Childhood Overweight and Obesity Key Points

• Childhood obesity rarely is associated with a primary medical disorder.

• When present in childhood obesity, underlying disorders are almost always associated with statural growth reduction.

• The risk of adult obesity increases with the age of the obese child.

• Intervention can be more effective in children than in adults and should involve the entire family.

Only a small proportion of obese children participate in a medically supervised program. Although many studies of obesity management in the pediatric population have had methodologic limitations, efforts to make lifestyle behavioral changes in physical activity and diet have been found to be of benefit (Oude et al., 2009). Family therapy, school-based programs, and in particular involvement of parents are also beneficial (Hill et al., 2002). Interventions for children may be more effective than those for adults.

The approach of treatment in childhood is primarily related to the lifestyle issues of proper diet and exercise. The goals of treatment should be a reduction in BMI to less than the 95th percentile for age and prevention or reversal of comorbidities. Parental involvement is a key component in childhood weight management. However, parents may not recognize the problem of overweight and obesity in their children, particularly in their sons (Jeffery et al., 2005). Poor parental recognition of their own obesity is also noted. In addition, health care providers may overlook obesity at well-child visits (Cook et al., 2005). Therefore, health care providers may need to educate themselves and their patients about the appropriate recognition and treatment of obesity. Individual and family counseling may be indicated in patients with more severe obesity.

During well-child visits, BMI should be calculated and risk factors for obesity noted. These include parental obesity, maternal smoking during pregnancy, a predilection for sedentary activities, and poor dietary habits. When followed through early childhood, BMI typically will decrease until a period known as adiposity rebound occurs between ages 5 and 7 years. An early adiposity rebound noted on BMI for age charts increases the risk of adult obesity. The physician should discuss with all parents the importance of developing healthy eating habits early in life, as well as limiting sedentary activities such as television and computer games. Encouraging parents to model this lifestyle is beneficial.

In children, underlying hormonal factors leading to obesity also tend to lead to short stature. The association of short stature with excess weight gain should therefore prompt an investigation into a possible underlying endocrine disorder (Brown et al., 2002). In contrast, childhood obesity related to exogenous factors is associated with an increased rate of statural growth. This increased growth in height is associated with increased bone age and early puberty.

An adolescent who has been identified as overweight should be screened for comorbidities. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services recommends a lipid panel and fasting blood glucose for adolescents with a BMI over the 85th percentile if there is a family history of lipid disorders or early-onset cardiovascular disease (Brown et al., 2002).

A staged treatment approach is recommended depending on the child's age and degree of obesity (Barlow, 2007). For the child between the 85th and 95th percentile for BMI, diet and exercise continue to be key components of treatment. The approach should involve modest calorie restriction while increasing energy expenditure. Overly restrictive diets have the potential of interfering with growth rate, bone mineralization, and menstruation. At a BMI over the 95th percentile, a more structured and aggressive approach may be appropriate, perhaps with referral to a subspecialist.

In an infant, breastfeeding should be encouraged up to the age of 1 year. Restriction or elimination of sweetened beverages such as soft drinks and sports drinks can greatly reduce calorie consumption in children who consume large amounts. The American Academy of Pediatrics (AAP) recommends that sweetened beverages and fruit juice be limited to 4 to 6 ounces daily for children age 1 to 6 years and 8 to 12 ounces for children and adolescents age 7 to 18 years. Replacing sugar-sweetened beverages with milk not only reduces calorie intake but also provides calcium needed for adequate mineralization of bone. All children older than 2 years should be receiving low-fat dairy products such as skim or 1% milk rather than whole milk, which has higher saturated-fat content. Increasing consumption of foods low in energy density but high in nutritional density, such as vegetables and fruits, can reduce calorie intake and improve nutritional status. In general, food should not be used as a reward, and children should not be required to clean their plate at every meal; rather, they should be taught to choose an appropriate portion size when selecting food. Health-supporting foods should be available through school cafeterias and vending machines.

A sedentary lifestyle is a risk factor for obesity among children and, therefore, there is good reason to promote a physically active lifestyle as a key component in the prevention and treatment of obesity. AAP recommends that sedentary activities (e.g., TV, computer) be limited to no more than 2 hours daily. Rather than requiring specific physical activities, limiting time spent in sedentary activities allows children or teenagers to explore options and find activities they enjoy and are more likely to maintain. School districts should be encouraged to include and fund physical education programs, and community exercise facilities should be readily available to children.

Because of the potential problems of restrictive dieting in children, parents should work with their children through lifestyle changes to maintain a stable weight while height increases, which will result in a decreasing BMI. However, particularly if complications of obesity have developed, a more aggressive approach might be indicated. Nutritional adequacy, growth, and maturation should be closely monitored during more restrictive diets, and referral to a registered dietitian can be beneficial.

Medication use is rarely indicated in children. Sibutramine is approved for use in those older than 16 years and orlistat in those over 12. Both medications are associated with potential side effects. In obese adolescents, sibutramine with behavioral approaches resulted in greater improvement in BMI than with placebo, but almost half the active-treatment group experienced elevated BP or heart rate, necessitating a reduction or discontinuation of the medication (Berkowitz et al., 2003). Bariatric surgery in children and adolescents is also controversial. Although good data are lacking, guidelines are available for both pharmacotherapy and bariatric surgery in children and adolescents (Apovian et al., 2005; August et al., 2008).

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