binge eating, sneaking food Sedentary behavior – daily screen time; numbers of televisions, gaming consoles, computers and smart phones in the bedroom and home; pattern of screen time Physical activity – after school and weekend recreation, sports participation, transport to and from school, family activities Sleep – duration and routines

Treatment Strategies

Systematic reviews of pediatric obesity treatment show that lifestyle interventions can lead to improvements in weight and cardiometabolic outcomes [7, 8]. While there is no evidence to support one specific treatment program over another, meta-analyses show that family-targeted behavioral lifestyle interventions can lead to a

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mean BMI reduction of 1.25 to 1.30 when compared with no treatment or usual care [8]. The longer the duration of treatment, the greater the weight loss observed [8]. Lifestyle interventions also lead to improvements in low-density lipoprotein cholesterol, triglycerides, fasting insulin and blood pressure up to 1 year from baseline [8]. Some of the challenges of treatment are that ‘real-world’ obesity clinics are often more poorly resourced than in clinical trials, and clinic patients may be more socially disadvantaged, or have a broader range of comorbidities, than those who take part in trials, making treatment adherence more difficult.

Baur

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167 DOI: 10.1159/000360331

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may include liver ultrasound, an oral glucose tolerance test, more detailed endocrine assessment and polysomnography.

Table 2. Physical examination of obese children or adolescents and important physical findings [9, 11]

Organ system

Physical findings

Skin/subcutaneous tissues

Acanthosis nigricans, skin tags, hirsutism, acne, striae, pseudogynecomastia (males), intertrigo, xanthelasmas (hypercholesterolemia)

Neurological

Papilledema and/or reduced venous pulsations on funduscopy (pseudotumor cerebri)

Head and neck

Tonsillar size, obstructed breathing

Cardiovascular

Hypertension, heart rate (cardiorespiratory fitness)

Respiratory

Exercise intolerance, wheeze (asthma)

Gastrointestinal

Hepatomegaly and hepatic tenderness (nonalcoholic fatty liver disease), abdominal tenderness (secondary to gallstones or gastroesophageal reflux)

Musculoskeletal

Pes planus, groin pain, and painful or waddling gait (slipped capital femoral epiphysis), tibia vara (Blount disease), lower-limb arthralgia and restriction of joint movement

Endocrine

Goiter, extensive striae, hypertension, dorsocervical fat pad, pubertal staging, reduced growth velocity

Psychosocial

Flat affect and low mood, poor self-esteem, social isolation

Other – evidence of a possible underlying genetic syndrome

Short stature, disproportion, dysmorphism, developmental delay

Elements of Treatment

Family Focus Many clinical trials show that family-based interventions can lead to long-term relative weight loss, i.e. from 2 to 10 years. Parental involvement when managing obese preadolescent children appears vital, although there are more limited data on management of adolescents.

A Developmentally Appropriate Approach For preadolescent children, weight outcomes may be improved with a parent-focused intervention, without direct engagement of the child [9]. There are more limited data on the treatment of adolescent obesity than on younger children, and especially on interventions that would be sustainable in most health care settings. Generally, provision of at least some separate therapist session time with the adolescent seems appropriate.

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Behavior Modification Weight outcomes are improved with the use of a broader range of behavior change techniques [1– 4]. One such technique, goal-setting, can include performance goals (such as changing eating or activity behaviors) or outcome goals (such as specific weight loss). Examples of the former include not buying cookies, or reducing television time to 3 h per day. Another technique, stimulus control, refers to modifying or restricting environmental

Management of Child and Adolescent Obesity

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167 DOI: 10.1159/000360331

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However, the broad principles of management are well recognized [1–4, 7, 8]: management of obesity-associated comorbidities; family involvement; a developmentally appropriate approach; long-term behavior modification; dietary change; increased physical activity; decreased sedentary behaviors; a plan for longer-term weight maintenance strategies; and consideration of the use of pharmacotherapy and other nonconventional therapies.

influences in order to aid weight control, with examples including not eating in front of the television, or using smaller plates and bowls within the home. A third commonly used technique, selfmonitoring, involves the recording of a specific behavior or outcome, such as the use of a food diary, daily pedometer measurement of physical activity, or weekly weighing.

While most people with obesity do not have a binge eating disorder, the latter is more common in people with severe obesity. Further, overweight adolescents are more likely to binge-eat, and childhood obesity is a risk factor for later bulimia. However, professionally run pediatric obesity programs do not increase the risk of disordered eating and may improve psychological wellbeing [10].

Dietary Change and Eating Behaviors Treatment programs incorporating a dietary component can be effective in achieving relative weight loss in children and adolescents, although no one dietary prescription appears superior to another [8]. However, dietary interventions are usually part of a broader lifestyle change program, and are rarely evaluated on their own. The two most commonly reported diets are: (a) the modified stop/traffic light approach, where foods are color-coded on the basis of nutritional value and energy content to indicate those to be eaten freely (green) or more cautiously (amber, red), and (b) a calorie restriction/hypocaloric diet approach. Both diets can lead to sustained weight loss across different settings and age groups [8]. The role of dietary macronutrient modification in the management of obese children and adolescents remains unclear. In general, dietary interventions should follow national nutritional guidelines and have an emphasis on the following [1–3]: • Regular meals • Eating together as a family • Choosing nutrient-rich foods which are lower in energy and glycemic index • Increased vegetable and fruit intake • Healthier snack food options • Decreased portion sizes • Drinking water as the main beverage • Reduction in sugary drink intake • Involvement of the entire family in making sustainable dietary changes In advising patients and families on dietary changes, is there a risk of an eating disorder developing?

Physical Activity and Sedentary Behaviors In clinical practice, increased physical activity may best result from a change in incidental, or unplanned, activity, such as by walking or cycling for transport, undertaking household chores and playing. Organized exercise programs have a role, with children and adolescents being encouraged to choose activities that they enjoy and which are sustainable. Limiting television and other smallscreen recreation to less than 2 h per day is particularly strategic, but may be challenging [11]. Parental involvement is vital and may include monitoring and limiting television use, role-modeling of healthy behaviors, and providing access to recreation areas or recreational equipment.

Nonconventional Therapies

There is relatively limited evidence to guide the use of less orthodox treatment approaches such as very-low-energy diets, pharmacological therapy or bariatric surgery in treating severe pediatric obesity. Such therapies should occur on the background of a behavioral weight management program and be restricted to specialist centers with expertise in managing severe obesity.

Baur

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167 DOI: 10.1159/000360331

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Long-Term Weight Maintenance In those who undergo an initial weight management intervention, a period of further therapeutic contact appears to slow weight regain [12]. At present, there is limited evidence to guide the nature and type of long-term weight maintenance interventions.

Health Service Delivery Issues

Given the high prevalence and chronicity of pediatric obesity, there is a need for coordinated models of care for health service delivery. One potential approach, the chronic disease care model, is based upon a tiered level of service delivery relating to disease severity [16]. Thus, while most people affected by the problem of obesity can be managed via self-care or family-based care, with support from primary care or community-based health service providers, there is a need for treatment by multidisciplinary care teams, and possibly tertiary care clinics, for those who are more severely affected. Individual clinicians should be aware of the presence of other services within their geographic region, and the capacity of these to take referrals or to comanage patients.

References 1 Barlow SE; Expert Committee: Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120(suppl 4):S164–S192. 2 National Health and Medical Research Council: Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. 2013. http://www.nhmrc. gov.au/guidelines/publications/n57. 3 Scottish Intercollegiate Guidelines Network: Management of obesity: a national clinical guideline. 2010. http://www. sign.ac.uk/pdf/sign115.pdf/. 4 National Institute for Health and Clinical Excellence: Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. 2006. http://guidance.nice.org.uk/CG43/ NICEGuidance/pdf/English. 5 Freedman DS, Wang J, Thornton JC, et al: Classification of body fatness by body

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mass index-for-age categories among children. Arch Pediatr Adolesc Med 2009;163:805–811. Garnett SP, Baur LA, Cowell CT: Waistto-height ratio: a simple option for determining excess central adiposity in young people. Int J Obes (Lond) 2008; 32:1028–1030. Oude Luttikhuis H, Baur L, Jansen H, et al: Interventions for treating obesity in children. Cochrane Database Syst Rev 2009;1:CD001872. Ho M, Garnett SP, Baur LA, et al: Effectiveness of lifestyle interventions in child obesity: systematic review with meta-analysis. Pediatrics 2012; 130:e1647–e1671. Golan M, Crow S: Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obesity Res 2004;12:357–361. Hill AJ: Obesity and eating disorders. Obes Rev 2007;8(suppl 1):151–155. Whitaker RC: Obesity prevention in pediatric primary care: four behaviors to

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target. Arch Pediatr Adolesc Med 2003; 157:725–727. Wilfley DE, Stein RI, Saelens BE, et al: Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. JAMA 2007;298:1661–1673. Quinn SM, Baur LA, Garnett SP, Cowell CT: Treatment of clinical insulin resistance in children: a systematic review. Obes Rev 2010;11:722–730. Baur LA, Fitzgerald DA: Recommendations for bariatric surgery in adolescents in Australia and New Zealand. J Paediatr Child Health 2010;46:704–707. Inge TH, Krebs NF, Garcia VF, et al: Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics 2004;114:217–223. Department of Health: Supporting people with long term health conditions. 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/ DH_4100317.

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Existing recommendations on management of pediatric obesity suggest that drug therapy (largely orlistat, a gastrointestinal and pancreatic lipase inhibitor) can be used in the treatment of severely obese adolescents, in the context of a tertiary care protocol provided by a multidisciplinary care team and incorporating continued diet and activity counseling [1–4]. For obese, insulin-resistant adolescents there may be a role for the use of metformin, an insulin-sensitizing agent [13]. The few consensus guidelines for bariatric surgery in adolescents have highlighted its use in severely obese adolescents, with consideration of the adolescent’s decisional capacity and attainment of physical maturity, as well as the presence of a supportive family environment [1, 3, 4, 14, 15]. The need for management in centers with multidisciplinary weight management teams, for the surgery to be performed in tertiary institutions experienced in bariatric surgery and for long-term multidisciplinary follow-up has been emphasized.

3.5 Management of child and adolescent obesity.

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