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Obesity in children

Synopsis

Key Points

  • Obesity refers to an excess of body fat; estimated clinically by the relationship between height and weight, taking into account the age and sex of the child
  • Measure height and weight, calculate BMI, and determine BMI percentile using appropriate growth chart at least annually (eg, at well-child visit)
  • Diagnose obesity in children aged 2 and older with BMI at or above 95th percentile for age and sex; those with BMI at or above the 85th and below the 95th percentile for age and sex are overweight r1r2
  • Children younger than 2 years are considered overweight if weight for length is greater than 95th percentile for age and sex
  • Work-up should include history, systems review, and physical examination to assess for weight-related comorbidities and complications, with additional investigations (eg, fasting lipid panel, fasting glucose level, AST and ALT levels, endocrine evaluation, genetic tests) based on the age of child, BMI, and clinical findings
  • Treatment consists of age-appropriate intensive lifestyle modification (ie, diet, physical activity, behavior) for child and family
  • Intensity of intervention should increase in a stepwise fashion and is tailored to motivation of the family and degree of obesity; pharmacologic therapy and bariatric surgery are options for severely obese adolescents who have failed to respond to behavioral approaches
  • Obese children are at risk for type 2 diabetes mellitus, hypertension, orthopedic problems, sleep apnea, and obesity in adulthood

Pitfalls

  • BMI must be plotted on appropriate growth curves to determine percentile for age and sex; use CDC growth charts for children aged 2 to 18 yearsr3 and WHO growth curves from birth to age 23 monthsr4

Terminology

Clinical Clarification

  • Obesity refers to an excess of body fat; in clinical practice, this is estimated by the relationship between height and weight, taking into account age and sex
  • Defined as BMI at or above the 95th percentile for children and adolescents of the same age and sex, according to CDC BMI reference standards for people aged between 2 and 20 years r3
    • Overweight is defined as BMI at or above the 85th and below the 95th percentile for age and sex

Classification

  • Primary (exogenous) obesity r5
    • Most common form of obesity in children and adolescents
    • An imbalance in energy intake and expenditure leads to accumulation of excess adipose tissue
    • Multifactorial cause with a polygenic basis; environmental factors result in weight gain in combination with other variables
  • Monogenic obesity r5
    • Affects a minority of obese children
    • Alteration in single gene leads to early onset severe obesity
    • Most common is MC4R mutation; other forms include leptin deficiency, leptin receptor mutations, and POMC deficiency
    • May be associated with malformation syndromes such as Prader-Willi or Bardet-Biedl syndromes
  • Secondary obesity r5
    • Results from a disease or treatment (eg, hypothyroidism, growth hormone deficiency, certain medications)

Diagnosis

Clinical Presentation

History

  • Determine rapidity of weight gain and any associated symptoms, such as fatigue or exercise intolerance c1c2c3
  • History of dietary intake and other factors that affect weight, including:
    • Nutrition r6
      • Food choices
      • Caloric intake
      • Family meals
      • Snacking
      • Beverage intake
      • Frequency of dining out
    • Physical activity r6
      • Involvement in sports
      • Time spent outside
      • Intensity of activity
      • Mode of transportation used to get to school
    • Sedentary activities r6c4
      • Screen time
      • Locations of screens at home (eg, in bedroom)
    • Environment
      • Access to parks
      • Availability of playground equipment, pool, and gym
      • Safety of neighborhood
    • Medications
      • Antipsychotics r6c5
      • Glucocorticoids c6
  • Inquire about risk factors for pediatric obesity
    • Maternal diabetes mellitus c7
    • Small for gestational age c8
    • Large for gestational age c9
    • Parental obesity (particularly maternal) c10c11
    • Breastfeeding duration c12
    • Weight of siblings c13
  • Other history may indicate comorbidities/associated findings in obesity
    • Developmental delay may be sign of a genetic syndrome c14
    • Early failure to thrive and hypotonia with later weight gain and voracious appetite may be signs of Prader-Willi syndrome c15c16c17c18
    • Snoring or disrupted sleep with daytime drowsiness may be sign of sleep apnea r6c19c20c21
    • Headaches may indicate hypertension or sleep apnea r6c22c23
    • Joint pain may be result of excess weight and may indicate slipped capital femoral epiphysis or Blount disease c24c25c26
    • Menstrual irregularity may result from obesity and may be sign of polycystic ovary syndrome when accompanied by acne or hirsutism r6c27c28
    • Polyuria and polydipsia may be signs of type 2 diabetes r6c29c30
    • Fatigue with dry skin, poor appetite, and cold intolerance may be signs of hypothyroidism c31c32c33c34
    • Social isolation and lack of interest in activities may be signs of depression r6c35c36

Physical examination

  • Height and weight
    • Calculate BMI from weight and height r6
      • BMI = weight in kilograms / (height in meters)²
      • Plot BMI on appropriate CDC growth chart for children aged 2 to 18 yearsr3; use WHO growth curves from birth to age 23 monthsr4
    • Compare weight gain with height gain
      • Height and height velocity are usually increased in endogenous obesity c37c38
      • Short stature and decreased height velocity suggest possible endocrine cause such as hypothyroidism or growth hormone deficiencies c39c40c41c42c43c44
  • Waist circumference at level of iliac crest
    • Limited pediatric references for these measurements
  • Weight distribution: central obesity versus generalized obesity c45
    • Central obesity more commonly seen in Cushing syndrome
  • Vital signs
  • Skin findings
    • Violaceous striae may be sign of Cushing syndrome c46
    • Acanthosis nigricans and skin tags may indicate insulin resistance r6c47c48
    • Severe acne and hirsutism in pubertal girls suggest polycystic ovary disease r6c49c50
  • Signs associated with syndromic obesity, for example:
    • Neurodevelopmental delay c51
    • Dysmorphic facial features characteristic of Prader-Willi syndrome or Down syndrome c52c53
    • Small hands and feet c54c55
    • Polydactyly c56
    • Short stature c57
    • Tall stature and rapid growth c58c59
    • Hypotonia c60
  • Signs associated with underlying causes or complications of obesity, for example:
    • Abnormal gait; hip, knee, or foot tenderness; or limited range of motion in hip c61c62c63c64c65
    • Hepatomegaly or right upper quadrant tenderness c66c67
    • Goiter c68
    • Premature appearance of secondary sexual characteristics c69

Causes and Risk Factors

Causes

  • Primary (exogenous) obesity is caused by complex relationships between genetics, nutrition, physical activity, and environmental factors r5c70
  • Obesity may be secondary to a variety of disease states, including: r5
    • Endocrine conditions c71
      • Hypothyroidism c72
      • Cushing syndrome c73
      • Growth hormone deficiency c74
      • Pseudohypoparathyroidism c75
      • Neonatal hyperinsulinemia c76
    • Hypothalamic dysfunction c77
      • Resection of brain tumors, such as craniopharyngioma c78c79
    • Medications
      • Antipsychotic drugs c80
      • Glucocorticoids c81
  • Obesity may accompany several genetic syndromes or single gene defects r5c82c83

Risk factors and/or associations

Age
  • Prevalence of obesity in US children aged 2 to 19 years (2011-2014) r7
    • Preschool-aged children: 8.9% c84
    • School-aged children: 17.5% c85
    • Adolescents: 20.5% c86
    • Overall: 17%
  • Increasing prevalence rate of obesity with increasing age is observed worldwide
Sex
  • Higher incidence in males in all age groups in the United States r8c87c88
Genetics
  • Monogenic obesity r5
    • Mutation of MC4R (melanocortin 4 receptor) is associated with severe early onset obesity, tall stature, and hyperphagia; it is the most common monogenic risk factorr9c89c90c91c92
    • Leptin deficiency and leptin receptor mutations are associated with severe early onset obesity and hypogonadotropic hypogonadism c93c94c95c96
    • Deficiency of POMC (pro-opiomelanocortin) is associated with severe early onset obesity, low plasma cortisol level, and skin and hair abnormalities c97c98c99c100
    • Deficiency of PCSK1 (prohormone convertase 1) is associated with severe early onset obesity and low insulin and cortisol levels c101c102c103
    • Abnormalities in genes associated with hypothalamic development (eg, SIM1, BDNF, NTRK2) have been associated with obesity in a small number of cases c104c105c106
  • Syndromic obesity
    • Several genetic syndromes are associated with obesity and neurodevelopmental abnormalities r5
      • Prader-Willi syndrome c107d1
      • Bardet-Biedl syndrome c108
      • Alström syndrome c109
      • Wolfram syndrome c110
      • Beckwith-Wiedemann syndrome c111d2
      • WAGRO syndrome c112
      • Carpenter syndrome c113
      • Cohen syndrome c114
      • Down syndrome c115d3
      • MEHMO syndrome c116
      • MOMO syndrome c117
      • Smith-Magenis syndrome c118
      • Wilson-Turner syndrome c119
      • Börjeson-Forssman-Lehmann syndrome c120
  • Primary obesity
    • Era of genome-wide association studies is confirming that polygenic factors are important in primary obesity and is identifying relevant loci, although much remains unknown r10
Ethnicity/race
  • Prevalence of obesity in US children aged 2 to 19 years (2011-2014) r11
    • Non-Hispanic Asian youth: 8.6% c121
    • Non-Hispanic white youth: 14.7% c122
    • Non-Hispanic black youth: 19.5% c123
    • Hispanic youth: 21.9% c124
  • Prevalence of overweight and obesity in children worldwide varies between countries and across world regions; highest in Western and industrialized countries r12
    • Americas and Eastern Mediterranean region: 30% to 40% r12c125c126
    • Europe: 20% to 30% r12c127
    • Southeast Asia, Western Pacific region, and Africa: 10% to 20% r12c128c129c130
Other risk factors/associations
  • Prenatal risk factors
  • Childhood risk factors
  • Other factors r22
    • Excess intake of sugar-sweetened beverages c139
    • Skipping breakfast c140
    • Dining out, particularly at fast-food restaurants c141
    • Low intake of fruits and vegetables c142c143
    • Physical inactivity c144
    • Television viewing c145
  • Prevalence of childhood obesity is lowest in wealthier socioeconomic groups r8r11c146c147

Diagnostic Procedures

Primary diagnostic tools

  • Calculate BMI at least annually (eg, well-child visit) and determine BMI percentile using appropriate growth chart c148c149
    • Use CDC growth charts for children aged 2 to 18 yearsr3 and WHO growth curves from birth to age 23 monthsr4
  • Diagnose obesity in children aged 2 years and older with BMI at or above 95th percentile for age and sex; those with BMI at or above the 85th and below the 95th percentile for age and sex are overweight r1r2
    • Children younger than 2 years are considered overweight if weight for length is greater than 95th percentile for age and sex r23
  • Include history, systems review, and physical examination in initial work-up to assess for weight-related comorbidities and complications
  • While not strictly required for diagnosis, additional evaluations are based on age of child, BMI, and clinical findings r23r24
    • Obtain fasting lipid panel in children aged 2 to 8 years with BMI in the 95th percentile or greater, or BMI between 85th and 94th percentile and family history of dyslipidemia or other high-risk condition
    • Obtain fasting lipid panel in children aged 9 to 18 years with BMI between 85th and 94th percentile and no risk factors; alternatively screen with nonfasting non-HDL cholesterol and follow-up with fasting lipid panel if results are abnormal
    • Obtain fasting lipid panel and fasting levels of glucose, AST, and ALT in children aged 9 to 18 years with BMI in the 95th percentile or higher, or BMI between 85th and 94th percentile with risk factors (elevated blood pressure, family history of obesity-related diseases)
    • Endocrine evaluation is indicated if specific endocrine causes of obesity are suspected
    • Additional investigations may be indicated for evaluation of specific comorbidities or complications, including: r25
      • Glucose tolerance test if diabetes is suspected
      • Radiologic evaluation for certain orthopedic complications
      • Polysomnography if sleep apnea is suspected
      • Abdominal ultrasonography for nonalcoholic fatty liver disease or polycystic ovary disease
      • Genetic testing for specific syndromes associated with obesity

Laboratory c150c151c152c153c154c155c156c157c158c159c160c161c162c163c164c165c166

Imaging c167c168c169c170

Differential Diagnosis

Most common

  • Secondary obesity c171
    • Obesity may be accompanied by signs and symptoms of underlying disorder (eg, hypothyroidism, Cushing syndrome) or associated with medication use
    • Differentiate on basis of history, physical examination, and laboratory tests (eg, thyroid function tests, cortisol levels) as directed by clinical findings
  • Monogenic obesity c172
    • Presents with severe, early onset obesity
    • Suspect in children who have history of unexplained weight gain from infancy and are in 97th percentile or greater for weight by age 3 years
    • May be differentiated on basis of genetic testing; however, this does not alter management
  • Syndromic obesity c173
    • Occurs in the context of several neurodevelopmental syndromes including trisomy 21 (Down) syndrome, Prader-Willi syndrome, or Bardet-Biedl syndrome
    • Differentiate on basis of history and physical examination demonstrating characteristic dysmorphic and neurodevelopmental features of specific syndromes

Treatment

Goals

  • Weight loss or weight maintenance during linear growth
  • Prevention of obesity-related complications

Disposition

Admission criteria

  • Admit to hospital if undergoing bariatric surgery

Recommendations for specialist referral

  • Refer to an endocrinologist if a hormonal cause of obesity is suspected or if diabetes mellitus is diagnosed
  • Refer to appropriate specialist based on complications and suspected causes (eg, orthopedic surgeon, geneticist, psychologist)
  • Refer to multidisciplinary obesity clinic if obesity is severe and does not improve after initial treatment stages

Treatment Options

A staged approach to treatment is recommended for all children between ages 2 and 19 years with BMI greater than 85th percentile r23

  • Consists of age-appropriate intensive lifestyle modification (ie, diet, physical activity, behavior) for child and family r26r27
  • Intensity of interventions increases with each stage and is tailored to motivation of the family and degree of obesity
  • If the child and family have attempted changes for 3 to 6 months without improvement in BMI, then they should progress in intensity to the next stage
  • Stage 1: prevention plus (primary care setting) r23
    • Families focus on basic healthy eating and activity habits to improve BMI
      • Eat at least 5 servings of fruits and vegetables each day
      • Minimize sugar-sweetened drinks
      • Limit screen time to less than 2 hours per day
      • Be physically active for at least 1 hour each day
      • Prepare more meals at home
      • Eat together as a family 5 to 6 days per week
      • Eat a healthy breakfast every day
      • Involve entire family in lifestyle changes
      • Allow child to self-regulate amounts during meals
    • Need to consider behaviors to target depending on current behaviors, families' cultural values, schedule, and motivation
  • Stage 2: structured weight management (primary care setting)
    • Specific eating and activity goals supplement the goals in stage 1
      • Planned diet with balanced macronutrients
      • Structured daily meals and planned snack
      • Additional reduction of screen time to less than 1 hour per day
      • Planned physical activity for 1 hour each day
      • Monitor behavior with logs
      • Reinforce achieving targets
    • Eating plan requires input of dietitian
    • Some families need counseling to help with parenting skills or motivation
    • Best implemented with monthly visits
  • Stage 3: comprehensive multidisciplinary intervention (pediatric weight management setting)
    • Intensity of this stage usually requires multidisciplinary weight management clinic
      • Structured behavior modification program with food and activity goal setting
      • Parental participation, especially in children younger than 12 years
      • Parent education about improving home environment
      • Multidisciplinary team approach
      • Systematic measurement of body measurements, diet, and physical activity
      • Frequent office visits with weekly and later, monthly, visits
      • Group therapy may be helpful
  • Stage 4: tertiary care intervention
    • Intense interventions for severely obese teens that have attempted weight control in stage 3 program
      • Pharmacologic therapy
        • Orlistat
          • Only FDA-approved agent for pediatric obesity; approved for people aged 12 years and older r28
          • Reversible pancreatic and gastric lipase inhibitor that limits absorption of dietary fat r29
          • May be considered in conjunction with lifestyle modification program in adolescents with severe obesity or comorbidities
          • Results in modest improvement in BMI when combined with diet and exercise in obese adolescents r29
          • Gastrointestinal adverse effects may limit use r28
        • Other agents providing weight loss benefits include metformin, exenatide, and topiramate r28
          • Further studies are needed to establish role in management of obesity in pediatric patients; none are approved for use in this context
        • Liraglutide, a glucagon-like peptide 1 analogue, was studied in a randomized, controlled trial in adolescents with a poor response to lifestyle therapy alone; the use of liraglutide (3 mg) plus lifestyle therapy led to a significantly greater reduction in the BMI standard-deviation score than placebo plus lifestyle therapy r30
      • Bariatric surgery
        • May be considered in select adolescents who fulfill the following criteria: r4
          • BMI
            • American Society of Metabolic and Bariatric Surgery BMI criteria r31
              • BMI of 35 kg/m² or higher with major comorbidities (eg, type 2 diabetes, moderate to severe sleep apnea, severe nonalcoholic fatty liver disease)
              • BMI of 40 kg/m² or higher with other comorbidities (eg, hypertension, glucose intolerance, dyslipidemia, impaired quality of life)
            • Others recommend more stringent BMI criteria (eg, BMI of 50 kg/m² or higher or 40 kg/m² or higher in presence of comorbidities)
          • Final or near-final adult height attained, as determined by degree of pubertal development or bone age
          • Failure of 12 months of organized weight loss attempt
          • Supportive family environment and emotional and cognitive maturity
        • Most common approach is Roux-en-Y gastric bypass; other emerging options include vertical sleeve gastrectomy, and adjustable gastric band (off-label for patients younger than 18 years) r31
        • Surgery should be performed at regional bariatric centers of excellence with expertise in adolescent patients
        • Outcomes and safety of bariatric surgery in adolescents are comparable or better than for adults r31

Drug therapy

  • Orlistat r29c174
    • FDA approved for ages 12 years and older; however, small studies have been conducted using orlistat in patients as young as 8 years r29
    • Orlistat Oral capsule; Children and Adolescents 12 years and older: 1 capsule (120 mg) PO 3 times daily with each main meal containing fat, taken during the meal or up to 1 hour after the meal. If a meal is occasionally missed or contains no fat, the dose of orlistat can be omitted. Because the absorption of fat-soluble vitamins A, D, E, K, and beta-carotene is reduced, supplement a daily multivitamin containing these vitamins at least 2 hours before or after orlistat.

Nondrug and supportive care c175c176c177c178c179c180c181c182c183c184c185c186c187c188

Procedures
Roux-en-Y gastric bypass c189c190c191c192c193c194c195c196c197c198c199c200c201c202c203c204c205c206c207c208c209c210
General explanation
  • Considered the gold standard r4
  • Stomach is divided into a small upper pouch and a larger lower remnant pouch, thereby restricting the volume of food that can be consumed
  • Small intestine is reconstructed to enable drainage of both gastric segments; usually by means of a proximal bypass
    • Small intestine is divided distal to the duodenojejunal junction, creating a Y-shaped biliopancreatic limb and a Roux limb
    • Proximal end of the Roux limb is connected to the small upper gastric pouch, and the distal end of the biliopancreatic limb is connected to the Roux limb, creating a bypass effect
Indication
  • May be considered in select adolescents, who fulfill the following criteria: r4
    • BMI
      • American Society of Metabolic and Bariatric Surgery BMI criteria r31
        • BMI of 35 kg/m² or higher with major comorbidities (eg, type 2 diabetes, moderate to severe sleep apnea, severe nonalcoholic fatty liver disease)
        • BMI of 40 kg/m² or higher with other comorbidities (eg, hypertension, glucose intolerance, dyslipidemia, impaired quality of life)
      • Others recommend more stringent BMI criteria (eg, BMI of 50 kg/m² or higher or 40 kg/m² or higher in presence of comorbidities)
    • Final or near-final adult height attained, as determined by degree of pubertal development or bone age
    • Failure of 12 months of organized weight loss attempt
    • Supportive family environment and emotional and cognitive maturity
Contraindications
  • Preadolescent child r6
  • Unresolved eating disorders r6
  • Prader-Willi syndrome
  • Pregnancy, breastfeeding, or plan to become pregnant within 2 years r6
  • Untreated psychiatric disorder r6
Complications
  • Anastomotic stricture
  • Gastrointestinal leak
  • Small bowel obstruction
  • Dumping syndrome
  • Nutritional deficiencies owing to malabsorption

Comorbidities c211

Special populations

  • Patients younger than 2 years r23
    • Infants younger than 2 years are defined as overweight if weight is greater than the 95th percentile for age and sex; no thresholds exist for obesity in this age group
      • WHO growth curves plot weight-for-age and weight-for-length in this age group rather than BMI
    • Management consists of the following:
      • Encourage exclusive breastfeeding from birth to age 6 months, and continued breastfeeding once solid foods are introduced to age 12 months and beyond
      • Avoid sugar-sweetened beverages
      • For toddlers aged 12 to 24 months, use age-appropriate strategies
        • Eat 3 meals per day at table with other family members
        • Snacks with water instead of juice
        • Frequent opportunities for play
        • Limited television with no screens in the bedroom

Monitoring

  • Measure growth parameters, including BMI, at all well-child visits c212c213
  • Frequency of visits depends on intensity and stage of treatment, usually every 1 week to 1 month, to monitor progress
  • Monitor fasting lipid panel and fasting levels of glucose, AST, and ALT in children aged 9 to 18 years with BMI in the 95th percentile or higher, or BMI between 85th and 94th percentile with risk factors (eg, elevated blood pressure, family history of obesity-related diseases) r23

Complications and Prognosis

Complications

  • Obesity-related conditions affect almost every system r23
    • Obstruction sleep apnea c214
    • Worsening asthma c215
    • Nonalcoholic fatty liver disease c216
    • Gallstones c217
    • Gastroesophageal reflux disease c218
    • Type 2 diabetes c219
    • Polycystic ovary syndrome c220
    • Hypertension c221
    • Dyslipidemia c222
    • Pseudotumor cerebri c223
    • Slipped capital femoral epiphysis c224
    • Blount disease c225
    • Chronic skin inflammation and infections c226c227
    • Depression c228
    • Eating disorders c229

Prognosis

  • Obesity is often a chronic condition; many overweight children become overweight adults r32
  • Obese children aged 2 to 5 years with BMI higher than 95th percentile are more than 4 times more likely to become obese adults r33

Screening and Prevention

Screening

At-risk populations

  • Universal screening is recommended r23
  • The US Preventive Services Task Force recommends that clinicians screen for obesity in children and adolescents aged 6 years and older and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status r34

Screening tests

  • Calculate BMI and determine BMI percentile using appropriate growth chart at least annually (eg, at well-child visit) c230
  • Assess diet, physical activity, and sedentary behaviors annually c231c232c233

Prevention

  • Identify children at risk and recommend lifestyle behavior changes to prevent obesity in children with healthy BMIs r35
    • Implement prevention interventions when BMI starts to cross percentiles upwards, even before they reach the 85th to 95th percentile
    • Target behaviors r23
      • Encourage exclusive breastfeeding from birth to age 6 months, then supplement with breastfeeding when solid foods are introduced until age 12 months and beyond c234c235
      • Limit consumption of sugar-sweetened beverages c236
      • Encourage intake of fruits and vegetables c237
      • Limit screen time to 2 hours; avoid in children younger than 2 years c238
      • Encourage eating breakfast daily c239
      • Limit dining out at restaurants, especially fast-food restaurants c240c241
      • Encourage family meals c242
      • Adjust portion sizes appropriately for age; allow child to self-regulate intake c243c244
      • Encourage diet rich in calcium and high in fiber c245c246
      • Encourage diet with balanced macronutrients c247
      • Limit consumption of energy dense foods c248
      • Promote moderate to vigorous exercise for at least 60 minutes daily c249
      • Ensure adequate sleep duration c250
    • Interventions that include diet combined with physical activity interventions can reduce the risk of obesity in young children aged up to 5 years; interventions that focus only on physical activity do not appear to be effective in children of this age r36
    • Interventions that only focus on physical activity can reduce the risk of obesity in children aged 6 to 12 years, and adolescents aged 13 to 18 years; in these age groups, there is no evidence that interventions that only focus on diet are effective r36
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