Update Management of Obesity in Children
- Theoretically, any therapeutic interventions in the child with obesity must achieve control of weight gain and reduction in body mass index (BMI) safely and effectively and should prevent the long-term complications of obesity in childhood and adulthood.
- Manage any acute or chronic complications of obesity (see Prognosis) and request psychiatric assistance for unusual eating disorders or severe depression. Devise a care plan that emphasizes long-term diet and exercise, family support, and the avoidance of dramatic swings in body weight. A team approach to therapy, involving the efforts of nurse educators, nutritionists, exercise physiologists, and counselors, is likely to prove most effective. Consultations with a pulmonary (sleep) medicine specialist, orthopedist, and/or gastroenterologist may be appropriate in some cases. Avoid a punitive approach and reward positive behaviors.
- Recognize that a loss of 5-20% of total body weight can reduce many of the health risks associated with obesity in adults; however, whether modest weight loss or moderate reductions in BMI can improve outcomes in pediatric patients or reduce the long-term risks of obesity in adulthood is not known. Because dramatic reductions in BMI are difficult to achieve and sustain in children and adolescents as well as adults, initiating counseling and therapy may be prudent with realistic goals that emphasize gradual reductions in body fat and BMI and maintenance of weight loss rather than a rapid return to ideal body weight. Reductions in body weight are accompanied by equivalent reductions in energy expenditure. Consequently, maintenance of a given weight in a patient with obesity necessitates a lower energy intake than maintenance of an equivalent weight in a patient who has never been obese.
- Kalarchian et al found that family-based behavioral weight control is effective for severely obese children.  In a randomized, controlled trial in 192 children aged 8-12 years whose average body mass index (BMI) percentile for age and sex was 99.18, intervention was associated with significant decreases in percentage of child overweight at 6 months compared with usual care. Small significant improvements in medical outcomes were observed at 6 and 12 months. Children who attended 75% or more of intervention sessions maintained decreases in percentage overweight through 18 months.
- Wildes et al found that in severely obese children, binge eating affects initial response to family-based behavioral treatment. In a randomized controlled trial in 192 children aged 8-12 years, children who self-reported binge eating showed a 2.6% increase in percentage overweight in response to acute treatment, whereas those without binge eating showed an 8.5% decrease; this difference was not maintained during longer-term follow-up. Children who reported binge eating comprised 11.5% of study subjects, and they were younger; had more depressive, anxiety, and eating disorder symptoms; and had lower self-esteem than those without binge eating.
- Any intervention is likely to fail if it does not involve the active participation and support of family members. The child at hand may be only one of many family members who have obesity, and successful treatment often requires a change in the entire family’s approach to eating. In selected cases, family therapy may be highly beneficial.
- In contrast to the above findings, DeBar et al recently reported that an intensive, group therapy approach was superior to standard, family-based therapy in achieving lifestyle changes (eg, less consumption of fast foods) and in reducing the BMI of overweight adolescents.
Lifestyle Modifications, Exercise, and Physical Activity
- Oude et al concluded that, although no one treatment program can be conclusively recommended, combined behavioral lifestyle interventions produce a significant reduction in weight. Although orlistat and sibutramine (withdrawn from US market) may be used as adjuncts to lifestyle interventions, they must be carefully considered.
- Smoking tobacco reduces appetite and is used by many adults and some teenagers to prevent or limit weight gain. The deleterious consequences of smoking clearly outweigh the benefits achieved by weight control, and all children and adolescents should be urged never to smoke. Measures to prevent excessive weight gain should be undertaken in obese adolescents who discontinue smoking.
- Physicians and parents should encourage children to participate in vigorous physical activity throughout adolescence and young adulthood and to limit time spent watching television and videos and playing computer games. Even regular walking for 20-30 minutes per day can facilitate weight control.
- Exercise reduces weight accretion through increases in energy expenditure and has favorable effects on cardiovascular status, decreases body fat and total cholesterol levels, increases lean body mass and high-density lipoprotein (HDL) levels, and improves psychologic well-being. Controlled trials have demonstrated that lifestyle exercise programs, in association with dietary restrictions, provide long-term weight control in children and adolescents.
- The results from a systematic review and meta-analysis study noted that exercise referral schemes have not been proven as an effective means of increasing physical activity or reducing depression in sedentary individuals when compared with usual care. Further studies are needed to assess the effect on health-related outcomes. However, the results from a 2012 study suggest that low levels of cardiorespiratory fitness have also been associated with elevated depressive symptoms in obese adolescents.
The World Health Organization released guidelines on sugar intake. The guidelines include the following:
- WHO recommends a reduced intake of free sugars throughout the lifecourse.
- In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake.
- WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake. Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices, and fruit juice concentrates.
- For countries with a low intake of free sugars, levels should not be increased. Higher intakes of free sugars threaten the nutrient quality of diets by providing significant energy without specific nutrients.
- These recommendations were based on the totality of evidence reviewed regarding the relationship between free sugars intake and body weight and dental caries.
- Increasing or decreasing free sugars is associated with parallel changes in body weight, and the relationship is present regardless of the level of intake of free sugars. The excess body weight associated with free sugars intake results from excess energy intake.
- Although exposure to fluoride reduces dental caries at a given age and delays the onset of the cavitation process, it does not completely prevent dental caries, and dental caries still progresses in populations exposed to fluoride.
- Intake of free sugars is not considered an appropriate strategy for increasing caloric intake in individuals with inadequate energy intake if other options are available.
- These recommendations do not apply to individuals in need of therapeutic diets, including for the management of severe and moderate acute malnutrition. Specific guidelines for management of severe and moderate acute malnutrition are being developed separately.
Reduced Fat and Very Controlled–Energy Diets
- An energy-restricted balanced diet, in association with patient and parent education, behavioral modification, and exercise can limit weight gain in many pediatric patients who have mild or moderate obesity.
- Programs that modify family patterns of eating are most likely to be successful. One study noted that patients who attended 12-week commercial weight-management programs realized greater weight loss than those who received primary care programs, which were more costly to provide.
- Reductions in total and saturated fat may be particularly useful in adolescents who consume large quantities of high fat, snack, and packaged fast foods, including french fries, pizza, chips, and crackers. Studies in adult subjects demonstrate that lower fat intake is associated with relatively lower body weight, BMI and waist circumference. While similar findings have not been confirmed in children, a meta-analysis of available pediatric studies suggests a direct relationship between fat intake and weight gain.
- The average diet for children and adolescents in the United States contains approximately 35% fat. Reducing fat intake to 30% of total energy is recommended by the World Health Organization (WHO); however, little evidence, epidemiologic or experimental, supports the idea that a reduced-fat but otherwise unlimited diet suffices for substantial weight reduction in obese individuals. A reduced-fat diet may be more useful for primary or secondary prevention of weight gain in individuals with previous obesity individuals, particularly in those with a familial susceptibility.
Very controlled–energy diets
- A protein-sparing modified fast can achieve rapid weight loss in an inpatient or outpatient setting and has been successfully used by numerous investigators in children and adolescents with obesity. For example, a year-long study of 73 pediatric patients aged 7-17 years showed significant reductions in the percentage overweight, total body fat (TBF), body mass index (BMI), total and low-density lipoprotein (LDL) cholesterol, triglycerides, and fasting serum insulin with no change in fat-free mass. Unfortunately, this study and many others combined the diet with behavior modification and a vigorous exercise program; thus, assessing the effects of the diet itself is impossible.
- Duckworth et al found that a high-protein diet does not reduce obese children’s desire to eat. Overweight and obese children who were assigned to 1 of 2 isoenergetic diets, a standard 15% protein diet or a 25% protein diet, achieved similar effects on weight loss, body composition, and changes in appetite or mood. Overall, children lost 5.2 ± 3 kg in body weight and reduced their BMI standard deviation score by 0.25. However, with both diets, ratings of desire to eat significantly increased over the duration of the intervention.
- In general, very controlled–energy diets are hampered by high dropout rates and, in adults, have been associated with losses in lean weight, gallstone formation, cardiac arrhythmias, and sudden death. Moreover, some studies suggest that regain of weight after severe dieting may lead to overshoot, with excess weight deposited as a higher percentage of body fat. Concerns have been raised regarding the long-term cardiovascular risks of such weight cycling in adults, but the potential hazards of dramatic or cyclical weight changes in children and adolescents are unknown.
- More important, the long-term effects of very controlled–energy diets on adolescent growth and development and subsequent reproductive function, musculoskeletal development, and intermediary metabolism remain poorly understood. Because of these uncertainties and the difficulties inherent in maintaining severe caloric restriction, the very controlled–energy diets cannot be recommended for the vast majority of children and adolescents with obesity.
Psychopathology – Intensive Intervention
- Anecdotal evidence suggests that children with severe obesity may develop major psychiatric disorders (eg, suicide attempts, manic depression, other depressive disorders) that require hospitalization or long-term medication. Whether most of these psychiatric disorders predate, cause, or result from the obesity or its treatment is unclear. Like adults, children who enter obesity treatment programs may be at particularly high risk for the development of psychopathology.
- Treatment of the psychiatric conditions may complicate or exacerbate problems associated with weight control, because numerous antidepressant medications, particularly tricyclic antidepressants (TCAs), stimulate appetite and weight gain. Offer psychologic support to patients who have obesity, and refer these patients for psychiatric evaluation and care if evidence of psychopathology or dysfunction is present.
- As noted earlier, any therapeutic intervention in the child or adolescent with obesity is unlikely to succeed without the understanding, approval, and active participation of family members. Family therapy is effective in patients resistant to other therapeutic interventions, particularly those with parents who have obesity. (See Family-Based Behavioral Treatment)
- Various bariatric surgical procedures have been used in adults and some adolescents (in most centers, patients ≥ 15 y) with a body mass index (BMI) of more than 40 kg/m2 or weight exceeding 100% of ideal body weight (IBW).
- The most common procedures involve gastric restriction. In the vertical-banded gastroplasty (VBG), a pouch of 15-30–mL capacity is constructed, greatly reducing the amount of food that can be eaten at any time. In the gastric bypass, a larger pouch that empties into the jejunum is created. As a result, nutrients bypass the duodenum and most of the stomach, which often creates a dumping syndrome. Overall effectiveness is good with significant weight loss, reduction in obesity complications, and increased life expectancy; however, mortality rate of the procedure is 1% in adults, and complications include encephalopathy, nephrolithiasis, cholelithiasis, protein-losing enteropathy, and other nutritional deficiencies.
Laparoscopic adjustable gastric banding
- Laparoscopic placement of an adjustable gastric band (LAGB) has supplanted the VBG, both because of its relative safety and because of its reversibility. Use of the LAGB involves placing a collar with an internal, saline-filled balloon around the upper stomach, 1-2 cm below the esophagogastric junction. This creates a 30-mL upper gastric pouch that can be modified by injecting a small amount of saline into a subcutaneous port linked to the balloon.
- Data suggest that the LAGB is associated with superior outcomes relative to those observed following VBG, and its low complication rate and reversibility make LAGB a viable alternative treatment for the adolescent patient. Nevertheless, the LAGB, or any surgical approach, should be considered only in the most severe cases of adolescent obesity that are resistant to all other forms of therapy.
- O’Brien et al found that in adolescents, laparoscopic adjustable gastric banding resulted in a greater percentage of patients achieving a loss of 50% of excess weight, compared with lifestyle intervention. In a prospective, randomized controlled trial in 50 patients aged 14-18 years with a BMI higher than 35 kg/m2, 21 patients (84%) in the gastric banding and 3 (12%) in the group assigned to supervised lifestyle intervention lost more than 50% of excess weight, corrected for age. Overall, the mean changes in the gastric banding group were a weight loss of 34.6 kg, representing an excess weight loss of 78.8%, 12.7 BMI units, and a BMI z-score change from 2.39 to 1.32. The mean losses in the lifestyle group were 3 kg, representing an excess weight loss of 13.2%, 1.3 BMI units , and a BMI z-score change from 2.41 to 2.26.
In 2015, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition released the following guidelines on bariatric surgery in children and adolescents:
- Consider bariatric surgery in “carefully selected” patients with a body mass index (BMI) >40 kg/m 2 who have severe comorbidities such as nonalcoholic fatty liver disease (NAFLD), or in those with a BMI > 50kg/m 2 who have milder comorbidities.
- Additional factors to consider in deciding whether a child or adolescent should undergo bariatric surgery include physical and psychological maturity, personal desire to undergo the procedure, previous attempts at weight loss, and ability to adhere to follow-up care.
- The Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy are the most widely used procedures in pediatric obesity, but their use is associated with subsequent nutritional deficiencies. Temporary intragastric devices could represent a better option for initial treatment in pediatric populations.
- Current evidence suggests that bariatric surgery can decrease the grade of steatosis, hepatic inflammation, and fibrosis in NAFLD.
- Uncomplicated NAFLD is not an indication for bariatric surgery.
- Roux-en-Y gastric bypass is considered a safe and effective option for extremely obese adolescents, as long as appropriate long-term follow-up is provided.
- Laparoscopic adjustable gastric banding has not been approved by the FDA for use in adolescents and therefore should be considered investigational.
- Sleeve gastrectomy and other types of weight loss surgery that have grown increasingly common in adults still need to be considered investigational.